Mr. President, I rise for the purpose of introducing a bill on health care reform. I know the Presiding Officer has immense interest in it, as do a number of other Senators. I have read his bill and…
Mr. President, I rise for the purpose of introducing a bill on health care reform. I know the Presiding Officer has immense interest in it, as do a number of other Senators. I have read his bill and incorporated many parts of that.
Health care reform is one of the biggest needs in this country. It is the fastest escalating price in this country. It is the biggest cost to companies and individuals in this country. We need to have a solution.
I have been working with Senator Kennedy, who is the chairman of the Health, Education, Labor and Pensions Committee. He has a very full plate with the Higher Education Act, the higher education reconciliation, information technology, and I could go on to mention about 53 bills we are working on in that committee. So I have had some latitude as ranking member to try to pull together some information-- some legislation that would deal with health care for this Nation. This is a work in progress. This is not a finished document.
I wish to thank Senator Kennedy for working with me and his staff and my staff to come up with some health care principles we wanted to follow. Of course, I appreciate the work Senator Nelson did with me in previous times and currently on small business health plans. I appreciate Senator Baucus's efforts on health care and how the tax
package goes together with that. We can see there are a lot of moving parts to anything we do with health. Senator Coburn has an outstanding and very comprehensive package on how we can solve many of the health care and health insurance problems in this Nation. Senator Lott, Senator DeMint, Senator McConnell; as I mentioned, the Presiding Officer, Senator Whitehouse; Senator Lincoln, Senator Carper, Senator Salazar, and Senator Durbin--these are all people who have come up with either a comprehensive plan or a piece of a plan that would work to make an important difference in health care in this country.
Congressman McCreary on the House side has been a real leader on this and, of course, the President and the administration have made contributions as well. The President, in his State of the Union speech, made some comments about how taxes would fit in with solving some of the uninsured problems in the country, and some of those provisions are in here as well.
Without the work of everyone on this, it can't be done. If it gets polarized, it can't be done. This is something which has to be done in a very bipartisan way. I hope we have a framework from which we can all operate, making changes, finding third ways.
I work on an 80-percent rule. I anticipate and from experience have found that usually everybody can agree on 80 percent of the issues, and among the 80 percent of the issues on which they agree, they can agree on 80 percent of any one of those issues. You never get a perfect bill around here. If you can get 80 percent, you can get a lot done. That is what we are trying to do on health care--make an 80-percent change for the people of America. Eighty percent would be a huge difference and will help out a lot of people.
So I rise today to talk about an issue that is literally a heartbeat away from devastating the lives of every American; that is, our current health care crisis. Undeniably, we have a problem. There are 46.1 million Americans, according to the last tabulation, who are uninsured. Now, we always talk about that figure and change it slightly differently because there are 7 million of those people who make over $80,000 a year and don't have insurance, so they must choose not to have insurance, but they are uninsured. People who are on Medicaid, they don't have to sign up for anything before they have an emergency. When they go to the hospital, they can sign up then. That is a significant number of the 46.1 million people as well. So I don't know whether to really say they don't have insurance, but at any rate, let's just use that figure of 46.1 million Americans who are uninsured and figure out a way to solve that, as well as to help people who also have insurance to perhaps be able to handle the situation even better.
Health care costs are outstripping inflation. They are increasing annually at three times the rate of the Consumer Price Index. It is little surprise that three out of every four Americans are concerned about health care--three out of four. I think probably, if you are talking to people, you would think the percentage was even higher than that.
Employer-provided health insurance is voluntary and in critical condition. Sixty percent of the country's employers offer insurance today, but that is down 9 percent from a few years ago. It is partly due to the fact that the cost of health insurance for companies has nearly doubled in the same amount of time. With employers expected to pay over $8,000 per employee versus $4,000 5 years ago, we have no choice but to stabilize the system and provide more options for businesses so they can continue to provide health care for their employees.
We must also provide real options--real options for those without employer-based health care. My own home State of Wyoming is hard-hit. On average, one in five Wyoming residents is uninsured, and more and more residents are losing the coverage they do have as the costs go up. It is largely due to the fact that much of Wyoming's economy is small business. Nearly 70 percent of Wyoming employers are small business. Actually, if you use the Federal definition of small business and you talk about companies headquartered in Wyoming, 100 percent of the companies are small business. We don't have a single one, according to the Federal definition, that is based in Wyoming. But nearly 70 percent of the employers find that it is nearly impossible to afford health care coverage for their employees.
