Medicare Payment Advisory Commission (MedPAC) Reform Act of 2009

Mr. Speaker, each generation has had to take up the question of how to provide for the health of the people of our nation. And each generation has grappled with difficult questions of how to meet the needs of our people. I believe health care is a civil right. Each time as a nation we have reached to expand our basic rights, we have witnessed a slow and painful unfolding of a democratic pageant of striving, of resistance, of breakthroughs, of opposition, of unrelenting efforts and of eventual triumph.

I have spent my life struggling for the rights of working class people and for health care. I grew up understanding first hand what it meant for families who did not get access to needed care. I lived in 21 different places by the time I was 17, including in a couple of cars. I understand the connection between poverty and poor health care, the deeper meaning of what Native Americans have called ``hole in the body, hole in the spirit.'' I struggled with Crohn's disease much of my adult life, to discover sixteen years ago a near-cure in alternative medicine and following a plant-based diet. I have learned with difficulty the benefits of taking charge personally of my own health care. On those few occasions when I have needed it, I have had access to the best allopathic practitioners. As a result I have received the blessings of vitality and high energy. Health and health care is personal for each one of us. As a former surgical technician I know that there are many people who dedicate their lives to helping others improve theirs. I also know their struggles with an insufficient health care system.

There are some who believe that health care is a privilege based on ability to pay. This is the model President Obama is dealing with, attempting to open up health care to another 30 million people, within the context of a system run by insurance companies who make money by denying care. There are others who believe that health care is a basic right and ought to be provided through a not-for-profit plan. This is what I have tirelessly advocated.

I have carried the banner of national health care in two presidential campaigns, in party platform meetings, and as co-author of H.R. 676, Medicare for All. I have worked to expand the health care debate beyond the current unsustainable system, to include a robust public option and my amendment to free the states to pursue single-payer. An early version of the health care bill, while badly flawed, contained these provisions which I believed made the bill worth supporting when it was considered by the Committee on Education and Labor. I voted for it. The provisions were taken out of the bill after it passed the Committee.

I joined with the Congressional Progressive Caucus in saying that I would not support the bill unless it had a strong public option and unless it protected the right of people to pursue single payer at a state level. It did not. I kept my pledge and voted against the bill when it was considered by the full House of Representatives. Since then, I have continued to oppose it while trying to get the provisions back into the bill. Some have speculated that, as the final vote on this health care package drew closer, I might have been in a position of casting the deciding vote. The President's visit to my district on Monday underscored the urgency of this moment.

I have taken this fight further than many in Congress cared to carry it because I know what my constituents experience on a daily basis. Come to my district in Cleveland and you will understand.

The people of Ohio's 10th district have been hard hit by an economy where wealth has accelerated upwards through plant closings, massive unemployment, small business failings, lack of access to credit, foreclosures and the high cost of health care and limited access to care. I take my responsibilities to the people of my district personally. The focus of my district office is constituent service, which more often than not involves social work to help people survive economic perils. It also involves intervening with insurance companies.

In the two weeks before the vote on the final health care package, it became clear that the vote would be very close. I take this vote with the utmost seriousness. I am quite aware of the historic fight that has lasted the better part of the last century to bring America in line with so many other modern democracies in providing single-payer health care. I have seen the political pressure and the financial pressure being asserted to prevent a real challenge to a highly profitable system dominated by private insurance companies.

I know I have to make a decision, not on the bill as I would like to see it, but the bill as

it is. My criticisms of the legislation have been well reported. I do not retract them. I incorporate them in this statement. They still stand as legitimate and cautionary. I still have doubts about the bill. I do not think it is a first step toward anything I have supported in the past. This is not the bill I wanted to support, even as I continue efforts until the last minute to modify the bill.

However after careful discussions with President Obama, Speaker Pelosi, my wife Elizabeth, the frequently personal and tragic stories of my constituents and close friends, I have decided to cast a vote in favor of the legislation. If my vote is to be counted, let it now count for passage of the bill, hopefully in the direction of comprehensive health care reform. We must include coverage for those excluded from this bill. We must free the states. We must have control over private insurance companies and the cost their very existence imposes on American families. We must strive to provide a significant place for alternative and complementary medicine, religious health science practice, and the personal responsibility aspects of health care which include diet, nutrition, and exercise.

The health care debate has been severely hampered by fear, myths, and by hyper-partisanship. The President clearly does not advocate socialism or a government takeover of health care. The fear that this legislation has engendered has deep roots, not in foreign ideology but in a lack of confidence, a timidity, mistrust and fear which post 911 America has been unable to shake.

This fear has so infected our politics, our economics and our international relations that as a nation we are losing sight of the expanded vision, the electrifying potential we caught a glimpse of with the election of Barack Obama. The transformational potential of his presidency, and of ourselves, can still be courageously summoned in ways that will reconnect America to our hopes for expanded opportunities for jobs, housing, education, peace, and yes, health care.

