Native American Business Development Enhancement Act of 2009

I ask unanimous consent that of the 30 minutes that I control, the ranking member of the Ways and Means Committee, the gentleman from Michigan (Mr. Camp), control 15 of those minutes.

I would yield myself 1 minute.

Mr. Speaker, the only fix that's in this bill before us is ``the fix is in.'' This is nothing more than a repayment to the American Medical Association for endorsing the larger health care bill that was on the floor several weeks ago. There is not one dime of pay-for in this bill. It is a wave the magic wand, erase the accumulated deficit of the last 10 years or so in the SGR formula, and let's kick the can on down the road.

The bill is so narrowly construed that we couldn't offer in the motion to recommit a real pay-for because this bill doesn't have a pay- for. This is nothing more than a political payoff to the American Medical Association. Republicans support really fixing the SGR system, but we think it ought to be done all at the same time. So we would hope that we would vote against this sham today.

I reserve the balance of my time.

Parliamentary inquiry.

Under the rules that we operate where we alternate back and forth, is it allowable for myself to make a rebuttal and then recognize the gentleman from Indiana? Or do I have to do one or the other?

I am going to recognize myself for 1 minute to comment on my friend from Maryland's comments. Then hopefully the Chair will let me recognize the gentleman from Indiana (Mr. Pence) for 3 minutes.

Mr. Speaker, first of all, under Republican control, every bill that we brought to the floor, except one bill, was paid for either in that bill or in our budget resolution. There was one exception to that where we did not pay for it. So that is answer number one. Answer number two, this is not paid for. Under a bill that my friends in the majority passed in July, they say we're going to start pay-for, but it doesn't count for the doctors fix, it doesn't count for the alternative minimum tax, and it doesn't count for the estate tax.

But once we do all that without paying for it, then the pay for will kick in. So in that sense, my good friend from Maryland is accurate. But in the sense of this bill, he is totally inaccurate. This bill is not paid for.

Now, Mr. Speaker, if I am allowed to, I yield 3 minutes to my good friend from Indiana (Mr. Pence).

(Mr. PENCE asked and was given permission to revise and extend his remarks.)

I yield 1 minute to the gentleman from Kentucky (Mr. Whitfield), a member of the Health Subcommittee.

I yield myself 1 minute.

I would ask the distinguished chairman of the Health Subcommittee:

Where is the fix? There is no fix in this bill.

They split one formula into two, but there is no reform in it. It is not based on medical expenses. It is not based on anything. There is no automatic reduction. It simply erases the current deficit in the account, has two formulas instead of one, and then 4 or 5 years from now, we will kick the can down the road again.

If there really is a fix, let's have somebody on the majority side explain it. You can't explain it because it is not there.

I yield 1 minute to a member of the Health Subcommittee, the gentleman from Georgia (Mr. Gingrey).

Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from Texas (Mr. Gohmert).

Mr. Speaker, I yield myself 1 minute.

Since my friends on the Democrat side won't explain their procedure, their bill, I am going to try and do it, and if I am wrong, I am sure that they will correct me.

Current law, we have one SGR formula. It is based on GDP and inflation. It is not based on any kind of medical index. Whatever that is perceived to be each year, that is the amount of increase we can pay our physicians. All physicians get the same increase.

Under this bill, they say if you are a primary care doctor, you get the formula plus 2 percent. If you are a specialist, you get the formula plus 1 percent, but they don't change the formula. The formula is the same as it is under the current law, and they don't change the enforcement mechanism. The enforcement mechanism is the same as it is under current law; i.e., Congress has to vote to either accept the cuts or to not accept the cuts and provide a temporary fix. As I understand it, that is their fix. Now, if I am wrong in that, I want my friend Mr. Waxman or Mr. Pallone or Mr. Rangel or Mr. Stark to tell me how I am wrong.

Mr. Speaker, I yield 1 minute to the gentleman from Nebraska (Mr. Terry), a member of the Energy and Commerce Committee.

Mr. Speaker, I yield 1 minute to the distinguished minority leader from the great State of Ohio (Mr. Boehner).

Mr. Speaker, could I inquire as to how much time I still control, please.

I want to yield 1 of those 3 minutes to the gentlewoman from Nashville, Tennessee, a member of the Energy and Commerce Committee, Congresswoman Marsha Blackburn.

Mr. Speaker, I'm not used to dealing with a warm and fuzzy Pete Stark. I have to admit that was a very good speech.

Mr. Speaker, I yield 1 minute to my good friend from Michigan from the Energy and Commerce Committee, Mr. Rogers.

Mr. Speaker, I yield myself the balance of the time.

I'd like to put into the Record a statement from the vice chairman of the American Medical Association on March 20, 1997, where they went on record before the Ways and Means Committee subcommittee supporting the current system. And now, I understand and I accept what Subcommittee Chairman Stark said, that mistakes have been made, and I think, in hindsight, both sides can agree that a mistake has been made.

It is my opinion, and I think most of the Republicans would share this opinion, that this is not the solution. When all you do is change which formula gets reimbursed, either primary care or specialist, but you use the same underlying formula, the same lack of enforcement, that's not, in my opinion, a fix. So respectfully, I believe that we should defeat this bill and then work together.

I do sense some bipartisanship on this floor. Let's work together to come up with a real fix. It will not be easy. It's not easy to come up with $350 billion. It's not easy to allocate that. It's not easy to change the formula to something that more accurately reflects the costs of practicing medicine in the modern era. But, we can do it. This is not the solution. I hope we'll vote this down.

As has been pointed out, this bill isn't going anywhere in the Senate. This is an act, in my opinion, of paying off a political debt to the American Medical Association for endorsing the larger health care bill several weeks ago. Please vote ``no.''

Statement of Thomas R. Reardon, M.D., Vice Chair, American Medical

Association

Mr. Chairman, my name is Thomas R. Reardon, M.D. I am a

general practitioner from Boring, Oregon, and a member of the

Board of Trustees for the American Medical Association (AMA).

On behalf of the 300,000 physician and medical student

members of the AMA, I thank you for this opportunity to

testify before the Subcommittee today regarding Medicare

physician payment issues.

A wide range of experts have independently concluded that,

despite Medicare's clear success in improving the health

status of our elderly and disabled citizens, the program

cannot be sustained without fundamental restructuring. The

Hospital Insurance Trust Fund faces bankruptcy in five years

or less, and Medicare's current overall expenditure growth

cannot be sustained. Medicare faces a much more serious long-

term problem as the ``baby boom'' generation ages and the

number of workers paying taxes for every Medicare

beneficiaries will decline from 3.9 currently to only 2.2 in

the year 2030.