Thankfully, I am not here today to talk about these problems; I am here to provide real solutions. Americans need and deserve real solutions to this crisis now, and they are counting on this body to work together to get that. The time has come to move beyond the rhetoric and principles to true comprehensive health care reform.
Congress could enact 10 major steps for health care reform. These 10 steps are the basis of the legislation I am introducing today, the Ten Steps to Transform Health Care in America, or simply ``Ten Steps.''
In putting together these 10 steps, I first wanted to understand the problem, and all the proposals others have been discussing help with that. I have studied those other proposals very carefully, and my colleagues will find that I have included many of the concepts of those other proposals in the 10 steps. I particularly wish to recognize again and thank Senator Baucus, Senator Kennedy, Senator Nelson, Senator Coburn, Senator Lott, Senator DeMint, Senator McConnell, Senator Whitehouse, Senator Lincoln, Senator Carper, Senator Salazar, Senator Durbin, Congressman McCreary, the President, the administration--all of them for their contributions, for their patience, and for their willingness to share their ideas.
However, to truly do this right, we have to move beyond the usual jurisdictional issues, beyond the usual reauthorizations of a single program at a time. We have to examine the whole health care system and together--together, we have to put forward a bold and comprehensive solution that addresses our health care crisis. That is what Ten Steps does. It is a comprehensive solution to a very big problem. It can be done in parts. It doesn't have to be done as one structure.
It needs to go through the committee process. I have pointed out several times that bills that don't go through the committee process usually don't make it through the process at all. They are good for making rhetoric, they are good for making points, they are sometimes good for advancing a principle, but they seldom ever make it to the President's desk for signature. So I know this will have to go through more than one committee. I know the jurisdictional issues between Health, Education, Labor and Pensions and the Finance Committees. I have no problem. We did the pensions bill last year, going through those same kinds of multiple committees and getting agreement from everybody, and that can be done on this issue as well--of course, as long as we don't polarize it.
So I want to reiterate again that this is not a final bill. One of the things we have done in the HELP Committee which has helped to move things along is to consider every bill a work in progress. At a lot of the committee meetings, when you have a markup, different amendments are presented and they are voted up or down, just like on the floor. Well, that doesn't result in a lot of compromise. So what we have done on the HELP Committee is use the markup process as an indication of problems and the level of intensity of those problems, and we have agreed to work through those problems even after the bill makes it through committee. As a result, it seldom makes it through committee unanimously, but it makes it through committee in a bipartisan way, and that encourages people to work together to find solutions. Sometimes it is one way or the other, but usually it is finding a third way to come up with a mechanism to do what we are trying to do. Once we can put away some of the old ``diving into the weeds'' things that have happened year after year, we are able to come up with something new and different that actually reaches the goal we have been trying to reach as we jumped into the weeds through the whole process.
So I want to remind everybody that it is a work in progress. We want more ideas. We want some of those third ways. But primarily, we want everybody to take a look at what is in here because it is a compilation of a number of people who have really taken a look at the situation.
So what does it do? These 10 steps--I will break them down into the actual 10 steps and go through each of them.
First, we eliminate unfair tax treatment of health insurance, which expands choices and coverage and gives all Americans more control over their health care.
Our current health insurance system is biased toward employer-based coverage--kind of due to a historical accident. The wage controls of World War II increased competition among employers for recruiting the best employees and incentivized employers to offer health benefits instead of what they couldn't do, which was increase wages. In 1954, Congress codified a provision declaring that such a contribution would not count as taxable income. This tax policy made it very favorable for individuals to get their health benefits through their employers and consequently has penalized individuals who get coverage through the individual market. So if you work for a big company--a tax break. If you don't--penalized.
The Joint Committee on Taxation estimated that moving this tax bias and a few related health care tax policies will save the Government $3.6 trillion over the next 10 years. Even around here, that is a lot of money. That is a lot of money which can and should be used to expand choices and access and give individuals more control over their health care. Ten Steps ensures that every American can benefit from this savings--whether they get their health care from their employer, from the individual insurance market or they decide they want to get off Medicaid and switch to private insurance.
Let me be clear. My goal is not to erode employer-based health insurance, given that the Ten Steps does not alter the way employers treat health insurance. Rather, I wish to provide more options for individuals who don't currently have insurance through their employer. Everyone should be treated equally.
Once the employee exclusion for health care insurance is eliminated, we must provide additional tax incentives for the purchase of health care insurance. Ten Steps is a hybrid approach, combining the standard deduction for health insurance with a tax subsidy for those who need it the most. That way, no particular population is adversely affected.
