Physician Workforce Enhancement Act of 2009

I thank the Speaker for the recognition.

Mr. Speaker, I come to the House floor tonight to talk a little bit more about health care. It is, it seems, the number one topic of the day here in Washington, D.C. It's interesting because probably 50 percent of Americans care more about what we are doing as far as job creation, and 14 percent are concerned about health care. You would think that we would adopt the Bill Clinton phrase of ``focusing like a laser beam'' on the economy and ``focusing like a laser beam'' on job creation. But health care is important, and it is appropriate that we spend some time discussing it because, likely as not, before the end of this month, certainly before the end of this year, it is possible that some type of bill will pass this House, although it may not be to the liking of a great number of Americans.

Mr. Speaker, I know that my comments must be directed to you and not to others, but I would say, Mr. Speaker, that if I were able to talk to people about what they could do, a plan for action, I will be discussing that toward the end of this hour.

So I do encourage people to stay tuned to this debate--not necessarily to this discussion this hour--but stay tuned to this debate because it is important. It is going to affect the lives and livelihoods of Americans from this day forward for a long, long time. It is extremely appropriate that we take our time, that we get this right, that we do not hurry through the process, that we do not cut corners.

Now, Mr. Speaker, you look at where we are 10 months into this year. Do we have the trust of the American people in this body? The answer to that question is, it doesn't seem so. What people have seen this year-- and even going back into last year in the term of the previous President, President Bush, they saw a couple of bailouts last year, they've seen more of the same this year, they've seen stimulus, they've seen automobile takeovers, financial sector takeovers, cap-and-trade that passed the floor of this House that

many Americans felt was inadvisable in a time of economic downturn; and Washington yet still has the nerve to say, Trust us because we can take care of you and we will make your lives better. But the current polling numbers don't really suggest that that is something that's believed by the American people.

Now true enough, the President started this year with extremely high approval ratings, somewhere likely in excess of 80 percent approval ratings at the time of the inauguration--an extremely popular individual--and has retained a great deal of that popularity, depending upon the poll that you select. Now it is down to about 50 percent, 49 percent this morning in Rasmussen, 52 percent in the RealClearPolitics daily average poll. But, still, one out of every two Americans still has a favorable impression of the President.

What about the United States Congress? Is it one out of two? Is it one out of three? It's one out of every five people holds the United States Congress in high regard.

So with our current approval ratings hovering around 20 percent, why do we think the American people would believe that we, in fact, do know best and that they should trust us on an undertaking of this mammoth scale? And you can see how big the undertaking is.

We heard previous speakers in the last hour talk about how difficult it is. We have had three health care bills that passed the various committees in the House last summer. You had one health care bill that passed the Senate Health, Education, Labor and Pensions Committee in June of this year; and then most recently you had the talking points memo that passed out of the Senate Finance Committee yesterday with a single Republican vote on that. I do not believe there were any Republican votes on any of the House products in the three committees that considered this bill under their various jurisdictions.

The Congress doesn't have a lot of credibility right now on this or, quite frankly, many other issues. It would be a great thing, in my opinion, if Congress spent some time in trying to rebuild that credibility; but unfortunately, it's the old adage: Don't check the weather; we're going to fly anyway.

And off we go with a big cap-and-trade bill in June that upset a lot of people; we did the three health care bills on the House side in the various committees in July. We ran into the town hall meetings during the month of August when people told us what they thought of our efforts, and now we're back here in the fall taking up the big bill on health care reform.

As we've watched this debate, you think back to a year ago, we were in the middle of a presidential campaign. Both presidential candidates had ideas about what should happen as far as health care and the possibilities for health care reform. Remember now-President Obama's position last fall was significantly tilted towards getting coverage for the uninsured. It was a moral imperative. It was something that we had to do. Then we worked through some of the more difficult parts of the economic downturn, a lot of job losses were incurred during that time; and at the beginning of the year, many more people were concerned about the cost of health care and would they be able to continue to afford their insurance, would they be able to continue to afford health care. So affordability became perhaps a higher priority for Members of Congress who were considering these reforms during the spring.

In June when the first congressional committee in the Senate, the Health, Education, Labor, and Pensions Committee passed their bill out of the Senate committee, the focus was all on cost and coverage. The cost numbers turned out to be significantly higher than anyone thought they would be; somewhere in the neighborhood of $1.5 trillion over 10 years' time. The coverage numbers were disappointing at only a third of the uninsured actually being picked up. And there's no question that that delayed the second Senate committee, the Senate Finance Committee, in introducing a bill and marking up a bill which they just completed this week because they were trying to fine-tune those numbers.

Now on the House side, we did, in fact, get a Congressional Budget Office score that came in around a trillion dollars for a 10-year bill. A little disingenuous because the Congressional Budget Office--in the hearings we had on Energy and Commerce from the Congressional Budget Office, the score was administered not on legislative language but on conversations, telephone calls, that the members of the Congressional Budget Office had with members of the Democratic majority who were writing the bill. So, yes, it was a cost number but there was some question as to the accuracy of that.

And then here was a really big problem and one that really hasn't been addressed yet. These are enormous programs to undertake. They are not going to start overnight. So even if we pass a bill before the end of the year, it is going to be some time before these programs--whether it be a public option, whether it be exchanges within the States--it is going to be some time before the Centers for Medicare and Medicaid Services in the Department of Health and Human Services--which is likely to be charged with writing the rules and regulations under which these new products are formed--it's going to be some time before those things happen.

The benefits are actually not scheduled to begin to kick in until the year 2012, 2014. It will be some time before those benefits occur. The taxes, of course, will begin the minute the ink is dry on the President's signature on the bill. So if we have a tax on high-end insurance plans, if we have a tax on medical devices, if we have a tax on any number of things, these taxes will begin to accrue January 1 of that year, but the benefits don't actually begin to kick in for some time.

And once again, the United States Congress, when it's questioned by the American people, the United States Congress says, Don't worry. Trust us. We know best how to plan for you. We know best how to take care of you. We know that you don't know how to do this for yourself. And Congress, with its 20 percent approval rating, is just the man for the job to get this done for you.