I want to thank those who have supported me personally and politically as I have struggled with this decision. I ask for continued support in our ongoing efforts to bring about meaningful change. I have taken a detour through supporting this bill, but I know the destination I will continue to seek, for as long as it takes, whatever it takes, is an America where health care will be firmly established as a civil right.

Empowering individuals

Smart personal choices in areas like diet, nutrition, and exercise are essential to a healthier world. At the same time, we must remove the barriers and change the incentives that discourage or prevent responsible behavior. The Institute of Medicine estimates that in 2004 approximately $10 billion was spent on food advertising directed at children, using every method available--television, radio, the internet, even embedded in video games. Simply put, marketing to children works--companies would not make such a substantial investment if it were ineffective.

Marketing directed at youth is extremely well constructed and relies heavily on behavioral science. The developing brain of the child can not discriminate fact from opinion and can not think critically; it is no match for a $10 billion industry that exploits this vulnerability using cartoons, cross branding with popular toys, giveaways, and myriad other methods to develop brand loyalty and shape judgment as early as possible. Established early, these affinities are the most enduring.

Astonishingly, the Federal Government subsidizes this methodical preying on children by granting a tax write-off for expenses associated with it. This must stop. The government must take action to protect American children and ensure that they grow up in a healthy environment. My bill, H.R. 4310, would eliminate the tax deductibility of fast food and junk food advertising directed at children. H.R. 4310 has the potential to raise billions of dollars in revenue to fund child nutrition and anti-obesity initiatives.

There is precedent: approximately 50 countries, including Sweden, Norway, Australia, and Great Britain, have limited or prohibited food advertising directed at youth. Additionally, recent research has concluded that eliminating the tax deductibility of food advertising directed at youth would reduce obesity rates. Long-term health care reform must address the personal responsibility, the corporate responsibility, and the government's fair share of the responsibility for improved health. I will work to ensure that is the case.

Each generation has had to take up the question of how to provide for the health of the people of our nation. And each generation has grappled with difficult questions of how to meet the needs of our people. I believe health care is a civil right. Each time as a nation we have reached to expand our basic rights, we have witnessed a slow and painful unfolding of a democratic pageant of striving, of resistance, of breakthroughs, of opposition, of unrelenting efforts and of eventual triumph.

I have spent my life struggling for the rights of working class people and for health care. I grew up understanding first hand what it meant for families who did not get access to needed care. I lived in 21 different places by the time I was 17, including in a couple of cars. I understand the connection between poverty and poor health care, the deeper meaning of what Native Americans have called ``hole in the body, hole in the spirit.'' I struggled with Crohn's disease much of my adult life, to discover sixteen years ago a near-cure in alternative medicine and following a plant-based diet. I have learned with difficulty the benefits of taking charge personally of my own health care. On those few occasions when I have needed it, I have had access to the best allopathic practitioners. As a result I have received the blessings of vitality and high energy. Health and health care is personal for each one of us. As a former surgical technician I know that there are many people who dedicate their lives to helping others improve theirs. I also know their struggles with an insufficient health care system.

There are some who believe that health care is a privilege based on ability to pay. This is the model President Obama is dealing with, attempting to open up health care to another 30 million people, within the context of the for-profit insurance system. There are others who believe that health care is a basic right and ought to be provided through a not-for-profit plan. This is what I have tirelessly advocated.

I have carried the banner of national health care in two presidential campaigns, in party platform meetings, and as co-author of H.R. 676, Medicare for All. I have worked to expand the health care debate beyond the current unsustainable system, to include a robust public option and my amendment to free the states to pursue single-payer. An early version of the health care bill, while badly flawed, contained these provisions which I believed made the bill worth supporting when it was considered by the Committee on Education and Labor. I voted for it. The provisions were taken out of the bill after it passed the Committee.

I joined with the Congressional Progressive Caucus in saying that I would not support the bill unless it had a strong public option and unless it protected the right of people to pursue single payer at a state level. It did not. I kept my pledge and voted against the bill when it was considered by the full House of Representatives. Since then, I have continued to oppose it while trying to get the provisions back into the bill. Some have speculated that, as the final vote on this health care package drew closer, I might have been in a position of casting the deciding vote. The President's visit to my district on Monday underscored the urgency of this moment.

I have taken this fight further than many in Congress cared to carry it because I know what my constituents experience on a daily basis. Come to my district in Cleveland and you will understand.

The people of Ohio's 10th district have been hard hit by an economy where wealth has accelerated upwards through plant closings, massive unemployment, small business failings, lack of access to credit, foreclosures and the high cost of health care and limited access to care. I take my responsibilities to the people of my district personally. The focus of my district office is constituent service, which more often then not involves social work to help people survive economic perils. It also involves intervening with insurance companies.

In the two weeks before the vote on the final health care package, it became clear that the vote would be very close. I take this vote with the utmost seriousness. I am quite aware of the historic fight that has lasted the better part of the last century to bring America in line with so many other modern democracies in providing single-payer health care. I have seen the political pressure and the financial pressure being asserted to prevent a real challenge to a highly profitable system dominated by private insurance companies.