The second step of Ten Steps would increase affordable options for working families to purchase health insurance through a standard tax deduction. The national above-the-line standard deduction for health insurance will equal $15,000 for a family and $7,500 for an individual. I wish to also note the earned-income tax credit for taxpayers with qualifying children is held harmless--that is very important--so those receiving the earned-income tax credit will not be affected by these changes. Actually, they will be affected in a positive way.
For example, say Bob from Gillette, WY, has total compensation of $38,000, made up of $34,000 in wages and $4,000 in health insurance premiums paid by his employer. Because of the current unfair tax treatment of premiums, Bob's current taxable income is reduced to $34,000, which means he paid about $5,000 in taxes. To an accountant, this is all fascinating; for other people, I am not so sure.
Under the Ten Steps, which eliminates the exclusion of premiums from tax, Bob's total compensation and thus taxable income would be $38,000. By providing Bob with a $7,500 standard deduction for health insurance, his taxable income under this bill would be lowered to $30,500, which means he would pay about $4,000 in taxes. So Bob's total savings under this proposal is $1,000 a year.
The third step of Ten Steps is what makes this a hybrid approach. I couple the standard deduction with a refundable, advanceable, assignable tax-based subsidy. That is a mouthful, but it ensures that Americans receive this credit in a meaningful way that allows them to purchase real insurance coverage.
Given that everybody is not familiar with these terms, I will explain them. As a refundable credit, it benefits folks even if they don't have tax liability. They don't have to owe taxes in order to get it. This helps low-income individuals. Advanceable means the subsidy would be paid at the beginning of the year so individuals can use the funds to immediately purchase health insurance. If it wasn't advanceable, individuals would need to first pay for their health insurance and then get the money back at the end of the year to pay them back for that purchase. To encourage everyone to obtain health insurance right away, we should provide those funds upfront. Further, to ensure that the subsidy goes toward the purchase of health care insurance, it is also assignable--paid directly from the IRS to the insurance carrier that the individual chooses.
Ten Steps includes the tax subsidy equal to $5,000 for a family or $2,500 for an individual. The full subsidy amount is available to individuals at or below 100 percent of the Federal poverty level, which is $20,650 right now for a family of four. The subsidy is phased out between up to 300 percent of Federal poverty level, with individuals at 200 percent receiving half the subsidy and individuals at 301 percent receiving the standard deduction instead of the subsidy. I am sure everybody got that.
The fourth key step for health care reform is to provide market-based pooling to reduce growing health care costs and increase access not only for small businesses, unions and other kinds of organizations and their workers, members, and families. That is a change from anything I have done on pooling before, but it is a change that was requested by the other organizations and unions, as well as small business. Those of you who know me well recognize how central this would be to any health care reform proposal of mine.
While I have not yet introduced the small business health plan legislation from last year, I have not abandoned those key principles. Every day, emergency rooms treat more than 30,000 uninsured Americans who work for or depend on small businesses. That is at least 30,000 reasons why I will not abandon the concept. However, in the proposal I am introducing, I have addressed some of the criticisms of the bill, and I have offered what I believe are appropriate solutions.
For instance, while the earlier bill focused heavily on small businesses--and this one still does--it simply became clear that other organizations, including unions and churches, can benefit from better pooling options too. Therefore, under this bill, the umbrella of the pooling option has been expanded to include more kinds of organizations but with the same strong focus on consumer protections and State-based oversight.
Of course, a big elephant in the room was dealing with those who were misled to fear how the initial proposal dealt with insurance mandates. I hope those who were so vocal before will pause this time around. By incorporating what many have described as the Snowe amendment--which I am sure we would have passed at the time we were talking about that before--the legislation would require benefit mandate categories if a majority of the States required them. While I still have some concerns, I am comfortable with this compromise because the mandate requirement is coupled with something it needs to encourage pooling and that is a common definition of what that mandate means. We do it with the Federal insurance plan because definitions in all the States run a little bit different. If you are trying to do something comprehensively, it is pretty hard to figure out what each definition means, so there needs to be a way of streamlining it and coming up with a common definition for that mandate. I don't think people have a problem with that, especially since we do it with the Federal plan.
As I learned with the previous debate, mandates for many different services and items are not consistent from State to State. Thus, if we are to discuss requiring those, we should at least have a consistent definition of what those mandates require. We should not further complicate the pooling option with a multitude of definitions. We want to make insurance as simple as possible. I know that is kind of an oxymoron, I am sure, because I know nobody in America relishes having their insurance agent come over and spend an evening explaining the bill to them. But we want to have this little bit of streamlining so it is simpler and people will be able to understand it, to the degree that is possible with insurance.