During the presidential campaign last year, President Obama promised to bring all parties together and not negotiate behind closed doors and to be broadcasting those negotiations on C-SPAN. Now we had kind of an unusual situation occur in May and June of this year when stakeholders in the health care community met at the White House and offered up things that they could do, things that they could do to hold down the cost of health care--you had to wonder where were these individuals for the 15 years before--but you had groups. The American Medical Association, of which I am a member, was in those meetings; the American Hospital Association was in those meetings and offered up a number of things that they could do for substantial cost savings.

A little bit of controversy then last week as the Senate was working through its product, will those things that the American Hospital Association offered, are those going to be taxed or not? And there was some back-and-forth with the Congressional Budget Office as to what those numbers actually meant.

Medical devices. Again, similar situation. PhRMA came to the table with--I forget the number now, but it seems like it was about $80 billion in cuts that they were going to be offering.

Well, none of these things that were agreed to behind closed doors last May, none of these deals are available to us as Members of Congress so that we can know what did America's health insurance plan group, when they came to the table and said, We can save you billions of dollars, Mr. President, and he said, What took you so long? But as members of the committee that were charged with working through this bill last July, why did we not have that information available to us? Why was it a surprise at the Senate Finance Committee when, hey, we thought these breaks we were giving the hospitals were going to still be subject to a corporate income tax, not an off-tax item? Why was there even that discrepancy or that discussion? Why not share with us those deals that were struck down at the White House?

And indeed, last month I sent a letter to the White House and asked for the

release of those discussions, the transcripts of those discussions, the minutes or notes of those discussions, pertinent e-mails that may have occurred during those discussions.

Just quoting from my letter to the White House: It has been now over 4 months since the White House announced numerous deals with major stakeholders in the health care debate to save upwards of $2 trillion in the health care system. Little to no details regarding the negotiations have been released. And recent actions and press reports have reminded me of the importance of openness and transparency throughout the legislative process--the very openness and transparency that we were promised by this President during the campaign.

So the letter has gone to the White House. I eagerly await a response to that. I am in fact somewhat surprised, my committee, the Committee on Energy and Commerce that has a fairly robust oversight and investigation subcommittee, I am somewhat surprised that they have not been curious about the deals that were made down at the White House early in the spring; why they have not been curious about some of the e-mails that may have occurred during the back-and-forth working through these negotiations. Again, the letter went to the White House on September 30, and I await a reply.

I will ask later to include this letter as part of the Congressional Record this evening so that people will have the opportunity to read through that letter themselves.

But again, the American people just simply do not trust the American Congress, the United States Congress, to make these kinds of decisions for them.

When you look at some recent polling data when the question was asked if Congress works through this process and comes up with a major health care reform piece of legislation, is health care going to get better or is it going to get worse? Well, a quarter of folks think it's going to get better. About 26 percent say, Yeah, we think Congress will make the kinds of improvements that are necessary and health care will, in fact, improve. Fifty percent say it will get worse. Not great numbers with which we're working.

You know, it was startling for many of us, the interest that was out there over the summer during the August recess on the health care bill, on cap-and-trade. Town hall activity was widely reported in news media outlets across this country. My district back in Texas was no exception. Town halls where I might typically have 30, 40, 50 people show up on a Saturday morning, 1 or 2,000 people would show up. In fact, one venue we had to change from inside to outside and just held the bulk of the meeting out in the parking lot because of the number of people that showed up.

I have to tell you, Mr. Speaker, August in Texas in the parking lot is--you're asking a lot of people to stay with you through an hour or so discussion of a health care bill. But they did, and they asked questions, and they were respectful.

I don't think that this August was an anomaly. I don't think that the American people had some sort of fugue state during August where they reacted to the health care legislation and the cap-and-trade legislation and reacted in no uncertain terms as to how angry, how anxious they were about these bills that we were passing.

But when we get back to Congress in September, it's like August never happened. It was unimportant. ``Don't pay any attention to those people back home because we're Congress. Trust us. We know best. We know best how to take care of you. We know best how to give you what we think you need.''

We got back in September and I think I thought after seeing the August town halls, I thought this Congress would hit the pause button, hit the reset button, hopefully the rewind button on this health care legislation, but no such luck.

We went at it full force. We, in fact, even had a little bit of an extended markup in the Energy and Commerce Committee where it was suggested to the chairman of my committee, you know, that August was a rough month for a lot of people, a lot of people on both sides of the dais--Republicans and Democrats both, even Republicans who voted against the bill--people were angry that the bill was even being considered and would likely pass.

On the Democratic side, there were a number of town halls that were quite contentious. We thought, I thought Members would welcome the opportunity to, well, let's sit down and revisit this. Let's reorganize. Maybe there were some good ideas on the other side of the dais. Maybe Republican members should have been brought into this process and take some ownership of this bill, if nothing else. Don't leave us being the only ones out there to defend it; but, no, that wasn't the case.

The chairman of the committee said August, in so many words, August didn't matter. The people that spoke up were few and far between, and these large crowds that showed up at the town halls were somehow manufactured and didn't count. Not only did they not count, we were not reconsidering any part of the bill. We had some additional amendments that Members on the Democratic side wanted to offer. I offered a couple on our side as did other Members on the Republican side. But for the most part those amendments were struck down on a party-line vote.

Both sides of the aisle genuinely see a problem and genuinely want to work toward improvement of the process. You have heard me say it before. You have heard other Members of Congress say it before. Some people dispute it as a fact, but I will say it: America has the best health care system in the world. There are distributional problems, and there are inequities in the insurance system that need to be fixed, and they are within our purview. They are within our capability of fixing, but we do not need to turn the entire system on its head to effect those ends.

How could we best go about improving what we call health care in America? Well, we can ensure that patients continue to have, continue to get, care, have access to care, and continue to get the best care. That would be a good thing for us to work on together.

Instead of being an obstacle, instead of threatening cuts every time you turn around, we could help doctors, nurses and hospitals continue to provide that excellent care. We, as Members of Congress, and sometimes it's do as I say, not as I do, but perhaps we could set a better example about living healthy lifestyles, staying within our-- staying within our ideal weight. Maybe that's something we should look at.