I know I have to make a decision, not on the bill as I would like to see it, but the bill as it is. My criticisms of the legislation have been well reported. I do not retract them. I incorporate them int this statement. They still stand as legitimate and cautionary. I still have doubts about the bill. I do not think it is a first step toward anything I have supported in the past. This is not the bill I wanted to support, even as I continue efforts until the last minute to modify the bill.

However after careful discussions with the President Obama, Speaker Pelosi, my wife Elizabeth, and in consideration of the frequently personal and tragic stories of my constituents, I have decided to cast a vote in favor of the legislation. If my vote is to be counted, let it now count for passage of the bill, hopefully in the direction of comprehensive health care reform. We must include coverage for those excluded from this bill. We must free the states. We must have control over private insurance companies and the cost their very existence imposes on American

families. We must strive to provide a significant place for alternative and complementary medicine, religious health science practice, and the personal responsibility aspects of health care which include diet, nutrition, and exercise.

The health care debate has been severely hampered by fear, myths, and by hyper-partisanship. The President clearly does not advocate socialism or a government takeover of health care. The fear that this legislation has engendered has deep roots, not in foreign ideology but in a lack of confidence, a timidity, mistrust and fear which post 911 America has been unable to shake.

This fear has so infected our politics, our economics and our international relations that as a nation we are losing sight of the expanded vision, the electrifying potential we caught a glimpse of with the election of Barack Obama. The transformational potential of his presidency, and of ourselves, can still be courageously summoned in ways that will reconnect America to our hopes for expanded opportunities for jobs, housing, education, peace, and yes, health care.

I want to thank those who have supported me personally and politically as I have struggled with this decision. I ask for continued support in our ongoing efforts to bring about meaningful change. As this bill passes I will renew my efforts to help those state organizations which are aimed at stirring a single payer movement which eliminates the predatory role of private insurers who make money not providing health care. I have taken a detour through supporting this bill, but I know the destination I will continue to seek, for as long as it takes, whatever it takes, is an America where health care will be firmly established as a civil right.

moving Toward True Health Care Reform

In pursuing meaningful change in the health care system, there can be no better investment than to remove federal barriers to allowing states to implement the only model of health care proven to cover everyone, lower costs and increase quality: single-payer.

Systems that remove the insurance companies from care are well tested and consistently outperform systems that rely on private insurance. Their costs are lower, their access is universal, the coverage is comprehensive, and their systems are far more equitable. Such a single- payer health care system would also provide major economic stimulus. Half of all bankruptcies in the U.S. are the result of the failure of an insurance plan to do the very thing that drives us to buy health insurance--protect us from catastrophic financial burdens that arise from health care needs. Only single-payer health care can rid us of the economic drag of medical bankruptcies by providing truly comprehensive coverage--for less money than we are currently paying.

It is no wonder then that states are demanding single payer. Not only does it help people stay out of poverty, but it would provide major relief for states facing budget difficulties. The Lewin Group's financial analysis of the California single payer bill that recently passed the legislature twice found that ``the net cost of the program to state and local governments is a savings of about $900 million'' in 2006 alone. There are also strong single payer movements in Pennsylvania, New York, Illinois, Colorado, and New Mexico. In fact, the savings to a state from a single-payer plan have been well documented. Fourteen states are listed below, along with their savings and the year of the applicable study. The worst-case scenario is Maine, which would break even.

State: Annual Single-payer Savings--Year

New Mexico (Lewin Group): $151,800,000--1994

Delaware (Solutions for Progress): $229,000,000--1995

Minnesota (Lewin Group): $718,000,000--1995

Massachusetts (Lewin Group, Solutions for Progress/Boston

University School of Public Health): $1,800,000,000--

$3,600,000,000--1998

Maryland (Lewin Group): $345,000,000--2000

Vermont (Lewin Group): $118,000,000--2001

California (Lewin Group): $7,500,000,000--2002

Maine (Mathemetica Policy): $0--2002

Rhode Island (Solutions for Progress/Boston University

School of Public Health): $270,000,000--2002

Missouri (Missouri Foundation for Health): $1,700,000,000--

2003

Georgia (Lewin Group): $716,000,000--2004

California (Lewin Group): $8,000,000,000--2005

Colorado (Lewin Group): $1,400,000,000--2007

Kansas (Lewin Group): $869,000,000--2007

The Employee Retirement Income Security Act (ERISA) has been used to thwart efforts at the state and regional level to improve health care. Though the law was intended to protect the integrity and quality of employee benefit plans including health care, ERISA has been used in courts to stop or make impractical health care reform efforts in Maryland, San Francisco, and Suffolk County, New York. It is the most difficult federal barrier a single-payer state will face, though there will be others.

I will continue to work to help these states. We must yield to the wishes of those in a state who demand a health care system that is proven to work well. It would be entirely voluntary. If a state wants better health care than can be provided by the federal government, the federal government should not stand in their way.