The high growth rates for many of the services are due to a

combination of factors, including increased beneficiary

demand for new services, flaws in payment rules which

encourage high volume growth in some categories of service,

insulation of most beneficiaries from cost considerations,

and ineffective approaches to cost control. However, as the

chart below indicates, physician spending growth is well

below the rate for any other major sector of Medicare, and

well below overall Medicare growth. The AMA is pleased that

the President's 1998 budget proposal explicitly recognizes

this fact.

We are also pleased that the Administration's budget

supports the development of innovative provider sponsored

organizations in order to offer greater choice to Medicare

beneficiaries. We believe these types of options hold the

promise of enhancing beneficiary choice while controlling

Medicare's costs. The AMA also supports the President's

investment in preventive health care to improve seniors'

health status by covering colorectal screening, diabetes

management, and annual mammograms without copayments, and by

increasing reimbursement rates for immunizations to ensure

that Medicare beneficiaries are protected from pneumonia,

influenza and hepatitis.

Unfortunately, the Administration's budget primarily adopts

the strategy of cutting physician and other provider payments

in hopes of getting more services for less money. We believe

this approach will ultimately divorce the Medicare system and

its beneficiaries from the mainstream of American medical

care, while postponing the major restructuring needed for

Medicare's long-term survival. In the meantime, the long-term

problems will only grow larger, requiring more draconian and

expensive solutions.

AMA's Proposal For Medicare Transformation

The AMA has a plan which addresses both the short and long-

term problems with Medicare, while preserving the bond of

trust between a patient and physician that makes medicine

unique. The AMA's Transforming Medicare proposal is based on

the idea of a competitive market-driven system as the best

option for the future of the Medicare program because it

offers more choice to senior citizens and the disabled. We

must give the patient both the opportunity and the

responsibility to make wise prospective choices of physician

and health plan, with the reasonable opportunity to change

either if they prove unsatisfactory.

Our plan would modernize traditional Medicare, eliminating

the need for Medigap, while preserving the security and

quality of care beneficiaries now receive. It would create a

new MediChoice option, which would provide a broad menu of

health plan choices for Medicare beneficiaries to choose

from, including medical savings accounts and provider

sponsored organizations. And finally, it would ensure that a

healthy Medicare is available for future generations. The AMA

would welcome the opportunity to discuss our Transforming

Medicare proposal with the Subcommittee in greater detail at

an appropriate forum.

Improving the Physician Payment System

The Administration's 1998 budget proposal targets $5

billion in savings over five years from refinements to the

Medicare physician payment schedule. In particular, the

Administration proposes moving to a single conversion factor

(CF) for the payment schedule, and replacing the current

Medicare Volume Performance Standard (MVPS) update formula

with a Sustainable Growth Rate (SGR) formula.

Under the Administration's budget proposal, the overall

payment update for 1998 would be set at 1.9%, yielding an

overall CF of $36.63 in 1998. With the move to a single CF of

$36.63, surgical service payments would fall by 10.6%

compared to 1997 levels, while primary care payments would

increase by 2.4% and other service payments would increase by

8.2%. The payment reductions for surgical services are

further exacerbated by the implementation of resource-based

practice expense relative value units scheduled for 1998, as

discussed below.

The AMA has consistently sought a return to a single growth

standard and conversion factor for physician services. We

adopted this position well before any indication of which

services would benefit from multiple standards. At our Annual

House of Delegates meeting in 1996, AMA policy was modified

to adopt a compromise that responds to two realties. First,

because moving to a single conversion factor could lead to

large single year cuts for some services and specialties, we

support a transition of as close to three years as possible.

Second, because we also recognize that one of the purposes of

a transition is to allow those who face cuts time to adjust,

and that there has been ``fair notice'' of a shift to a

single conversion factor, our House of Delegates voted that

the ``clock should start running'' on such a transition on

January 1, 1997.

In addition to moving to a single conversion factor, the

AMA supports replacing the MVPS system of updating physician

payments. There is widespread agreement that the current

method of updating physician payments, the MVPS system, is

fundamentally flawed. The Congress, the Administration, and

the Physician Payment Review Commission (PPRC) have all

proposed replacing the current MVPS update formula with a

sustainable growth rate (SGR) formula, which uses real per

capita gross domestic product (GDP) to adjust for volume and

intensity.

The Administration's fiscal year 1998 budget proposes

implementing an SGR formula, with the volume target in the

SGR formula initially set at growth in real per-capita GDP

plus one percentage point. However, the Congressional Budget

Office (CBO) scoring of the proposal apparently failed to

yield the targeted savings of $5 billion in savings from the

Medicare fee schedule, and the volume allowance in the SGR

was reportedly reduced to GDP+0.

In general, the AMA supports implementing the SGR approach

as a needed correction for the MVPS. Fundamentally, the

question for policymakers is determining the level of annual

spending growth for physician services that best balances

patient care

needs and the federal budget. Under the current MVPS

physician update formula, the projected Medicare payment

level for physicians is a steep actual decline, while

hospital and other provider payment rates go up, as the chart

below indicates. Although these non-physician services are

unlikely to see their full projected increases, their

budget savings will be charged against this rising

baseline, while further savings from physicians require

even steeper cuts.

Budget reconciliation for Medicare should reflect the fact

that physician spending is under better control than any

other major Medicare segment, and that the budget baseline

already assumes steep annual payment cuts. Physician practice

costs, as measured by the Medicare Economic Index (MEI),

continue to rise while physician reimbursement under Medicare

is projected to fall. Physicians are only asking for the

opportunity to have Medicare payments keep up with the costs

of providing care to Medicare beneficiaries, and are willing

to accept the challenge of maintaining volume growth at

current low levels.

While we believe that MEI is the appropriate goal for

physician updates, we understand that budgetary constraints

may not presently allow for a full MEI update for physicians.

Physicians are willing to do their part to put Medicare's

fiscal house in order, as we have repeatedly done in the

past. Physicians, who accounted for 32% of combined physician

and hospital Medicare spending from 1987 to 1993, absorbed

43% of Medicare provider cuts over the same time. We would be

willing to accept GDP+2 under an SGR system as a temporary

measure, if there were assurances that this could be

increased to cover MEI once the necessary Medicare savings

were obtained. In contrast, under GDP+O as the Administration

proposes, physician payments would continue to fall well

below MEI, as they are projected to do under the current MVPS

system.