Again, an amendment to that effect was turned back in my committee on Energy and Commerce. You know, really, one of the keys is going to be, if we are going to hold down medical costs, we really do have to involve the patient in the process. We have to have patient involvement in the doctor's office. We have to have patient involvement in making those healthy lifestyle choices. If we do not have the patient involvement and increase the patient knowledge base, the health literacy, if you will, about things like preventive care, about things like the importance of eating right and staying fit and the importance of regular health checkups and medical screenings, if we don't do that, the cost for health care is going to continue to increase and increase at a rate at which it's go going to be very, very difficult, regardless of the number of new taxes, regardless of the cuts to doctors and hospitals and nurses. Regardless of all of those things it's going to be very, very difficult for Congress to keep up.

We do put the system at risk when we do that. There could be a day when the generation or two coming behind us will say we can no longer afford the type of tax rate that you have left for us. We will have to do something drastically different, and we don't want to do that. We don't need to do that.

Now, you have heard a lot of discussion about how Republicans have been obstructing the process. Let me clarify that just for a moment. There are 177 or 178 Republicans in this body, 256 Democrats in this body. It takes 218 votes to pass a bill, to send it on to the Senate. The Democrats in this body could pass whatever bill they wanted. They do not need Republican support. They have, in fact, told us that on more than one occasion. The famous phrase that came out in January or February, well, after all, we won. There hasn't been a lot of reaching across the aisle, because it was just simply not necessary.

Now, you think back to February. Again, the President had an approval rating of, I don't know, 70, 75, 80 percent. The President could have passed whatever health care bill he wanted in February of this year. There would have been nothing anyone could have done to stop it. In fact, there likely would have been very few people with the courage to try to stop it because the President was seen as so popular and so powerful, evidenced by the fact that the President did get a $787 billion stimulus bill passed through this House, a bill that many thought was ill advised, a bill that many thought was duplicative, unnecessary and wasteful.

But they got it passed, no Republican input into that bill as it was being written and no Republican support on the floor; but they didn't need it. It passed overwhelmingly with only Democratic votes, went down to the Senate for a similar fate, went down to the White House and was promptly signed into law by the President.

It was followed a week later by an omnibus bill that spent a lot of the same dollars on the same things. Again, not much in the way of Republican support was solicited or required for that. It passed because, after all, 218 votes are all that are required to pass a bill on the floor of this House. The Democrats with their 256 majority have more than enough votes to pass almost anything they want.

Now, the Republicans even tried--and I don't know the answer to that for everyone, but I will tell you that I did. I met with the transition team in November of last year.

I met with the chairman of my committee in January of this year and said, look, I didn't give up a 25-year medical career to come here to sit on the sidelines. I want to be involved in this debate. I may not be able to be with you on some issues. There are some things that I think are just the wrong approach to reforming health care, but let's sit down and have the discussion and see what can be worked out.

I was thanked for my interest and never received a call back. Oh, I did get called down to the White House in March for a photo op, but that was about it. There wasn't much more to it than that.

Then as the bill was being written behind closed doors for the various committees where we worked on the bill on the House side, certainly at no point was I ever offered any input.

Now, I did, as did many members in my committee, offer a number of amendments, and we did amend the bill in committee. It would be interesting to see now whether or not those amendments stay in the bill.

But I don't think anyone is fooling themselves. There was not--there was no way to amend that bill, H.R. 3200. There was literally no amendment you could offer except striking the language in the bill and offering the new bill. There really was not. It was not salvageable, in my opinion.

Now it's interesting because all three committees have passed the bill. They all amended it and some of those amendments will be completely--the incentives will be aligned. Some of them actually will be at a 90-degree intersection.

Someone is going to have to redo that bill. That is happening now, and you can expect that there is probably a heavy hand from the White House in aligning all three of those House bills into one product. We will likely get to see it a few hours before we vote on it. It may come as early as the end of this month, and we are promised that it will, in any case, be something that we see before Thanksgiving. I expect that that is true.

I don't know whether any Members on my side will vote for it. There don't seem to be a large number of Republicans who are supporting H.R. 3200. I don't know if any Democrats will vote against it. We certainly saw that in all three committees that there were some Democrats who simply could not support the things in the bill and did vote against it.

The public option continues to be a political football kicked from one side of the rotunda to the other. The House wants a robust public option, the Senate not so much. How will it pass on the Senate side if they have a public option, or will a public option be ignored by the Senate but added back in the middle of the night when the two bills come together in the House Senate conference before we vote on the final product?

It's anybody's guess and, Mr. Speaker, again, you know, just speaking to you, I would say if I were able to speak to the American people, I would say stay tuned to this because it is going to be a very important process. You will have a House unified bill coming up the next couple of weeks. How long we have to evaluate that before we vote, I think, is going to be very telling. If it's a very short period of time, there is probably some bad stuff in the bill that they don't want you to know about before we actually vote.

Now, we are arguing for 72 hours. I will just tell you, for what's likely to be at least a 1,000-page bill, more likely a 1,500-page bill, 72 hours is a very short interval of time to work on a bill of that magnitude. Bill language is inherently very difficult to read. There is a lot of referral back to the Social Security Act. There is a lot of referral back to the Medicare or the Medicaid provisions in the United States Code.

It takes some doing to get through that bill language and really understand what the implications of what you are reading. But it doesn't mean we shouldn't do it. It just means that we need have the time to do it. I certainly encourage the Democratic leadership to give us the time necessary and make the facilities available to us so that we can have the opportunity to read through that bill and read through it with experts and come to understand what's being contained within the bill.

You know, the President has said repeatedly that if you have good ideas, I will listen. In fact, here in the House, in the joint session that was held on September 9, the President said, right from the podium behind me, and I am quoting now, ``I will continue to seek common ground in the weeks ahead. If you come to me with a serious set of proposals, I'll be there to listen to you.''

Well, that's kind of interesting, too. During the campaign, the President said that he would sit down with people who might be regarded as folks that don't like us very much, folks like Ahmadinejad and Hugo Chavez. The President said, I will sit down with leaders of other countries and meet with them without preconditions.