Public Option

A robust public option is not sufficient to control costs, cover everyone, and increase quality of care. However, it is a good interim option for those who do not want to be subject to the abuses of the insurance companies but are required to purchase health insurance under the health care bill we are passing today. The extreme inefficiency of the private health insurance companies and the inefficiency they cause throughout the health care system are well documented. Americans need refuge because the health insurance companies are ruthlessly efficient at one thing: denying care. They have to be because that is how they make money.

In the short term, I will continue to fight for a strong public option until a single payer plan is in place.

Integrative Medicine and Religious Health Care

A 2008 study by the National Center for Complementary and Alternative Medicine at the National Institutes of Health and the National Center for Health Statistics revealed that 38% of American adults used some form of integrative medicine to meet their health care needs. However, access to these services is limited because of lack of insurance coverage of these safe, cost-effective and clinically effective medical approaches. Some of those modalities include chiropractic care, acupuncture and many others under study at the National Institutes of Health.

However, some insurance companies are starting to realize that it is beneficial to their bottom line if they cover some integrative medicine approaches. More and more plans are covering chiropractic and acupuncture, for example. The medical literature abounds with studies showing that the cost-effectiveness of interventions like transcendental meditation for hypertension and heart disease is far better than that for conventional pharmaceutical interventions.

An early version of the health care overhaul bill included my amendment that would guarantee that a practitioner of integrative medicine is one of the people that decides the minimum required benefit package. It also created a task force of integrative medicine practitioners to help inform the decision makers about what should be covered. Finally, it required that when a patient goes to the Exchange website and looks up doctors, practitioners of integrative medicine are easily identifiable. Though the language was removed before a vote on the bill was taken by the full House of Representatives, I will continue to work to advance integrative medicine by increasing its accessibility and safety.

Under this bill, most Americans, including people who practice other distinctive approaches to health care, are forced to buy private health insurance. I recognize the difficult position for Christian Scientists and others similarly situated. Millions opt for spiritual care that coincides with their religion. But as of today, even though the care they prefer is covered by Medicare, Medicaid, TRICARE and some plans available to federal government employees, few private insurance plans cover it. The new healthcare legislation we are considering today does not prevent insurance companies from covering their care; it also does not create a pathway for its serious consideration by insurance companies. I look forward to helping to identify a way to ensure that spiritual and integrative care get a fair chance at coverage by insurance companies.

Mr. Speaker, this week, I had the honor and privilege of joining my Democratic colleagues at the White House, to witness President Barack Obama sign into law, the Patient Protection and Affordable Care Act (H.R. 3590)--the most significant piece of health care legislation since the enactment of Medicare in 1965.

This legislation fulfills one of the most basic tenets of the Declaration of Independence--the provision of our natural unalienable rights of life, liberty and the pursuit of happiness. H.R. 3590 secures these rights for every American by ensuring them access to quality, affordable healthcare.

While waiting for President Obama to sign the legislation, I thought about the thousands of families and friends who have lost loved ones because they lacked access to basic health care coverage.

I also thought about the generations of activists and policy makers who fought to make this monumental achievement a reality.

I have always been proud to be a Member of Congress but voting in favor H.R. 3590 and being present at the signing ceremony was by far my proudest moment.

By signing this legislation into law, President Obama ensured that the United States remains a leader among industrialized nations, and that the American people can now take comfort in knowing that an illness will no longer wipeout their life savings and lead to bankruptcy.

Although the idea of providing people with access to quality, affordable health care has been around since the early 1900s, it was the Democratic-led 111th Congress that made the historic statement that healthcare is in fact a right, not a privilege.

We affirmed to millions of Americans that we are aware of their struggles and that we are willing to fight for them and do what is morally and fundamentally right.

During the November 2008 election, Americans overwhelmingly voted for change.

They demanded a government willing to stand up to big business, and that is transparent in its actions.

But above all else, people demanded a government that is willing to be responsive to their needs--and we affirmed their trust in us by passing this legislation.

Is the legislation perfect? No!

I still favor a single payer system and I was a strong supporter of the public option.

That being said, H.R. 3590 is 100 percent better than what was previously available in this nation.

Prior to the enactment of this legislation:

Over 47 million Americans were uninsured. In 2008, 23 million uninsured were employed adults and 7.3 million were children;

Nearly 41 thousand people died each year because they lacked access to quality, affordable healthcare insurance; and

Every minute, 8 people were denied coverage, charged a higher rate, or otherwise discriminated against because of a pre-existing condition.

If Congress had not successfully passed this legislation:

Employers would be unable to afford rising health care costs, and an additional 3.5 million people would be unemployed and without benefits in the next 4 years.

Small businesses would lose $52.1 billion in profits to high health care costs over the next ten years; and

By 2019, national health care expenditures would reach $4.5 trillion--more than double 2007 spending.