Given a new SGR, with a realistic growth allowance, we

could also support a new ceiling on positive MVPS

adjustments, which would provide direct financial benefits to

the federal budget if actual volume is below target.

Moreover, the federal government receives a very real

additional benefit--the ability to pay for the payment rates

needed to maintain the viability of Medicare fee-for-

service out of reduced service volume. At the same time,

like the PPRC, we believe it essential to maintain the

current 5% maximum payment reduction from the MEI

(increased from 3% by OBRA 93) and to reject

Administration proposals to lower the floor to MEI minus

8.25%.

Resource-Based Practice Expense

As mentioned above, many physicians face additional extreme

payment reductions due to the implementation of the resource-

based practice expense in 1998. The Social Security Act

Amendments of 1994 requires the Health Care Financing

Administration (HCFA) to implement a ``resource-based''

practice expense component of the Medicare fee schedule by

January 1, 1998. That is, the payment for this component--

which represents over 40 percent of the payment for physician

services--is to be based on the actual expenses incurred in

delivering each service. Currently, the practice expense

allowance is derived from a formula based on the prior

reasonable charge payment system.

The AMA supports resource-based practice expenses so long

as they reflect actual practice expenses, but is seeking a

one-year extension of the implementation date. The 1994

legislation said that HCFA should ``recognize the staff,

equipment, and supplies used in the provision of various

medical and surgical services in various settings.'' HCFA

contracted with Abt Associates to conduct a two-part study of

3,000 physician practices expenses. When the survey was

pulled back due to poor response rates, HCFA was left without

adequate data to meet the intent of the law.

HCFA is relying primarily on data derived from clinical

practice expert panels, or CPEPs. Early review of the

recently-released CPEP findings suggest that they contain a

number of errors. HCFA has even rejected certain direct costs

that its expert panels found were part of the cost of surgery

when doctors supply their own staff and supplies in hospital

operating rooms. The AMA and medical specialties are working

to identify and correct those flaws but more time is needed.

Those who want to adhere to the current January 1, 1998,

deadline argue that any problems can be corrected later

through a refinement process similar to the one used when new

work values were implemented in 1992. The AMA believes this

is an inappropriate comparison. HCFA invested nearly three

times as much time and money on the design of new work values

as it has spent to revise practice expense values. Whereas

thousands of doctors were surveyed to come up with the work

values, in the end, there was no broad survey of practice

expenses. Simply put, with work values, the product being

tested was much further along in the development process than

is now the case with practice expense values.

Opponents of an extension also maintain that there is no

point in waiting another year because the demise of the

indirect cost survey shows that it will never be possible to

collect this information independently. We believe that with

another year, HCFA could develop alternative relative values

that bear some relationship to actual practice expenses.

There would be adequate time to validate and correct the CPEP

data. Better indirect cost allocation methodologies could be

developed and tested. Missing data could be collected,

perhaps through an expansion of existing surveys.

The cuts HCFA projected in January are so extreme that they

would nearly eliminate practice cost reimbursement for some

procedures and specialties. Many inpatient surgical

procedures and two specialties could suffer cuts of more than

80% in their practice expense values, and at least 40% in

their total payments. Under HCFA's projections, payments for

many surgical procedures would fall below Medicaid levels.

Thus, there is good reason to fear that if Medicare makes

deep cuts in its payments for complex procedures, doctors

performing these services may find that they can no longer

afford to accept Medicare patients.

In addition, even some of the specialties which seem

relatively unscathed in HCFA's projections could actually

experience significant cuts if other payers pick up the new

Medicare values because the projections do not show the

impact of cuts in procedures usually done on patients under

age 65. To impose such deep payment cuts based on such spotty

research seems certain to undermine physician support for the

Mr. Speaker, I yield myself 3 minutes.

(Mr. STARK asked and was given permission to revise and extend his remarks.)

Mr. Speaker, I would like to place in the Record a letter from the American Medical Association and a list of over 150 supporters of H.R. 3961, among which are the American College of Obstetricians and Gynecologists, the Iowa Medical Society, the Texas Medical Society, all of whom I think place Hippocrates ahead of Sarah Palin in terms of their assessment of what should be done.

I would further begin in addressing my dear friend from Texas in some of his inquiry earlier by quoting from the ranking member of the Health Subcommittee on the Ways and Means Committee back last July when he said he believed Members on both sides of the aisle agree that there is a need for a long-term fix for the Medicare physician payment. All 15 members, Republican members, of the Ways and Means Committee voted basically for the fix we're talking about today.

Let me make no mistake about blame and where we are. It may come as a surprise to our side of the aisle we make mistakes. In 1997 we made a mistake in setting the formula by which we would automatically limit the increase that doctors get paid. Well, we're here today trying to correct that mistake.

You've said so, correctly, that it's the same formula plus 2 percent for primary care, 1 percent for other physicians, some other plans to help encourage primary care doctors to come into practice. Hopefully, we've done it right, and recognizing if we don't correct it, we're talking about hundreds of billions of dollars by postponing. So we have postponed, whether on either side of the aisle, we have postponed correcting a mistake that we should have done earlier.

That's where we are today. No place else. And I hope that we can get the continued support to do that. I hope we don't have to come back and keep addressing it. I see not correcting it increases the amount we will have to pay in the future.

So there is plenty of blame, as the gentleman suggested, to go around. We could have fought harder to correct it earlier. We didn't and that's where we are today.

Literally every major medical society in the country has suggested that we do it this way, and I urge my colleagues to join with me, hopefully with my 15 colleagues on the Ways and Means Committee who haven't changed their mind, and support H.R. 3961 today so we can put this behind us. Then we can go on and have some really spirited debate about whether they do a better job in Texas or California of reforming medical care. That will be more fun.

But today let's fix this. Pass H.R. 3961, go home and have a wonderful Thanksgiving holiday, and come back to work on health care reform.

American Medical Association,

Chicago, IL, November 19, 2009.

Hon. Dave Camp,

Ranking Member, House of Representatives,

Washington, DC.

Dear Representative Camp: Thank you for your letter of

November 18, 2009, regarding the pending Congressional

consideration of H.R. 3961, the Medicare Physician Payment

Reform Act of 2009. We appreciate your agreement that having

physicians face annual cuts due to the flawed SGR is

unacceptable and your support for the intent of the

legislation. As you know, it is the same policy supported by

every Republican on the Ways and Means Committee during the

mark-up of H.R. 3200.