Well, when it comes to congressional Republicans, he does set some preconditions. We have to come with a serious set of proposals. We can't just show up with ideas. I prepared a serious set of proposals and sent it to the White House on September 16 of this year, about a week after we had the joint session of Congress. I prepared a number of things within the letter.

Attached to it were a number of bills that I had introduced that I thought should be parts of whatever type of health care reform is passed. I am still waiting for a response to that. Things like addressing the problems of the physician workforce, things like addressing the liability, the problems that doctors face with the liability insurance, fixing the sustainable growth rate formula, some price transparency, a lot of good ideas contained within here.

Again, I will, at the end of this, I will submit this for the Record. But, again, no response from the White House.

The list talked in some detail about those things that the Republicans agree should be a part of the meaningful reform. You know, we hear it said all the time that there is agreement on, like, 80 percent of the things contained within health care reform. I think that number is a little bit high. But, nevertheless, we hear it said all the time.

But what is the primary thing? What is the number one thing I heard about over and over and over again in the town halls in August?

The thing that is really grating on the American people is those individuals who want insurance but can't get it. They can't get it because they have had a tough medical diagnosis. They have a preexisting condition. They had insurance on their job and they lost their job and they couldn't keep up with the COBRA payments, so they lost their insurance. Now they are stuck without insurance, but have a preexisting condition. It wasn't that they wanted to drop their insurance; but the conditions were such, the rules were set, that they didn't have any choice but to let that insurance coverage go, even though they knew it

might be difficult to get back into a state of coverage in the future.

Another thing that just really bothers people is the fact that Americans can do the right thing and have health insurance and pay that premium religiously, get a tough medical diagnosis, and the insurance company looks back and says, you know what, we really never meant to offer that policy to you in the first place, or we think there was something you obscured in your history. Now, by a process of what are called ``insurance company rescissions,'' they are going to take that insurance policy away.

The President even referenced that in his speech on September 29, and that's wrong. People acknowledged that it's wrong, both sides of the aisle.

Now, in cases of fraud, correct. The insurance company has to have a right of action. They have to have a way to protect other people that have insurance. You don't want people coming and buying insurance under fraudulent terms.

But for people who have an omission from a medical history that makes no difference as to their subsequent care and diagnosis, these are things that are generally recognized by the American people as being egregious overstepping by the insurance companies, and that needs to be fixed. Here is the sad part, Mr. Speaker, that could have been fixed. That could have been fixed before we went home for the August recess. We just simply chose not to do it.

So, if we provide a way for someone who has a preexisting condition, perhaps through a reinsurance, perhaps through high-risk pools, perhaps through high-risk pools with additional State and Federal subsidies, there can be ways to bring individuals who have a preexisting condition into a state of coverage.

It's a shame. It's a shame we never had a hearing on that in our health subcommittee. We had hearings on almost every other issue under the sun, but we never had a hearing on, is there a way, short of an unconstitutional individual mandate, is there a way to get people insurance coverage who have had a bad medical diagnosis and lost their insurance? We never had a hearing on that. We could. I think we should. I think bright minds on both sides of the aisle could get together and work out ways that this problem could be solved.

Rescissions. Again, with a history that's now newly disclosed, has nothing to do with the medical diagnosis, and it was in no way fraudulently withheld from the insurer, rescissions need to stop. States that have high-risk pools, there are 34 of them. States that have the opportunity for reinsurance. These are States that are working, trying to offer their citizens a method of dealing with this problem. We could encourage more States to pick up high-risk pools. We've got some States where they're working well, some States where they're working less well. I always felt that in my home State of Texas, it wasn't working so well. It turns out it's really not a bad program, it's just not funded to the level that it need be.

Well, if we could encourage a contribution from the Federal Government, the State government and perhaps even the private sector, the insurance companies themselves, perhaps we could get that figure down to a point where people can actually utilize the program. Because people that then are subsequently covered by those high-risk pools in Texas love the program. I had someone come up to me after a town hall in the district in August that said, Please, whatever you do, don't do anything that's going to mess up my high-risk pool because that's the best insurance I've ever had. The problem is it's limited to the number of people who can access that.

We have people losing their jobs. It's an unfortunate, disastrous occurrence that happens in a recession. Some people are laid off. And if you have employer-sponsored insurance, there's trouble brewing. Yes, because of rules and laws that Congress passed many, many years ago, COBRA coverage that is extended for 18 months is available to an individual who loses his job, but that insurance has to be the same insurance that that person had while they were employed.

So the individual can pick up the premium for that employer-sponsored insurance, but most of the time the employer is not continuing to pay their part so the individual has to pay the entire freight; in fact, it's actually 102 percent because there's an administrative cost tacked onto that. Well, that is an expensive issue for someone who's just lost their job.

Could we offer people another choice? If someone loses their job, they've got good employer-sponsored health insurance, they are protected. As long as they keep their insurance, they're protected against falling into that preexisting condition trap. But right now it's either pay that large premium--and again you just lost your job so it may be hard to do that--or become uninsured.

We offer people two choices right now. What if we made something else available to people? What if we allowed people to transition into the individual market and not have to go through the COBRA system to do that, but still protect their ability to have the coverage for a preexisting condition should one have developed or develop during the time that that individual is transitioning to insurance on the individual market. Why does it always have to trigger the COBRA insurance? Why is there not an intermediary step that is less expensive, but still provides the protection?

Other things we could do. What if someone has COBRA, has that coverage, but they move to another State and they may not be allowed to take that coverage with them? Why not allow that transition from State to State without rerating that individual, without causing that individual to be rerated by a new insurance company where now their preexisting condition that they've acquired along the way prevents them from getting or obtaining that insurance in the individual market in a new State?

I liken that to the National Football League, and you have a player in the National Football League who gets traded from one city to another, their insurance goes with them. No problem. If they had a knee injury in one city, it's going to be taken care of in the new city. But if their fan who wants to follow their favorite football player moves from city A to city B, they've got to start all over again, if they're in the individual market, and during the time that they do that, they may find that they are rerated by their insurance company, reunderwritten by their insurance company, and if they had even a modest diagnosis like high blood pressure, depression or adult onset diabetes, it can be a very expensive adventure for them buying insurance in that new State.