The American people have waited for over 100 years for this legislation and this is what they will get immediately:

We provide tax credits to small businesses to make employee coverage more affordable;

$250 will be provided to Medicare beneficiaries who hit the ``donut hole'' in 2010;

Within 90 days, Americans who are uninsured because of a pre-existing condition will be able to obtain insurance through a temporary high- risk pool;

Within 6 months, insurance companies will be prohibited from denying coverage to children with pre-existing conditions;

Health plans will be required to allow young people up to their 26th birthday to remain on their parents' insurance policy;

Health plans will be prohibited from dropping people from coverage when they get sick;

Health plans will be prohibited from placing lifetime caps on coverage; and

Beginning January 2011, preventive services under Medicare will be free.

To put it simply, Congress met its moral obligation in passing healthcare reform. With our historic vote, we told future generations that no American will suffer and die because of a lack of insurance.

We told insurance companies that, while they are a valuable part of our nation, they will be held accountable for delivering on their promises.

We told our elderly that our commitment to them remains strong, and that the programs they have come to trust will continue to be deserving of that trust.

The reform we passed will help millions of Americans.

In addition to providing access to health care coverage, H.R. 3590 goes far in addressing health care disparities in our nation's minority communities.

Specifically, it includes language that I introduced with Representative Jesse Jackson, Jr., (D-Ill.) H.R. 2778, the Health Equity and Accountability Through Research Act.

This legislation sought to elevate the National Center on Minority Health and Health Disparities (NCMHD) to the level of Institute, giving it the authority to better address the appalling health disparities that are plaguing our nation's minority communities.

NCMHD was created to promote minority health and to lead, coordinate, and assess the efforts of the National Institutes of Health (NIH) in reducing and to ultimately eliminate health disparities.

Unfortunately, the previous structure of NCMHD created confusion regarding who has the responsibility for the coordinated minority health disparities research conducted or supported by NIH.

Additionally, NCMHD lacked real input into and authority over all NIH-supported health disparities activities and funds.

H.R. 3590 addressed these concerns by elevating the Center to the level of Institute, and clarifies the role of the Director as coordinator and manager of the NIH-wide minority health and health disparities portfolio.

The bill also provides the new Institute with professional judgment over NIH-wide minority health and health disparities budgets as well as management over NIH-wide minority health and health disparities allocations.

However, this is not the only improvement that minority and underserved communities will see.

This comprehensive healthcare package also includes $11 billion for community health centers, which offer comprehensive primary care and mental health services to underserved populations. These health centers are a critical stopgap, allowing better care for chronic conditions, while preventing unnecessary trips to the emergency room.

Last but certainly not least, H.R. 3590 honors the life of Deamonte Driver--a 12-year-old boy from Maryland whose life was cut drastically short three years ago when an untreated tooth infection spread to his brain.

Deamonte's tragic death haunts me to this day. Eighty dollars worth of dental care might have saved his life, but he never got that care because he lacked access to a dentist.

The health care bill that we passed will prevent others from dying in such a tragic fashion. Under the new law:

Pediatric dentistry is covered as an essential health benefit;

Funds will be provided to launch a dental campaign to new parents and traditionally underserved areas;

Workforce Training Grants will be available to provide technical assistance to pediatric training programs in developing and implementing instruction regarding the oral health status, dental care needs, and risk-based clinical disease management of all pediatric populations with an emphasis on underserved children; and

H.R. 3590 also includes a loan repayment program with preference given to qualified applicants who have a record of training individuals who are from a rural or disadvantaged background.

However, minorities and underserved communities will not be the only populations that will benefit from our actions. Millions will be touched by healthcare reform in their daily lives in marked, measurable ways.

Thirty-one million Americans will have the opportunity to protect themselves from the fear that a small injury could lead to bankruptcy; and

147,000 families and 14,000 small businesses in my District will receive tax credits to help cover their employees with health insurance; and 56,000 young people in my District will be able to get insurance, at fair prices, through policies currently owned by their parents.

To quote the great poet Virgil, ``The greatest wealth is health.''

By passing and signing this legislation, Congress and President Obama have provided the citizens of this nation with immeasurable wealth, comfort and security.

We have firmly put the power back into the hands of the people, and this is an experience that I will cherish long after I leave Congress.

Mr. Speaker, I rise in support of the Patient Protection and Affordable Health Care Act (H.R. 3590), with the accompanying changes in the reconciliation bill. This Congress is being given a once-in-a-lifetime opportunity to fix a broken health care system that has left millions of families without the coverage and care they deserve.

If we seize this opportunity tonight, we can ensure that tomorrow, a working mom in West Warwick will wake up knowing she can afford her family's health coverage; a dad in Providence will wake up knowing he can take his daughter to the doctor when she is sick; a small business owner in Westerly will wake up knowing he can finally give his employees the coverage he always intended; and a cancer survivor in Narragansett will wake up knowing she won't lose her insurance because of a pre-existing condition or a lifetime cap.