We are disappointed, however, that you and your colleagues

do not support the bill. As you know, the SGR was put into

place by the Balanced Budget Act of 1997, which originated in

your committee. At that time, the AMA wrote numerous letters

to Speaker Gingrich and your committee leadership warning

that limiting growth in physician services to GDP would

inevitably lead to sharp cuts in physician reimbursement and

a crisis in access to care for our nation's seniors.

Previously we had supported legislation that would have

allowed growth at a rate above GDP.

As predicted, the SGR did result in a 4.8% cut to

physicians for the year 2002. Congress declined to intervene

and that cut went into effect. In subsequent years, Congress

did step in to prevent additional cuts from occurring. The

Consolidated Appropriations Resolution of 2003, the Medicare

Modernization Act of 2003, the Deficit Reduction Act of 2005,

the Tax Relief and Health Care Act of 2006, the Medicare,

Medicaid, and SCHIP Extension Act of 2007, and the Medicare

Improvement for Patients and Providers Act of 2008 each

provided temporary relief for seniors and their physicians

from pending cuts.

What these bills did not do, however, was make any progress

toward fixing the problem. Instead, Congress fell into a

comfortable rhythm of kicking the can down the road and

putting off real reform to some unspecified point in the

future. In 2005, physicians faced a cut of 3.3% which was

averted by the MMA. At that time, the Congressional Budget

Office reported that the cost of just a ten-year freeze in

physician rates was $48.6 billion. Just four years later, the

pending cut stood at 21.5% and the cost of a ten year freeze

stood at $285 billion. The AMA believes that this cycle must

come to an end. Anything short of permanent reform will not

be supported by the AMA. Every year that Congress ``pays-

for'' a temporary solution, the cost of permanent reform

climbs higher still. These are obligations to our seniors

which the Medicare program has already made. To pretend that

they will not be incurred is unrealistic. To continue to grow

the size of the problem is irresponsible.

As for the implication that the recent action by the

Administration to remove drugs from the SGR are ``budget

gimmicks to hide the true deficit impact,'' we are reminded

of a letter you signed on May 21, 2004, to the Bush

administration calling the policy of including drugs in the

formula ``our greatest concern'' regarding the magnitude of

the

SGR problem. That letter was also signed by other members of

your committee. On June 16, 2004, Representative Cantor sent

a similar letter with Representative Pryce urging that CMS

``remove prescription drug expenditures from the Sustainable

Growth Rate (SGR) determination.''

The Congressional Record is replete with statements by

members from both sides of the aisle calling for permanent

reform. What is missing, however, is the result. The record

shows temporary patches and a ballooning problem.

The AMA does not support any motion to recommit that would

have a temporary fix. How steep will cuts be after those four

years? How many hundreds of billions of dollars will it then

cost to fix this problem? Medical liability reform remains

among the highest priorities of the AMA and all physicians.

However, when Republicans controlled both chambers of

Congress and the White House, capping damages could not be

accomplished. We fail to see why you believe it is possible

today. With less than seven weeks before Medicare rates are

cut more than 21%, we need solutions that can be achieved

quickly.

This should not be a partisan issue. Both sides of the

aisle have professed a desire to permanently address this

issue. The opportunity to advance permanent reform through

passage of H.R. 3961 cannot be missed. We urge all members to

vote for H.R. 3961.

Sincerely,

J. James Rohack.

H.R. 3961 is supported by a wide range of organizations

representing patients, doctors and other providers,

including: AARP; Air Force Association; Air Force Sergeants

Association; Air Force Women Officers Associated; Alliance

for Retired Americans; AMDA--Dedicated to Long Term Care

Medicine; American Academy of Allergy, Asthma and Immunology;

American Academy of Child and Adolescent Psychiatry; American

Academy of Cosmetic Surgery; American Academy of Dermatology

Association; American Academy of Facial Plastic and

Reconstructive Surgery; American Academy of Family

Physicians; American Academy of Hospice and Palliative

Medicine; American Academy of Neurology Professional

Association.

American Academy of Ophthalmology; American Academy of Pain

Medicine; American Academy of Pediatrics; American Academy of

Sleep Medicine; American Association of Clinical Urologists;

American Association of Hip and Knee Surgeons; American

Association of Neurological Surgeons; American Association of

Neuromuscular and Electrodiagnostic Medicine; American

Association of Orthopaedic Surgeons; American College of

Allergy, Asthma and Immunology; American College of

Cardiology; American College of Chest Physicians; American

College of Emergency Physicians; American College of

Gastroenterology.

American College of Obstetricians and Gynecologists;

American College of Osteopathic Internists; American College

of Osteopathic Surgeons; American College of Physicians;

American College of Radiation Oncology; American College of

Radiology; American College of Rheumatology; American College

of Surgeons; American Gastroenterological Association;

American Geriatrics Society; American Logistics Association;

American Medical Association; American Medical Group

Association; American Osteopathic Academy of Orthopedics;

American Osteopathic Association.

American Psychiatric Association; American Society for

Clinical Pathology; American Society for Gastrointestinal

Endoscopy; American Society for Metabolic and Bariatric

Surgery; American Society for Radiation Oncology; American

Society for Reproductive Medicine; American Society for

Surgery of the Hand; American Society of Addiction Medicine;

American Society of Anesthesiologists; American Society of

Cataract and Refractive Surgery; American Society of Clinical

Oncology; American Society of Hematology; American Society

of Nephrology; American Society of Ophthalmic Plastic and

Reconstructive Surgery; American Society of Plastic

Surgeons.

American Society of Transplant Surgeons; American Thoracic

Society; American Urological Association; AMVETS; Arizona

Medical Association; Arkansas Medical Society; Army Aviation

Association of America; Association of American Medical

Colleges; Association of Military Surgeons of the United

States; Association of the United States Army; Association of

the United States Navy; California Medical Association; Chief

Warrant Officer and Warrant Officer Association of the U.S.

Coast Guard; College of American Pathologists; Colorado

Medical Society.

Commissioned Officers Association of the U.S. Public Health

Service, Inc.; Congress of Neurological Surgeons; Connecticut

State Medical Society; Contact Lens Association of

Ophthalmologists; Emergency Department Practice Management

Association; Enlisted Association of the National Guard of

the United States; Fleet Reserve Association; Florida Medical

Association Inc.; Gold Star Wives of America; Hawaii Medical

Association; Heart Rhythm Society; Idaho Medical Association;

Illinois State Medical Society; Indiana State Medical

Association; Infectious Diseases Society of America.