While the next step is probably one of the most obvious ones, it is also one many have not yet discussed. Currently, HIPAA portability protections
are provided to group health plans. The protections provide assurances to consumers that insurers will deal with preexisting conditions fairly and provide coverage, even to small groups.
These protections have been a great help for individuals purchasing health care coverage in the group market. However, those consumer protections are not provided nearly as well to individuals who are purchasing in the individual market. Ten Steps blends the individual and group market to extend important HIPAA portability protections to the individual market so the insurance security can better move with you from job to job. It allows people to take that new opportunity and still be sure they will be covered, even if they have had some preexisting conditions.
The sixth step emphasizes preventive benefits and helps individuals with chronic diseases better manage their health. America should have health care, not sick care. Prevention, prevention, prevention. That makes a big difference in the cost.
We have all been discussing the need to do more to prevent disease, not just treat its symptoms. Even though I leave much to the markets to define some health insurance components, the one thing we must emphasize is the need for prevention. Any plan purchased with the tax subsidy must include basic preventive services and a medical self- management component.
This concept is modeled after a very successful program in Wyoming. In 2005, Wyoming EqualityCare, our Medicaid Program, began providing one-on-one case management for Medicaid participants with chronic illnesses, such as diabetes, asthma, depression or heart disease, to encourage better self-management of these conditions. The program provides educational information on self-management, as well as a nurse health coach who follows up with each patient to ensure they have what they need to take care of themselves.
In addition, EqualityCare provides a nursing hotline so all patients have a direct line to a health care provider when they are concerned about an illness. These programs targeting those with chronic illnesses were estimated to save nearly $13 million for the EqualityCare program in 2006. In a lot of States, that would not sound like a lot, but Wyoming is the least-populated of all of the States. We are hoping to get 500,000 people in the next census. When you talk about $13 million being saved in this EqualityCare Program dealing with Medicaid participants, it is a lot of money, proportionately, particularly because it cut down on inappropriate use of emergency room services.
Now, another key step of the Ten Steps for health care reform is to give individuals the choice to convert the value of their Medicaid and SCHIP program benefits into private health insurance, putting them in control of their health care, not the Federal Government. The rationale for this step is simple. If the market can provide better coverage at a lower price, why not allow Americans to access that care?
This gives low-income individuals more options about where they can receive their care and what care is available to them. Some providers don't see Medicaid and SCHIP patients. This provision will change that by letting the market forces work and give all patients more choices. It is time for people to start making decisions about their care. Let's get the Government out of the doctors office.
About 6,000 kids are enrolled in the Wyoming SCHIP program. An additional 6,000 kids are eligible for the program but are not enrolled. I wonder why that is. Maybe it is because folks in Wyoming are wary about accepting Government help, and they think there is a negative stigma associated with SCHIP and Medicaid. Well, under Ten Steps, they can use that money to purchase health care insurance through the private sector so that their family can attain the high quality care they need and deserve. This will cover more people.
The eighth step in Ten Steps is a bipartisan proposal which the HELP Committee approved last month--the ``Wired for Health Care Quality Act,'' which encouraged the adoption of cutting-edge information technologies in health care to improve patient care, reduce medical errors, and cut health care costs. Some of the most serious challenges facing health care today--medical errors, inconsistent quality, and rising costs--can be addressed through the effective application of available health information technology linking all elements of the health care system.
The widespread use of health IT can save lives. If somebody is traveling and gets in a car wreck or gets hurt in some other way, the emergency room doctor would be able to find out everything he or she needs to know to make the right treatment decisions, without the person having to fill out one of those little papers at the doctors office, which they may not be capable of doing if they have been in a requiem or have some other problem.
Better use of health IT would also allow medical data to move with people when they go to other locations. When someone goes to the doctor's office, they won't have to take the clipboard and a pencil and write down everything they can remember about their history. It will already be recorded and go with them. It will make a huge difference.
Beyond saving lives and saving time, more effective use of health information technology would save us a lot of money. A RAND study suggested that health IT has the potential to save--listen to this-- $162 billion a year. Even around here that is real money. In order for these savings to be realized, we have to create an infrastructure for interoperability.
All the different health providers and insurers and doctors have to be able to get the information electronically, but doctors, hospitals, health care advocates, the business community, including small businesses, are clamoring for Congress to take action and establish uniform health IT standards. That will cut down on the cost of the software.