So why don't we allow that type of transition so that someone doesn't have to be rerated? We talk a lot about being able to buy insurance across State lines. I think that's important, too. That's a little bit heavier lift. It's a little bit more difficult for Congress to come to that understanding, but this ability to allow someone to buy in the individual market without being rerated when they change States, that's easy and we should be able to do that. Again, I frankly don't understand why we don't take that up.

Again, remember if we pass this big, comprehensive, robust public option health care bill, when do you get the benefit? Four years. We're going to have people losing jobs next year. We're going to have people losing jobs the year after that. What are we going to do for those individuals in the short term?

And, again, I'll reference back to the President's own speech that he gave here on September 9. When he was at the podium giving the speech, John McCain was in the audience. He acknowledged that John McCain had a good idea for covering people with high-risk pools and that perhaps that would be a way to provide some immediate relief for people who couldn't wait for the 4 years before the Federal Government starts this new robust public option plan.

You hear me talk about medical liability. Medical liability is a big deal. The fact that it's been left out of the House and Senate bills, I think, is a big deal. Look, we're asking our doctors to be our partners. Whatever the brave new world of health care reform looks like, whatever we go to, we're going to ask our doctors to be there and be at our sides and help us, or be the ones to

take care of the patients and answer those emergency calls in the wee hours of the morning.

We're asking our doctors to stand with us on this. And yet we won't do the one thing that would simplify the lives of doctors across the country, keep doctors from dropping out of the practice of medicine, and, that is, bring some sense, some stability, to the medical justice system that we have in this country.

Now, Texas has done what I consider to be a very good thing, with putting caps on noneconomic damages. They did that in 2003. They had to do it with a constitutional amendment so that it would become immediately effective and didn't have to go through all sorts of court challenges; and, boy, it was like turning a switch and things have improved in Texas since that bill was passed. But you will also hear people say, Oh, medical liability, it doesn't save that much money. You can do whatever you want, but it's like a 1 percent savings.

But that's based on a very old study that really only looked at the cost of the premiums themselves, from back in the early 1990s, the American Medical Association, a very famous study called the Tonn study, frequently still quoted here 15, 20 years later. The Tonn study did say that you weren't going to save much money with medical liability. But, of course, the Tonn study discounted what would happen as far as the practice of defensive medicine.

Let me ask you this: medical liability premiums have gone up year over year over year. Medical liability has continued to be a problem year over year over year these last 20 years. Do you think the practice of defensive medicine is more widespread now than it was 20 years ago? Well, you bet it is. You bet it is. Twenty years ago we didn't have PET scans. We barely had MRIs. The more new things, new technology that becomes available, doctors are continually trying to see what is the maximum I can do so that I won't look bad if things go wrong and I'm called into court and have to defend my medical judgments. So it's no small wonder that the cost of defensive medicine has gone up and up and up.

Now the Congressional Budget Office has put out a new report. In a letter to Senator Hatch, they talk about their new estimate for what medical liability reform would save the Federal Government. This is just in the Medicare and Medicaid system, and it's estimated to be $54 billion over 10 years. That's getting to be a significant amount of money.

But wait a minute. Remember that the Federal Government is now responsible for about 50 cents out of every health care dollar that's spent in this country. Fifty cents out of every health care dollar that's spent in this country actually originates right here on the floor of this House. So that $54 billion over 10 years only represents about half of the medical expenditures in this country. It doesn't count those that are paid for by private insurance, those that are paid for out of just individuals paying their bills or that is gifted to people through charity.

So double that number. It's over $100 billion over the 10-year life of the health care bill that is a potential savings with modest medical liability reform. Again, that's not going to pay for the whole health care bill, but it would pay for 10 percent of it. Don't you think if we could pay for 10 percent of what's being proposed that we ought to at least consider it in our committees, that we should at least consider it in the legislative language that's being proposed?

I will just tell you what's happened in Texas since 2003 when we did pass a cap on noneconomic damages. Since 2003, Texas has licensed 15,000 new physicians. Over a similar time span preceding that, that number was about a third. We've gained 192 new obstetricians; 26 rural counties have added an obstetrician, including 10 where previously there was no OB doctor.

Texas is a big State. We've got 242 counties, so there's a lot of counties in Texas. But, still, 10 counties without an obstetrician before that now have one. That's prenatal care that's available to patients that wasn't available before unless you drove multiple miles to a medical center. That's doctors who are there when patients need them, frequently when time is of the essence, in the process of having a baby. So that is a good thing.

Thirty-three rural counties have gained ER doctors, including 26 counties that previously did not have an emergency room doctor now have one since the passage of commonsense medical liability reform in 2003. Doctors have contributed $594 million in charity care since the bill was passed.

I introduced similar language at the Federal level, H.R. 1468 for those keeping score at home; and I had offered that as an amendment to our committee bill last July. I was at first struck down on a technicality. Then I was struck down on a party-line vote. It doesn't seem that the Democratic majority has really had any interest in trying to reform the medical justice system in this country.

Yet now the Congressional Budget Office in a letter to Senator Hatch, where he requested a new analysis of the cost of defensive medicine, has said that it would be a savings of $54 billion over 10 years, and they do cite several studies in there where they've gained that information.

Again, at the end of this hour I will ask to make the Congressional Budget Office report, the letter to Senator Hatch, a part of the Record.

Portability, being able to take your insurance with you. There was a time when I was a youngster when you went to high school, perhaps went to college, but whether you graduated from college or just started after high school, you took a job and you probably continued that job until you got your gold watch in retirement.

It doesn't work that way anymore. I don't know exactly what the figure is, but the estimate from the Census Bureau is that people will have perhaps 10 or 11 jobs during the course of their productive years. So it only makes sense that if we continue, and we likely will continue, to have employer-sponsored health insurance, that we allow more portability than is within the system now. Some people have talked about things like defined contributions from employers, rather than just the employer providing the insurance, providing a designated sum of money for the purchase of that insurance.