International Society for Clinical Densitometry;

International Spine Intervention Society; Iowa Medical

Society; Iraq and Afghanistan Veterans of America; Jewish War

Veterans of the United States of America; Joint Council of

Allergy, Asthma and Immunology; Kansas Medical Society;

Kentucky Medical Association; Louisiana State Medical

Society; Maine Medical Association; Marine Corps League;

Marine Corps Reserve Association; Massachusetts Medical

Society; MedChi, The Maryland State Medical Society; Medical

Association of Georgia.

Medical Association of the State of Alabama; Medical Group

Management Association; Medical Society of Delaware; Medical

Society of the District of Columbia; Medical Society of the

State of New York; Medical Society of Virginia; Michigan

State Medical Society; Military Chaplains Association of

the United States of America; Military Officers

Association of America; Military Order of the Purple

Heart; Minnesota Medical Association; Mississippi State

Medical Association; Missouri State Medical Association;

Montana Medical Association; National Association for

Uniformed Services.

National Committee to Preserve Social Security and

Medicare; National Guard Association of the United States;

National Medical Association; National Military Family

Association; National Order of Battlefield Commissions; Naval

Enlisted Reserve Association; Nebraska Medical Association;

Nevada State Medical Association; New Hampshire Medical

Society; New Mexico Medical Society; Non Commissioned

Officers Association; North Carolina Medical Society; North

Dakota Medical Association; Ohio State Medical Association;

Oklahoma State Medical Association.

Oregon Medical Association; Pennsylvania Medical Society;

Renal Physicians Association; Reserve Enlisted Association;

Reserve Officers Association; Rhode Island Medical Society;

Society for Cardiovascular Angiography and Interventions;

Society for Maternal-Fetal Medicine; Society for Vascular

Surgery; Society of Critical Care Medicine; Society of

Gastrointestinal and Endoscopic Surgeons; Society of

Gynecologic Oncologists; Society of Hospital Medicine;

Society of Interventional Radiology; Society of Medical

Consultants to the Armed Forces.

South Carolina Medical Association; South Dakota State

Medical Association; Tennessee Medical Association; Texas

Medical Association; The Endocrine Society; The Retired

Enlisted Association; The Society of Thoracic Surgeons;

United States Army Warrant Officers Association; USCG Chief

Petty Officers Association; Utah Medical Association; Vermont

Medical Society; Veterans of Foreign Wars; Washington State

Medical Association; West Virginia State Medical Association;

Wisconsin Medical Society; Wyoming Medical Society.

Mr. Speaker, I reserve the balance of my time.

Announcement by the Speaker Pro Tempore

Mr. Speaker, at this time I'm delighted to yield 1 minute to the gentleman from Texas (Mr. Doggett).

Mr. Speaker, I am pleased at this time to recognize a distinguished member of the Ways and Means Committee, Mr. Neal of Massachusetts, for 1 minute.

I'd like to recognize Mr. Blumenauer from Oregon for 1 minute, but pending that, I yield myself 30 seconds to respond to my distinguished colleague and ranking member of the Ways and Means Committee that we debated this back in July, and that all of us agreed and voted for the fix that we're talking about today. And I hope that we could continue that. It was done on a bipartisan basis at that time. It was probably the only part of the bill that was bipartisan, but we did all vote for it and voted for exactly what we're talking about today, and I hope we could get those votes again.

I yield to the gentleman from Oregon (Mr. Blumenauer).

Mr. Speaker, could I inquire as to the remaining time on either side?

At this time, Mr. Speaker, I'm delighted to yield 1 minute to the distinguished gentleman from New Jersey (Mr. Pascrell).

I yield the gentleman an additional 15 seconds.

I yield myself 30 seconds, Mr. Speaker, just to remind the distinguished gentleman from Wisconsin that he and 14 of his colleagues voted for this bill in the Ways and Means Committee last July.

I don't mind mixing it up with the health care reform, but it's not. It's the doctor fix.

In just a moment, yes.

The important thing is that if we move this aside, we're correcting the mistake that was made. Let's forget about who made it. It was there.

Now this may not be the end-all correction, but there is no reason that we couldn't come back next year if we find that the formula doesn't work.

I will yield myself an additional 30 seconds.

If we don't do it and we do the 4-year fix that you, Mike, suggested, or the 3-year, and then it doesn't work, we will have $400 billion to correct.

My point is this. If we could remove it for a moment from the discussion on the overall health reform bill--which we can have a spirited discussion on--this is a technical fix which all of your members supported on a bipartisan basis.

I yield to the gentleman from Wisconsin.

Well, as I say, the gentleman supported it a few months ago.

At this point, Mr. Speaker, I'd like to yield 1 minute to the gentlelady from Nevada (Ms. Berkley).

I yield myself such time as I may consume, Mr. Speaker, to remind my distinguished friend from Louisiana that the American College of Cardiology, the Louisiana Medical Association, and most every medical association in the United States has endorsed the legislation.

I reserve the balance of my time.

Parliamentary Inquiry

Mr. Speaker, at this time I am pleased to yield 1\1/2\ minutes to the distinguished gentleman from North Carolina (Mr. Etheridge).

(Mr. ETHERIDGE asked and was given permission to revise and extend his remarks.)

Mr. Speaker, I yield to the gentlewoman from Texas (Ms. Jackson-Lee) for a unanimous consent request.

(Ms. JACKSON-LEE of Texas asked and was given permission to revise and extend her remarks.)

Mr. Speaker, I yield myself the balance of the time.

I again encourage my friends on the other side of the aisle to support this fix for the physician reimbursement. It was correct originally in our major health reform bill. The reason it was separated, I would have to admit, was purely political. We had to abide by the President's request that we did not exceed certain costs, and we separated it for that.

For those of you who suggest that the Senate may do nothing with this, I'm afraid we have to leave that to the American Medical Association and America's physicians. They will have to pressure the Senate to add this at some point in their deliberations. I think it's beyond us to do that, and my suspicion is that with the more than 150 medical societies around the country, they will be able to importune our friends on the other side of the Capitol.

Mr. Speaker, I believe that we will see a format of this bill facing us from the other side. I hope we do. We are talking about postponing any length of time increases, whether it's 4 years and we get $400 billion, whether it's a couple of years and we get $200 billion, there was a mistake made. The distinguished gentleman whom the current ranking member and I know so well is no longer with us. He is probably chuckling up his sleeve at the angst he has caused us.