Since coming to Congress in 2001, I have tirelessly advocated for fundamental changes to our health care system, and my constituents have demanded solutions. I have heard from Rhode Islanders who are struggling to pay their health care premiums, and from small business owners that can no longer afford to cover their employees. Families who are fortunate enough to have access to health insurance continue to face ever-increasing costs, while many of them are afraid they will lose their benefits altogether.

Tonight, we begin to institute the changes necessary to provide security and stability to Rhode Islanders who have health insurance, guarantee coverage to the thousands who don't, and lower health care costs for our families, businesses and taxpayers.

Beginning immediately in 2010, this landmark legislation will end abusive health insurance practices that prevent people from purchasing and maintaining their coverage when they are sick; it will ban yearly and lifetime insurance caps, so individuals with chronic, disabling conditions don't lose coverage and end up in bankruptcy; and it will require all insurers to reinvest more of our premiums back into health coverage through a ``medical loss ratio'' of at least 80 percent, ensuring that no more than 20 percent of our premiums go toward administrative expenses and windfall profits for insurance executives.

After this bill is signed into law, it will strengthen coverage for young people by allowing them to remain on their parents' insurance policy until they are 26 years old. It will help our seniors by starting to close the Medicare prescription drug ``donut hole'' so they can afford their medications. It will also provide immediate tax credits for small businesses to make optional employee coverage more affordable. These are only some of the changes that will take effect this year to make insurance coverage more accessible and affordable for everyone.

Over the longer term, this legislation will build on the strengths of our current employer-based system by offering tax benefits to small employers and encouraging businesses who offer their own coverage to continue doing so. Rhode Islanders who don't have coverage through their employer will be able to shop for their choice of a health plan through a new ``health insurance exchange,'' modeled after the tried and true Federal Employees Health Benefits Program, which has successfully provided coverage for over 9 million federal employees, retirees and their dependents, including members of Congress.

Unlike the limited options that are available to most consumers today, the exchange will provide a more convenient, transparent and affordable way to choose among a variety of health plans that meets individual needs. People who cannot afford to purchase coverage within the exchange will receive financial assistance to ensure that they can obtain the coverage that meets their needs.

Small business owners will reap significant benefits from this measure, both through immediate tax relief and the insurance exchange, which will allow them to band together and get the same lower rates as big companies. Small businesses are the back bone of the Rhode Island economy, and preventing triple-digit rate hikes is important to jumpstarting employment in our state.

Improving access to coverage will also require investments in our health care workforce. Currently, our system is strained by a lack of nurses and primary care physicians, particularly in underserved areas. That is why this bill strengthens important workforce development initiatives like new scholarships and loan repayment programs, increased reimbursements and grant programs for primary care training, as well as immediate financial support for community health centers. These new programs and resources will allow us to build the network of nurses, doctors and other health care professionals necessary to meet the increased demand for services.

Since the cost of medical malpractice is a longstanding concern for both doctors and patients, this bill establishes new grant programs designed to encourage states to implement alternatives to traditional medical malpractice litigation with the goal of reducing frivolous lawsuits while allowing legitimate cases to be heard.

But this debate is not just about expanding coverage and reducing costs for families and employers; it is also about putting our country on a fiscally sustainable path. This bill, which is completely paid for, will reduce our nation's deficit by $138 billion over the next 10 years and $1.2 trillion over the following decade--the largest deficit reduction in 17 years. I cannot overlook the impact that these numbers have on our communities, and how critical they are to moving our state forward.

Finally, I have stated from the beginning that I would not support a bill that funds taxpayer-subsidized abortions. I have worked tirelessly with my friends and colleagues--both Democrat and Republican, pro-life and pro-choice--to reach a common ground on this issue. After much dialogue, counsel, reflection and prayer, I have concluded that the Senate language does meet the longstanding Hyde standard of prohibiting federal funding of abortion. This position is reaffirmed by the Catholic Health Association, and many of my pro-life colleagues in Congress who support this bill.

Furthermore, I remain mindful that we must not lose sight of the big picture. Being pro-life means more than being anti-abortion. It also means protecting the 45,000 people who die every year because they lack proper health care. Nothing could be more pro-life than ensuring access to lifesaving and life-improving

treatments for every American, not just those who can afford it. That is what this bill begins to accomplish.

Mr. Speaker, after an injury left me paralyzed nearly thirty years ago, the members of my community rallied behind me and my family when we needed them the most. That support and encouragement changed my life forever. I made myself a promise that I would devote my life to public service so I could give back to them all that they gave to me. Tonight, I know that by passing this legislation, which makes health care a right, not a privilege, I am fulfilling that promise.

Mr. Speaker, today's historic passage of health care reform legislation marks a great victory for the El Paso community. This landmark legislation will significantly improve the quality of life for so many residents by providing access to affordable health care coverage to those who currently have none. It will also provide peace of mind to those families with insurance, who will no longer have to worry about the prospect of financial ruin due to a catastrophic illness or accident.