There is a lot of discrepancy for what insurance costs. In the State of New Jersey, the average health insurance premium for a family of four recently quoted at $10,000. You go across the State line to Pennsylvania and it drops $4,000, to $6,000. Well, there's not a lot of difference right there on the State line between one segment of the population and those that are north of the line in New Jersey. Why not? Why not allow people to perhaps look into the purchase of insurance in other markets that may fit their needs and may be more affordable?

And then, of course, again we get into the issue of someone who moves across the State line, why not allow that portability? Just in the interest of completeness, the State of Texas, a family of four, the average insurance premium is $5,000 a year. The State lines concept is one, and we heard the President talk about it in his speech of September 9. He talked about a part of rural Alabama where if someone was going to the individual market, they only had one insurance company from which to choose.

And that's not terribly surprising. Insurance companies tend to be natural monopolies. They tend to want to form monopolies and capture market share. But the President's quite correct; you don't get much competition if you've only got one insurance company. So the President's solution to this problem is, well, let's create a public option and we'll have two insurance companies for that family in Alabama to choose from. But there's over 1,300 insurance companies in the United States of America. Why not open the market up so that more of those 1,300 insurance companies that already exist in the country-- we don't have to create a new one, we don't have to pay all that start- up capital for creating a new program--why not just allow them to compete across state lines?

And you know, interestingly enough, Democrats that reflexively opposed this idea year in and year out now seem to be warming to the concept. At the very least, if you have a public option that is available in Alabama, it's going to be the same public option that's available in Tennessee, and the

same public option that's available in Texas. Guess what? That public option is going to be sold across state lines because it is a Federal program. So why don't we, before we go to all the trouble and expense and anxiety of creating an entirely new Federal entitlement and type of insurance, why not just simply allow some open competition across state lines?

Now, cooperatives are something that we hear, that word gets a lot of traction, co-ops. You know a purchasing co-op that could go across state lines, I could be okay with that. A co-op that was just a dressed-up public option, I'm not so much in favor of that. But certainly, allowing people to band together, people that may belong to the same alumni association, the same church, you name whatever association, realtors, dentists, physicians offices, that want to get the purchasing power of a much larger group in that individual market, we should allow them the freedom, the freedom to be able to make those associations and to purchase.

You know, tax credits--and I will admit there are people on my side that get nervous when you talk about tax credits. But tax credits to help with the purchase of insurance I think is certainly something that was talked about during the last presidential campaign. I think it is a way to provide immediate help, not help 4 years from now, but immediate help to people who don't have employer-sponsored insurance, where otherwise the cost of insurance is an obstruction to them getting that coverage. Maybe if we take away some of the issues with preexisting condition rescissions, we take away some of the issues with portability, still it may be an affordability issue, and if we could help that with the tax credit or even a pre-fundable tax credit, I think that is something that is, it's at least worth having the discussion.

And again, through all the hearings that we've had on this, we never once visited that issue. We never once invited the Congressional Budget Office in to kind of give us some views and estimates on what this might cost or what this might look like. Instead, we just simply said, we're Congress, we know best, we're going to build an entirely new insurance company that's administered by the Federal Government and that will be your competition. Take it and like it because we, after all, know best.

Again, the ability for people to associate, whether it be a church group, an alumni association, maybe it's time that we gave people the option of not having insurance that's tied to a single employer, because, again, many people will change jobs over time. Allow the cross-state purchasing.

We've talked about things like association health plans. Various bills have been introduced that would deal with this. H.R. 3218 introduced by Representative Shadegg from Arizona is one such plan. And certainly, that is one that should be included in any compendium of plans that are offered as conservative or Republican alternatives to what is being proposed in health care.

Medicare payment reform. We're going to pay for half of this trillion-dollar bill with cuts in Medicare. Well, I've got to tell you, I get more letters, more mail from individuals who are doctors who are concerned about what we, what Congress is doing to them in physician reimbursement. It's easy to say, oh, man, doctors they make so much money, so you cut them a little bit--who cares? December 31st of this year, under the current formula, sustainable growth rate formula, physicians will undergo a 20 percent reduction in reimbursement.

Now, true enough, Senator Baucus' bill does delay that by 1 year. That's our typical response. We'll do something to kick the can down the road. If we do that, then next year they face a 25 percent reduction in reimbursement. In some specialties, cardiologists, in particular, where there's been some re-basing of what are called relative value units for the work that they do, are facing cuts in excess of 30 percent at the end of the year. Well, I'm here to tell you that you don't have that much excess capacity in the average doctor's office where you can squeeze 30 cents out of every dollar in savings and expect those offices to stay open.

Well, wait a minute. We've got an unemployment rate that's approaching 10 percent. Cardiology offices are small business across the country, and they are facing a 30 percent reduction in Medicare reimbursement, when oftentimes Medicare is 50, 60 or 70 percent of the business that they do. How do we expect them to keep their doors open after January 1st? How do we expect them to make employment decisions for their employees in their offices over these next couple of months while they're living with this kind of limbo?

I mean, they're sitting here watching Congress and wondering if we're just going to run out the clock on December 31st. When these huge cuts go into effect, what are they going to tell their employees? If they wanted to hire someone new earlier this year they're certainly not thinking about doing that now. And we've got a 9.6 percent unemployment rate.

Cardiology offices are small businesses. Echo techs, phlebotomists that draw blood in the lab, people that put the patient back in the room. All of these jobs are now at risk because of what Congress is doing, or not doing, with fixing the sustainable growth rate formula and the cuts in Medicare. If we pass a bill like the Baucus bill, the cuts only become deeper and more Draconian. Again, you don't save $500 billion out of the Medicare program over 10 years by not making some pretty harsh decisions.

And you know, if you think it's bad now with the sustainable growth rate formula, what's it going to look like if we enact some of these things that have been discussed over on the Senate side and indeed on the House side? What if we create this body that's going to come to us every year and say, in order for the books to balance, Mr. or Mrs. Congressman, we are going to have to cut fees that are paid to hospitals, doctors, nurses, nursing homes by whatever percentage amount they say.