But we recognize the mistake. We did try to fix it. We did try to fix it on a bipartisan basis. I know there are other issues that are tangential to this. I hope we can put these aside today. Take care of the physician fix. Hopefully we've got the formula right. As I said earlier to the distinguished gentleman from Wisconsin, we might not have it perfect, but we have some time in the next year or 2 to make those adjustments. I commit to you that we certainly will, and I hope that you would work with us to help correct it if that comes in the future so we can set this aside. It's a separate debate.

We are going to have a long and strenuous debate on health care reform as we go down toward the end of the year and into next year. And I look forward to that. But I would like to see this set aside so that we can see that the physician payment fix, which we all know has been facing us for years, is ended today and that we pass this bill.

I thank my friends on the minority side for their kindness in this debate and, Mr. Speaker, I urge passage of the bill.

I yield back the balance of my time.

I thank the gentleman for yielding only to suggest that being nice doesn't seem to get you much around here.

This motion makes a mockery of the debate. My friends on the other side simply propose the same old same old. They can't even tell us or the American people how this will affect doctors or military families or others. It is legislating in the dark.

The distinguished minority whip voted in committee enthusiastically for the bill that is before us, now seems to have forgotten and changed his mind. It is a continuation of the Republican history of mismanagement of Medicare and dishonest budget gimmicks, and I urge its opposition.

I thank the distinguished chairman for yielding, and I rise in strong support of this legislation. I want to say to my friend who has just spoken, the ranking member of the committee who chaired the committee, who said they wanted to pay for things, what this bill does is put statutory PAYGO into law. He's right. But what he didn't say to you is when their side controlled the Presidency, the House, and the Senate, they jettisoned paying for things. They did away with statutory PAYGO, they did away with PAYGO generally, and what happened? We went from substantial surpluses under the Clinton administration to substantial deficits under the Bush administration.

Now we were told those substantial deficits and deficits that were being created would create economic growth in our country. In point of fact, however, after 8 years of that economic policy where they jettisoned PAYGO, a PAYGO which provided $5.6 trillion of surplus available in March 2001, according to President Bush; but they abandoned PAYGO, which is in this bill.

This is not a question of payoff to anybody. This was in the President's budget when he sent it down here earlier this year. It was in our budget that passed the House and the Senate. We said we were going to do this. Why? Because it's the right thing to do. Today, we have the chance to vote for health care our seniors can count on and a fiscal future for all Americans that they can have faith in.

Very frankly, my friend also said, We on the Republican side want to fix this. My question is simply: Why didn't you? Why do we still have this issue that confronts us year after year after year because we didn't have the courage to face it? I'm going to talk about the deficit, because this adds to the deficit. I will lament that, but there is not an option, as you added to the deficit every time you fixed it one year at a time. Doctors couldn't rely on it. More importantly, seniors couldn't rely on the fact that their doctors wouldn't have a big cut and push them out. I'm going to talk about that as well. We can do it by stopping a massive Medicare payment cut and by committing future policies to the tested principle of pay-as-you-go.

Now my friends on the other side of the aisle don't like pay-as-you- go because it constrained them in cutting revenues over a trillion dollars, which is one of the reasons we have such a large deficit, because they didn't pay for what they bought. Interestingly enough, my friends, they bought at a rate twice the growth in spending that occurred during the 1990s, in the 2000s, which was about 3\1/2\ percent per year. It was 7 percent a year when my friends on the other side of the aisle controlled all of the levers of power. So they decreased revenue and increased spending, and we had large deficits and the biggest recession we have faced since the 1930s were inherited by this administration and, frankly, by this Congress.

Now going back to the pay-as-you-go. First, the Medicare payment rate cut, if we do nothing, payments to doctors treating Medicare patients will drop by 21 percent in the new year with more cuts in the years to come. If we allow that to take place, many seniors will find their doctors no longer available to treat them.

So this is not only about compensating doctors for the services that are vitally important and we want them to give, but it is also protecting seniors' access to doctors. That will mean less access to health care, longer waiting lists, and serious conditions going untreated and.

In sum, if we do not act on this bill, it will mean sicker seniors. That's why it's essential that we stop these cuts before they're allowed to take effect. The cuts, of course, will occur on January 1 of this year, approximately 1 month from today.

It is important to remember that this bill would simply prevent cuts, not increase payments to doctors. But it is true that ensuring our seniors' access to their doctors will add to our deficit, just as extending any of the Bush tax cuts that are set to expire next year would do. Because seniors' health is at stake in this bill, I believe that stopping these payment cuts is worth the cost.

It's also worth pointing out that this bill represents a new honesty in budgeting. As far as Democrats are concerned, the days of pretending that the costs of the ``doctor fix'' will be made up by even deeper cuts next year are over. That, of course, is a policy we followed in the first 8 years of this decade. We pretended that somehow we'd

fix it later, and we never did. Indeed, most of the costs associated with this bill are the result of stopping the gimmicks that were used for years and cleaning up the mess created by those gimmicks. The first step to getting out of debt is being honest about the debt we're in. It is too deep, it is dangerous, and we need to address it.

So let's be honest. Our country is in a deep fiscal hole for reasons that go far beyond Medicare payments. In fact, there's no one reason for our record national debt. It's bipartisan in nature, not exclusively Republican or Democrat.

The causes include the previous administration's debt financed tax cuts, which I've spoken of, for America's essentially wealthier citizens who got most of the tax cuts; the cost of two wars, which we did not pay for; our escalating entitlements programs, which all of us have supported; the recession that we have confronted and that started in the seventh year of the previous administration's term; and the deficit spending--and we need to clean up that economic mess; spending that economists tell us is necessary to stimulate demand and recession.

In other words, we needed to spend the money to preclude a depression, not just a deep recession that we're in, and almost every economist, including Marty Feldstein, said that that was necessary.

A recent New York Times analysis tells us that 90 percent of our deficit has been brought about by the policies of the previous administration and the extension of its policies and the economic crisis that it left behind.

No one step will get us out of our fiscal hole, but the most important immediate step we can take is to commit ourselves to the principle that in new policies of our country, we will pay for what we buy. That is the principle of pay-as-you-go, or PAYGO, which was in place in the 1990s as we went from deep debt into surplus and that $5.6 trillion surplus that President Bush inherited in 2001. In the 1990s, President Clinton used it to turn huge deficits into a record surplus, and when President Bush abandoned PAYGO, and my friends on the other side of the aisle abandoned PAYGO, record deficits returned.