Time is of the essence. If Congress does not act, our health care system will move forward in a highly inefficient, fragmented, and disjointed way. Among other things, this bill will eliminate duplicative tests and reduce medical errors. That is a lot of where that $162 billion a year in savings comes from.
Health care reform cannot simply expand health insurance coverage. It must also expand access to actual providers of care. There are growing shortages of health care providers nationally, with a shortage of up to 200,000 primary care physicians and 1 million nurses expected by 2020. Who is going to take care of us at the hospital if we don't have nurses? Who is going to help make a diagnosis if we don't have doctors?
That is why the ninth step of Ten Steps helps future providers and nurses pay for their education while encouraging them to serve in areas with great need with five key reforms.
This legislation provides competitive matching grants for States to encourage nurses to return to the profession after having left the workforce for 3 years or more while reaffirming the commitment to current programs targeting nurse educators and nurse education. So this will encourage people to come back into providing that excellent service. To deal with the shortage right now, this legislation will expand the number of nonimmigrant skilled workers visa slots for nurses serving in medically underserved areas.
To expand access to those most vulnerable, Ten Steps reaffirms the commitment to current programs that are working, such as the Community Health Centers program and the loan repayment programs at the National Health Service Corps. Working together, these two programs provide key support in underserved areas.
To allow for greater access to health care services, clarification will be made that convenient care clinics may accept and receive reimbursement from Medicaid and SCHIP patients. These convenient care clinics are small health care facilities located in retail outlets providing affordable and accessible nonemergency health care from nurses, physician assistants, and physicians. Often open 7 days a week, these clinics provide an option for those seeking routine and preventive care services in a more convenient setting--at the retail outlets--and with patients seen typically within 15 minutes.
Finally, building upon the successes of current rural health programs, Ten Steps will ensure appropriate development of rural health systems and access to care for residents in rural areas.
In providing access to health care, I believe it is important to envision where we want to provide that care. Community and home-based care is often much preferred, less costly, and proven to increase quality of life. To encourage innovative approaches to keeping long- term care in residential settings, competitive grants will be available to give seniors more options for receiving care in home or community- based settings. We just had a hearing on that subject in the HELP Committee. It was both very helpful and very convincing.
The final step to Ten Steps decreases the skyrocketing cost of health care by restoring reliability in our medical justice system through State-based solutions. The bill I have been discussing today includes the Fair and Reliable Medical Justice Act, which I just introduced with Senator Baucus, for States to encourage early disclosure of preventable health care errors, prompt and fair compensation for injured patients, and careful analysis on patterns of health care errors to prevent future injuries. By funding demonstration projects, States are enabled to experiment with and learn from ideas leading to long-term solutions tailored to the unique circumstances of each State.
No one--not patients or health care providers--is appropriately served by our current medical litigation procedures. Right now, many patients who are hurt by negligent actions receive no compensation for their loss. Those who do receive merely 40 cents of every premium dollar, given the high cost of legal fees and administrative costs. That is simply a waste of medical resources.
Furthermore, the likelihood and the outcomes of lawsuits and settlements bear little relation to whether the health care provider was at fault. Consequently, we are not learning from our mistakes. Rather, we are simply diverting our doctors. When someone has a medical emergency, they want to see a doctor in an operating room, not a courtroom.
The medical liability system is losing information that could be used to improve the practice of medicine. Although zero medical errors is an unattainable goal, the reduction of medical errors should be the ultimate goal in medical reform. The Institute of Medicine, in its landmark study called ``To Err is Human,'' estimated that preventable medical errors kill somewhere between 44,000 and 98,000 Americans each year. That study further emphasized that to improve our health care outcomes, we should no longer focus on individual situations but on the whole system of care that is failing American patients.
In the 8 years since that study, little progress has been made. Instead, the practice of medicine has become more specialized and complex while the tort system is more focused on individual blame than on a system safety.
I realize I have talked for quite a bit about Ten Steps, and given the current crisis, we should be talking a lot more about real solutions, not just problems. I also want everyone to know I believe the introduction of this bill today is simply the first step forward. I look forward to talking with others about their thoughts on how to improve this proposal, how to better refine it so it can better serve all Americans.
With all of that talk, I also want action, real action, to provide real coverage for Americans, not a large expansion of a government program with a huge pricetag that does little to impact those who are uninsured.
We have an opportunity, we have an obligation to take care of the people of this country, and they are demanding it. Let's work from a basis of some information and see where we can take it so that we get a solution and we get action now.