Congress, if we pass this law, simply votes that up or down. They don't take any responsibility for it. There's no accountability. We just simply pass those cuts on. That's a terrible way to do business. Wouldn't it be better if we found a way to deliver care more economically so we didn't have to come to our provider community, to our doctors, to our hospitals, to our nurses and nursing homes, and say, We're going to have to keep a little bit more of your money this year in order to make our books balance?

Now, ensuring the future physician work force, I think, is extremely important. H.R. 914, the Physician Workforce Investment Act that I introduced last Congress and this Congress as well, I've provided that to the White House. You know, here's the deal. We can sit here and talk all night long about health insurance, and that may be an important discussion to have, but I've got to tell you, if you don't have any doctors there at the end of the day, all the insurance in the world isn't going to do you a bit of good. In fact, I'd far rather have a doctor and no insurance than I would have insurance and no doctor, because if I'm in trouble, if I'm needing someone to take care of me, the insurance company typically hasn't been all that great at that endeavor. But physicians always respond.

Preventive care and wellness programs. Clearly, these are going to be necessary in the world going forward. The model that was brought to us by Safeway Stores, the model that we were not allowed to consider in our markup in committee, but realistically, we have to do that. H.R. 3148, which is the Burgess-Christian CBO scoring bill, would allow for the Congressional Budget Office to score those savings that could be achieved with healthy lifestyles.

Price transparency. We did include some language in the bill that was passed. H.R. 2249 was the Health Care Transparency bill that I introduced two Congresses ago and have continued to introduce every Congress. A lot of that language was inserted into H.R. 3200, for which I was grateful. But at the same time, transparency has got to be there. So if we're going to ask people to make more and more decisions for themselves, we have to give them the information with which to do that. Mandates have no place in a free society.

And when I hear the Senate talk, and I hear the House talk about we're going to have an individual mandate and an

employer mandate, wait a minute. I'm not even sure that's constitutional. Mandates just create laziness, create laziness on the part of the insurers, create laziness on the part of the insured, and certainly create laziness on the part of your Congressman. Wouldn't it be better if we required people to actually build programs that people wanted, rather than just force people to take what we think they ought to want? Mandates are an anathema to free society.

And there are ways to do this. Prescription-drug benefit in part D, for all its faults, Dr. McClellan, when he was constructing that program, had six protected classes of drugs and said there had to be at least two drugs offered within those six protected classes, and people flocked to those programs. It has been a success in the number of seniors that now have credible drug coverage and seniors that are satisfied or very satisfied with the drug coverage that they have.

Normally, if you have a mandate you're going to get about 85 or 95 percent compliance. We've got about 85 percent compliance with the voluntary system right now. You're not going to get that much more with the mandate. Even without mandates in the prescription-drug benefit, by creating programs that brought value to people's lives, 93 percent uptake on a credible drug program.

So, you know, I've got to tell you. I will never sit down here and advocate for private insurers. But I will tell you that most Americans do have coverage under a private insurance, and they like it. They don't want to lose it. That has been one of the big obstacles to getting sweeping health care reform. The President always says if you like what you have you can keep it. I think that's right. Sixty percent of the American people like what they have, and they don't want it to change, so that makes it difficult to do reform that is on this scale and this sweeping.

I'll tell you another little secret. The Federal Government, the public option that we already have, doesn't pay its full share of the freight of the cost of delivering the care. It's subsidized by the private sector. If you shrink the private sector and grow the public sector, how are you going to make that up? Where's that money actually going to come from? And that's something that I never hear discussed.

Yeah, insurance companies do bad things. And we'll hear stories, we're going to hear stories in my committee tomorrow about how bad insurance companies are. But if we didn't have that cross-subsidization of the private sector, we could not afford the public sector. Now, people will tell you that it's the cost of the uninsured that we're leaning on the private sector to provide for us. No, that's a small amount. That cross-subsidization that's coming to the public sector is the lion's share of that. That 9 percent figure, about 2 percent is people who have no insurance; 7 percent goes to paying the freight that Medicare and Medicaid are not carrying themselves.

We have a good system. Let's build on what we have. Let's not tear it down and then create something out of whole cloth to go in its place. You know, the government can referee some of these things, but the government doesn't need to be the man in charge of all of these things. Again, remember, the United States Congress, we've got about a 20 percent approval rating. I think reforms can and should go forward. I think there are good ideas on both sides of the aisle here. I'll take the President at his word. I'm anxiously awaiting their response to my letters.

I look forward to this debate we're going to have over the next several weeks, and I would encourage people that, every morning when they get up, remember, you've got one Member of Congress and two Senators. They need to hear from you on this issue. Whether you agree with me or not, I promise you they need to hear from you on this issue before we have this vote.

For more information on H.R. 914, the Physician Workforce Enhancement Act of 2009; H.R. 1468, the Medical Justice Act of 2009; and H.R. 2249, the Health Care Price Transparency Promotion Act of 2009, log on to http://thomas.loc.gov.

House of Representatives,

Washington, DC, September 16, 2009.

President Barack Obama,

The White House,

Washington, DC.

Dear Mr. President, I am once again compelled to write to

you to accept your offer to meet with you at the White House

to discuss the health care reform proposals currently before

us.

I listened intently as you addressed the Joint Session of

Congress on September 9, 2009, and you once again extended an

olive branch to members of the minority. I want to reiterate

that I am completely committed to working in a bipartisan

fashion to deliver reforms that all Americans can be

comfortable with, increase access to care, lower health care

costs for America's families and businesses, and deliver

changes to the health system that improve quality.

I thank you for your public commitment to accept innovative

ideas from Republicans and hope that you will follow through

with your public pledge by reviewing this letter thoroughly.

As you stated last week: ``I will continue to seek common

ground in the weeks ahead. If you come to me with a serious

set of proposals, I will be there to listen. My door is

always open.''

I accept your gracious offer and want you to know that it

is not my intention to ``kill'' health reform. In fact, I

stand proudly by my bipartisan work in the U.S. House of

Representatives on health care issues. Several of my

amendments in the Energy & Commerce Committee were accepted

unanimously while others are currently under negotiation with

Chairman Waxman for inclusion in a final House product.

That said, I have read the America's Affordable Health

Choices Act (H.R. 3200) and I do concede I have many concerns

with the approach the bill takes. Many of the items you

outlined in your speech do have wide bipartisan support.