When Democrats took back the House majority in 2006, we demonstrated our commitment to fiscal responsibility by making PAYGO a part of the House rules. It's sometimes been difficult. And now with the support from President Obama and both Chambers of Congress, we have a real chance to give PAYGO the force of law by passing this bill. Under PAYGO, Congress will be forced to offset all new policies reducing revenues or expanding entitlements, so that they add nothing to our deficit.

In essence, we will be forced to make the hard budgeting choices that are so tempting to avoid. We are avoiding them today. We ought to admit that very honestly. Why are we doing it? Because as a practical matter, in the deep recession that we're in, we cannot pay for it without depressing the economy further.

That is not an acceptable alternative. If we want to cut taxes, we'll have to explain which programs will suffer cuts. If we want to expand entitlements, we'll have to spell out how we are going to pay for it. And no matter which party is in power, we'll be forced to distinguish wasteful spending and subsidies from the long-term priorities that really matter to our country.

Some have explained that statutory PAYGO would not apply to extensions of some existing policies that have bipartisan support, one of which is the one we're talking about today. Policies on the alternative minimum tax, which we've already done. And by the way, I am one of those--wasn't in the majority--who voted against extending the alternative minimum tax if we did not pay for it. In addition to that, Medicare doctor payments, which we're talking about today, and the estate and middle-income tax cuts passed in 2001 and 2003.

I sympathize with their concerns. They are not specious concerns. I have said repeatedly that I would fight to pay for all of these policies. Hear me, if the Senate sends this back paid for, I will support it. I challenge all of you on that side of the aisle and all of you on this side of the aisle to do the same. That stands in contrast, frankly, to the first 8 years of this decade, when repeatedly it was stated that they do not believe that extensions of tax cuts need to be paid for.

Unfortunately, it's a political reality that the votes to pay for extensions of the Bush policies are most likely not there. A PAYGO law that ignored that fact would be waived for those policies and then again and again. I prefer a law that we can enforce consistently. And very frankly, that is supported by some of the most consistent voters for fiscal responsibility on this floor.

Mr. Speaker, in our country's economic meltdown last year, we all saw the damage that deep debt can do. It's time for our Federal Government to learn that lesson and act on it. If we fail to act, liberal and conservative, Democratic and Republican, priorities will suffer alike. We can still prevent that outcome, ladies and gentlemen of this House. We cannot get back to fiscal health in one afternoon's vote, and we will not, perhaps not in this President's term or the next, but we must start. We must take a step toward that end.

This bill does that. It supports not only ensuring our seniors access to quality medical services but also ensures that we, again, adopt the policy that brought us $5.6 trillion in surplus.

Parliamentary Inquiry

Mr. Speaker, pursuant to House Resolution 903, I call up the bill (H.R. 3961) to amend title XVIII of the Social Security Act to reform the Medicare SGR payment system for physicians, and ask for its immediate consideration.

Mr. Speaker, I yield myself 3 minutes.

Today, we consider legislation that will maintain and strengthen Medicare for seniors and individuals with disabilities. A law passed in 1997 set a limit on payments to Medicare physicians. The idea was to save money, but the limit was set too low and required draconian cuts, forcing Congress to intervene with temporary fixes.

In 2004, the law required a 4.5 percent cut. In 2008, it was a 10.1 percent cut. This year, doctors face a 21 percent cut. These are unsustainable cuts that would bring about havoc in the Medicare program. Congress has responded by enacting temporary 1-year fixes. These temporary fixes only make the problem worse the next year. The result has been a cycle of ever increasing cuts followed by ever costlier fixes.

This is not a problem of mere budget or fiscal discipline; it is a kitchen table problem for America's seniors and for the physicians who are partners in the Medicare program. Medicare's ability to guarantee health care for seniors would be eliminated if these cuts went into effect.

We are rightly asking much of the health care providers in health reform. We are demanding they provide care more efficiently, that they improve the quality of care, and that they give taxpayers good value for their dollars. In return, we need to pay them fairly for their efforts and to be an honest partner. We have two basic choices. We can solve this problem permanently or we can enact another 1-year Band-Aid. This legislation says that we will finally enact a lasting reform.

The House recognized in our budget that honest accounting means facing this problem squarely and finding a way to address it. This legislation meets that call, replacing the sustainable growth rate for physicians, or SGR, which Congress enacted in 1997, with a more responsible and stable system for the future. We must be honest about this problem and address it responsibly and immediately. We can take that step today by passing this bill and combining it with statutory PAYGO, which will help restore fiscal discipline.

I urge Members to support adoption of this bill and reserve the balance of my time.

Mr. Speaker, I'm pleased at this point to yield 1 minute to the distinguished majority leader to speak on the legislation, the gentleman from Maryland (Mr. Hoyer).

Mr. Speaker, I yield myself 1 minute.

I do want the American people to understand the Republican position, because this is what they would do to Medicare. If we didn't have health reform, we still have to deal with the problem we are having with Medicare, where millions of seniors are relying on that program. And if they produce a 20 percent cut in physician fees, the people in Medicare will not be able to get access to doctors. That means that if we don't deal with the whole health care system and hold down the costs, and we don't do health reform, Medicare will face deeper and deeper cuts, and the Republicans are giving a clear indication of that's exactly what they would do.

Mr. Speaker, I yield 2 minutes to our champion on health reform, the gentleman from Michigan (Mr. Dingell).

(Mr. DINGELL asked and was given permission to revise and extend his remarks.)

Mr. Speaker, I am pleased at this time to yield 2 minutes to the gentleman from New Jersey (Mr. Pallone), the chairman of the Health Subcommittee of the Energy and Commerce Committee.

Mr. Speaker, I am pleased to yield 2 minutes to the chairman of the House Budget Committee, the gentleman from South Carolina (Mr. Spratt).

I yield the gentleman an additional 1 minute.

Mr. Speaker, I am pleased at this time to yield 1 minute to the gentleman from New York (Mr. Engel), an important member of our committee.

Mr. Speaker, I am pleased at this time to yield 1 minute to the gentleman from Maryland (Mr. Sarbanes), a member of the Energy and Commerce Committee and the Health Subcommittee.

Mr. Speaker, I yield myself 1 minute.

I want to point out to my colleagues while we're blaming each other on a partisan basis that the reason we got into this situation is in 1997 with a Republican Congress and a Democratic President, there was a so-called balanced budget proposal adopted, and the way it was funded for tax cuts was to make future cuts in Medicare, especially in the physician payment side. We are paying the price of that poorly thought- through approach, which was the reason I voted against that bill in 1997.