Every day, thousands of families are being forced to forgo health insurance due to rising costs, and now more than 46 million people lack basic health coverage. This disturbing trend is particularly evident in Texas, a state with the highest percentage of children and adults without insurance. More than 6.1 million adults and 1.4 million children are without basic coverage.

Sadly, Texas border communities fare even worse, and all of Texas' congressional districts along the border rank among the top 20 districts in the nation with the highest percentage without coverage. In El Paso alone, 230,000--1 in 3--people are without coverage.

Unfortunately, when it comes to meeting the health care needs of predominately Hispanic communities along the border, our state has failed. Our Governor would rather waste millions on cameras and helicopters than on health care for border communities that need it most.

The health care reform legislation that passed today is expected to provide coverage to 95 percent of Americans, while lowering health care costs over the long term. For the first time in history, insurance companies will be prohibited from denying health coverage due to pre- existing conditions, health status, and gender.

This legislation will provide tax credits to help individuals and small businesses purchase private health insurance. It also sets caps on out-of-pocket expenses for the first time ever, so families will never have to experience financial ruin due to a serious illness. Without these reforms, health care costs will continue to consume more of Americans' paychecks in the years ahead. The annual average cost of family coverage more than doubled between 1999 and 2009, from $5,800 to $13,400, and is expected to double again over the next decade without reform. Meanwhile, insurance companies are raising out-of-pocket expenses for families, and covering less in health care costs.

America now spends $2.2 trillion on health care annually, more than twice the amount per person than other nations, yet Americans aren't any healthier for it. Without action, health care costs will consume over 20 percent of the American economy in the next decade. This landmark bill will significantly reduce health care costs over the long term and will decrease the federal deficit by $143 billion over the next 10 years and an additional $1.2 trillion in deficit reduction in the following 10 years.

Many Americans living in the U.S.-Mexico border region used to depend on Mexico to access cheaper medical care and prescription drugs. For decades, El Pasoans have sought cheaper health care and prescription drugs across the border in Ciudad Juarez, Chihuahua. A recent study concluded that 1 in 3 people traveled to Mexico for prescription drugs, and 7 percent sought health care in Juarez. But the devastating drug- related violence that has ravaged Mexico for two years has prevented many families without insurance from accessing care across the border.

While our community is spending a greater share of property taxes to pay for individuals without health coverage, insurance companies have continued to engage in practices that protect their bottom lines. For too long, insurers have been the gatekeepers to our health care system, with the power to dictate who receives health coverage and who does not. Americans with preexisting conditions and serious illnesses are too often denied coverage or are dropped from their existing insurance plans for developing a serious illness or reaching their cap on coverage, and are denied access to the medical care they need.

When people lack access to quality affordable preventative care, they end up in our emergency rooms for ailments that could have been treated by a family doctor or seek treatment for conditions that should have been diagnosed earlier. When these patients fail to pay their medical bills from publicly-financed hospitals such as University Medical Center, local property taxes are used to cover these expenses. Since 1998, El Paso property tax payers have spent over $400 million to pay for treatment and services for those patients who could not afford to pay their medical bills.

As Congress debated this legislation last summer, I heard from many El Pasoans who shared their struggles under the current broken health insurance system. One of the stories that had the greatest impact on me was that of Mr. and Mrs. Jacob Lopez. Their lives were forever changed when their daughter, Danika, was born with a long list of ailments and birth defects that required over 80 days of intensive care treatment.

While the Lopez's had insurance through their employer, the co-pay for their daughter's treatment was more than the mortgage on their home. They exceeded their insurer's coverage limits, and were left with no other way to cover their daughter's medical expenses. No other insurance company wanted to insure the Lopez family due to Danika's pre-existing conditions. In desperation, the Lopez's had to quit their jobs to fall into poverty so their daughter could receive the treatment she needed under Medicaid. Last week, Mr. Lopez called my office to tell me that his family was forced into bankruptcy.

As a grandfather, I would never want my grandchildren to endure the hardships that Danika and her family have endured. It is for children like Danika, and my grandchildren, Amelia, Mateo, Julian, and Orlando, that I am proud to vote in favor of this bill.

Our local community leaders have expressed their support for health insurance reform, and both the City and the County have passed unanimous resolutions in support of reform. The Patient Protection and Affordable Care Act is endorsed by over 325 national organizations and associations, including the AARP, the American Medical Association, the American Cancer Society, the American Heart Association, the Consumers Union, the Catholic Health Association, the National Association of Public Hospitals and Health Systems, the American Nurses Association, and many other medical professional organizations.

The passage of this landmark legislation by the House of Representatives is an historic achievement and reflects the commitment and determined leadership of President Obama, Speaker Pelosi, and the Democratic Congress to follow through on a key promise to help middle class families, who have endured years of rising medical costs. I commend my colleagues for their determination to pass this truly historic legislation that will lower health care costs for all Americans, and strengthen our country's financial future.

Mr. Speaker, this week, each of us cast the most historic vote any of us is likely to ever make. With it, revolutionary changes have been made to the American health care system that will forever alter its very nature. This vote was a long time coming and much needed, unfortunately, what we did pass is long on promises of improved care, but preciously short on reforms that the American people really need for better and more affordable care.

It is no secret that the health care system is in need of reform. In 2007, the latest year that figures were available, total health expenditures reached $2.2 trillion, which translates to $7,421 for every man, woman and child; millions of Americans are without health insurance and San Diego doctors are finding it increasingly difficult to care for our city's most vulnerable residents. This week's debate was full of passion over many issues and arguments over the proper answer to health reform. While we can argue over many points, there is one issue where there is no debate: we need health care reform.

Studies have shown that the visit rates to emergency rooms for patients with no insurance are twice that of those with private insurance. While I support insuring all Americans can access health insurance and believe it must be the first priority of any health care reform legislation, I cannot support a bureaucratic system dictated and controlled by the Federal Government. Congress, just like the medical profession, must adhere to the Hippocratic Oath of: ``Above all, do no harm.''

Throughout the past year, I have supported many bipartisan issues that will increase health quality and access for not just San Diegans but all Americans without limiting our choice of health care options-- many of which were in the legislation we passed Sunday night. We must first allow Americans to have the same insurance as the Congress of the United States. It is not fair to stand here today and pontificate on the benefits of health care if we do not allow hard working Americans to have the same health care choices we enjoy. Citizens of this great country must be allowed to shop wherever they want in the United States for health insurance, free from the barriers of state lines. If New Jersey offers a plan that is cheaper than California, Californians should have the ability to purchase that plan. We must enact strong medical tort reforms that can save billions of dollars--$54 billion to be exact according to Congress' own Congressional Budget Office, CBO. Finally, I support strong enforcement mechanisms to prevent illegal immigrants from receiving taxpayer subsidized health care.

It is important to remember that American health care is in many ways the envy of the world. From our first class medical facilities to our world renowned life science enterprise, we are the leader in innovative care and solutions. These innovations are allowing Americans suffering from major illnesses to live longer, healthier lives. For instance, in a single decade, from 1993-2003 U.S. heart disease deaths dropped by 22 percent. However, for all these benefits there is work to be done but not at the expense of destroying the entire health care system.

The health care bill that was signed into law will destroy our already fragile economy and lead to government control of health care. Under this new law, there will be more than $520 billion in tax increases, including a $27 billion employer mandate tax and $15 billion individual mandate tax. With 1 in 9 San Diegans out of work, this will exacerbate the problem.

There are many examples in this legislation of government control but one striking example is the Independent Medicare Advisory Commission. The creation of the so-called Independent Payment Advisory Board (IPAB,) which for the first time will give unelected and unaccountable bureaucrats the mandate to make important decisions about the future of the Medicare program. The cuts they propose would be in addition to the over half trillion dollars of Medicare and Medicaid cuts already in this bill.

We all agree that Medicare reform is needed but the IPAB actually carves out large areas of the Medicare budget from potential savings, leaving draconian cuts in the reimbursement of life saving and life enhancing drugs as a likely outcome. As Co-Chair of the House Biomedical Research Caucus, I have seen the great promise that developments in medical technology can mean for American seniors. Just last summer, the existing Preventive Services Task Force changed its recommendations on mammograms, confusing millions of Americans in the process. Can you imagine if those recommendations had the force of law? As science progresses to further embrace the benefits of personalized medicine, we need to make sure that the unchecked decisions of a federal board in Washington do not unwittingly sabotage the doctor- patient relationship. I am very troubled by this provision, and I want to work with my colleagues on both sides of the aisle to fix it or repeal it before it becomes effective.

In order to pass this legislation, many back room deals were cut. From the ``Cornhusker Kickback'' to the ``Louisiana Purchase,'' many states were taken care of in order to secure support. However, California was once again left on the outside looking in. This bill does nothing to fix the Geographic Practice Cost

Index (GPCI), which to date finds San Diego doctors being paid at a rate of rural practitioners; all the while they continue to practice in a high cost area. Additionally, this legislation does nothing to fix the sustainable growth rate problem that finds California doctors facing continuing cuts in Medicare payment rates year after year and threatens patient's access to care.

I was in favor of rejecting this plan and coming back to the table and develop a proposal that fully addresses medical malpractice awards so we can save health care costs, allow United States citizens to purchase their health care across state lines and provide tax credits so hard working Americans, not Washington D.C., are in charge of their health care.

A strong and accessible health care system is one of the most fundamental components of a strong economy. I am committed to working in a bipartisan manner with my colleagues to put in place real reform that will protect the doctor-patient relationship but will not bankrupt our economy in the process. American families deserve better than socialized health care and I plan on helping to deliver it. I will continue to work with my colleagues to reform a broken health care system in a way that is sustainable, protects the promises we have already made to our nation's seniors and does not infringe on our liberties.