The gentleman from Texas made some points about the situation we're in. What he did not point out is that this bill is part of a comprehensive improvement in our health care system. It would reward primary care. It would provide for accountability care organizations, which would be a better delivery mechanism. This ought to be looked at in a more comprehensive way.

That's why I'm pleased to support this bill today and the health care reform bill that the House passed a week or so ago, and we hope to complete our actions with the Senate later this year.

Mr. Speaker, I yield the balance of my time to the Ways and Means Committee chairman, the gentleman from New York (Mr. Rangel), and I ask unanimous consent that he be allowed to control that time.

Mr. Speaker, I ask unanimous consent that all Members may have 5 legislative days in which to revise and extend their remarks and include extraneous material on H.R. 3961.

Mr. Speaker, I reserve a point of order.

I object.

Mr. Speaker, pursuant to clause 7 of House rule XVI, matters within the motion to recommit are not germane to the underlying bill, and I insist on my point of order.

Mr. Speaker, I don't believe the gentleman's argument is pertinent to the point of order. I insist on my point of order.

Mr. Speaker, I insist on my point of order.

Mr. Speaker, I move to table the appeal of the ruling of the Chair.

Mr. Speaker, I rise in opposition to the motion to recommit.

Mr. Speaker and my colleagues, this motion to recommit proposes to spend $22.3 billion for a $210 billion problem. It simply postpones the problem. It is the same old kicking the can down the road. There are no guarantees of cuts when this money runs out. The gentleman from Virginia says his proposal would mean no cuts for 2 years. I am not convinced of that 2-year period. But whatever period of time it would allow for, there would be another cliff, and that is why the American Medical Association wrote to the Honorable Dave Camp, ranking member of the Ways and Means Committee, that they oppose anything short of permanent reform. They want us to deal with this problem now and not just kick it down the road. The AMA does not support any motion to recommit that would have a temporary fix.

I want to yield at this time to the gentleman from California (Mr. Stark).

Mr. Speaker, I yield to the gentleman from Florida (Mr. Boyd).

Mr. Speaker, I urge a ``no'' vote on the motion to recommit and an ``aye'' vote on the underlying bill, and I yield back the balance of my time.

Parliamentary Inquiries

Mr. Speaker, I demand a recorded vote.

Thank you very much, Mr. Stark.

I rise to support H.R. 3961 because it provides a payment for our doctors, allows seniors to keep their doctors, and is paid for.

Mr. Speaker, I am pleased to stand before you today in support of the Medicare Physician Payment Reform Act. This bill, which will finally put an end to the cycle of threats of larger and larger fee-cuts followed by short-term fixes, is long overdue. This bill will repeal a 21 percent fee reduction that currently scheduled right around the corner, January 2010.

Given the fact that Healthcare reform has been, and still is, a very lively and relevant topic over the recent months, the timing of this bill is apropos in that is intended to make our nations healthcare system more efficient. The importance of this bill is evidenced by its widespread support from a range of organizations representing both patients and doctors, including the American Medical Association, AARP, and the American Academy of Family Physicians just to name a few. Their support shows that there has been a need for better management of the Medicare system, and this bill presents the sustainable solution that physicians and patients alike have been looking for.

Proper management of Medicare funding ensures that the Medicare system will be able to properly support the medical needs of its intended beneficiaries. This bill will help promote the use of primary care and give access to the use of primary care practitioners in Medicare and throughout the healthcare system. By providing incentives to physicians, this bill will also encourage integrated care and increased communications amongst doctors on the care of their specific patients. These improvements to the Medicare system will result in a higher quality of care and ultimately, a healthier population of patients.

With so many Americans currently uninsured or receiving inadequate healthcare, it is paramount that the funds set aside to support Medicare are used wisely to provide the best possible care for patients.

In my home state of Texas, the need for a more efficient healthcare is more prevalent now than ever. One in four Texans, about 5.7 million people, or 24.5 percent of the state's population, has no health insurance coverage. An estimated 1,339,550 Texas children--20.2 percent of Texas children--are uninsured. According to the U.S. Census Bureau, Texas has the nation's highest percentage of uninsured residents. This poses consequences for every person, business and local government in the state who bear extra costs to pay for uncompensated care. If Medicare funding is allowed to be cut or capped, the number of uninsured will grow dramatically.

I realize that we must consider budgetary concerns while we champion the push for better quality healthcare, and the Medicare Physician Payment Reform Act does just that. It was drafted with fiscal responsibility in mind. We want to protect both the medical and fiscal health of our people and this bill takes steps to do just that. The cost of the bill is already included in the House-passed and President's budgets. This money represents the ongoing care and maintenance of the Medicare program. The legislation fully complies with the House-passed PAYGO requirements because the PAYGO legislation explicitly accommodates physician reform legislation that is designed to maintain current spending. As such, the bill, while it contains new reforms, represents continuation of an existing policy rather than new spending. H.R. 3961 will be coupled with Statutory PAYGO legislation when it is sent to the Senate.

The cost of addressing this problem will only grow in the future. In 2005 a permanent freeze for physician payments was scored as costing $48.6 billion; today, a policy with a similar score costs $210 billion. Delays today mean larger and larger price tags in the future and continuing damage to the Medicare program. Therefore prompt action on this issue is necessary and must be taken.

As we talk about fixing the issue of Medicare payments to physicians, this raises similar fixes that I proposed in H.R. 3962--The America's Affordable Health Choices Act of 2009. Specifically, I proposed two changes to Section 1156 of H.R. 3962, to prevent existing physician- owned hospitals from being forced out of business, amendments that enjoyed bi-partisan support. First, to avoid harming existing physician-owned hospital projects, I proposed extending the date of the grandfathering provision of Section 1156 to

January 1, 2011 and by strengthening the requirements for Hospitals to qualify for an extension. Next, I suggested that we extend the cut-off date for determining the baseline number of beds and procedure rooms for purposes of the expansion prohibition (currently, date of enactment) to the same date proposed or the grandfathering provision.

Along with this, I share the concerns of health advocates that, as is, the public option in H.R. 3962 is not equipped to provide real competition to large mega insurance plans. As such, I proposed that H.R. 3962 incorporate Congressman Kucinich's proposal to allow states to choose public insurance options more robust than the Federal plan.

I look forward to working with the leadership going forward to fix these items along with a system that each year cuts Medicare reimbursements to Physicians.