While we may have disagreements on the policy approaches to

address those problems we will never know if we can find

common ground if we do not try.

To assist you in identifying measures that could gain wide

bipartisan support I am enclosing four pieces of legislation

that will make incremental but important reforms to our

health system. I believe that, with your leadership, these

measures could be passed and signed into law before

Thanksgiving. These efforts would show that we can work

together to make important reforms that improve access to

care and protect the doctor/patient relationship.

Physician Workforce: H.R. 914, the Physician Workforce

Enhancement Act, would establish an interest-free loan

program for eligible hospitals to establish residency

training programs in certain high-need specialties. Under the

program, eligible hospitals could receive up to $1,000,000

that must be repaid within 3 and a half years. H.R. 914 will

provide needed resources to smaller and emerging communities

so they can attract and retain the medical professionals

their communities will rely on in the future. If we do

nothing to assist the training of physicians, waiting lines

will grow longer, lapses in treatment will occur, and many of

our small and rural communities will be at risk of not having

physicians to meet their growing needs.

Medical Liability Reform: As you alluded to in your speech,

too many doctors are forced to practice defensive medicine

and face the constant threat of lawsuits and unsustainable

medical liability insurance rates. This results in millions

of dollars in unnecessary tests and procedures. Seasoned

medical professionals are retiring early because staying in

practice is no longer financially feasible, further

contributing to our nation's doctor shortage. This is a

growing crisis that is pushing affordable health care beyond

the grasp of millions of Americans. H.R. 1468, the Medical

Justice Act, is based on medical liability reform implemented

in Texas. The reforms have created a magnet for doctors and

provided the funding mechanism to improve access to care and

enhance patient safety. To prove the success of Texas'

reforms, I'd like to share a few of the statistics, from the

Texas Medical Association:

Since the 2003 reforms, Texas has licensed 14,496 new

physicians. This is a 36 percent increase from pre-reform.

Thirty-three rural counties have seen a net gain in ER

doctors, including 26 counties that previously had none.

After years of decline, the ranks of medical specialists

are growing in Texas. In my field of obstetrics, Texas saw a

net loss of 14 obstetricians in the two years preceding

reform. Since then the state has experienced a net gain of

192 obstetricians, and 26 rural counties have added an

obstetrician, including ten counties that previously had

none.

Charity care rendered by Texas hospitals has increased by

24 percent, resulting in $594 million in free care to Texas'

patients.

Texas physicians have saved $574 million in liability

insurance premiums, a significant savings that has allowed

more doctors to stay in their practice.

Medicare Reform: Many new Medicare beneficiaries find it

difficult to locate a doctor who will accept Medicare. This

is because physicians around the country realize that

Medicare is an unstable payer, subject to the whims of

political will and influence, and are doing what they must to

protect their small businesses. Physicians are scheduled to

receive a significant reduction in Medicare payments on

January 1, 2010. The Ensuring the Future Physician Workforce

Act, a bill I plan on introducing shortly, will give doctors

what they really need a stable and reasonable predictor of an

inflationary reimbursement under Medicare. This will allow

seniors to maintain access to their doctor. The legislation

also rewards quality reporting of data, further incentivizes

the adoption of Health Information Technology, and brings

increased transparency on utilization, billing, and funding

to the Medicare program.

Health Care Price Transparency: A patient should be able to

know what they are paying for and how much they will pay out-

of-pocket. H.R. 2249, the Health Care Price Transparency

Promotion Act, directs states to establish and maintain laws

requiring disclosure of information on hospital charges. The

legislation requires hospitals and health plans to make this

information available to the public, and to provide

individuals with information about estimated out-of-pocket

costs for health care services. H.R. 2249 aims to make health

care more affordable by promoting greater transparency about

the cost of health care services for patients seeking care.

The legislation sets a national floor for transparency. As

someone who has committed his Administration to transparency,

this is an important step in helping make health care, and

specifically health care costs, more transparent, which

empowers the consumer.

As a practicing physician for over 25 years, I believe I

bring a unique perspective to the current health care reform

debate. I am committed to finding areas of collaboration

between the political parties that can deliver meaningful

system reforms that will benefit all Americans. I would

greatly appreciate the opportunity to review both the efforts

outlined above and also my areas of concern with H.R. 3200 so

that we may mutually work to bring quality, affordable health

care to all Americans.

I look forward to the opportunity to meet with you at your

earliest convenience. Should your staff have any questions

about any of the attached proposals or would like to arrange

a meeting, please contact me or my Legislative Director J.P.

Paluskiewicz at my Washington, D.C. office.

Sincerely,

Michael C. Burgess, M.D.,

Member of Congress.

The last hour just ended, and you heard the admonition at the end of the hour that it is extremely important for people to pay attention. And during this hour, I am going to echo that thought. It is important for people to pay attention, Mr. Speaker, and, yes, I will direct my remarks to the Chair. But, Mr. Speaker, if I could talk to the American people, what I would tell them is now is the time, it is late at night, but now is the time for you to be keeping this House under intense scrutiny and watch what happens here over the next 72 hours as we drag this carcass of a health care bill across the finish line.

Now, how did we get here? It's probably useful to think about things for just a moment. We had a big election in 2008. People said they voted for change. Right before that election in 2008, in the other body, the chairman of the Senate Finance Committee held a big meeting over in the Library of Congress and had all the big players and the stakeholders in health care in the room, and came up with what was called a white paper on health care reform. For all the world, it looked like a bill. For all the world, it looked like it would be the bill that was brought forth in the Senate should the Democrats take control of the White House, the House and the Senate. Indeed, the election was held, and they did.

I will tell you, Mr. Speaker, I was somewhat surprised that there was not a health care bill, no health care bill came forth in those early days after the election. I thought perhaps we would see one in December of 2008 during the holiday season, but no health care bill. No health care bill in the weeks that the Congress was getting organized. We had a big inauguration, no health care bill. We had a designee named to be Secretary of Health and Human Services. Still no health care bill was forthcoming. Well, surely it will come along right after that confirmation for Health and Human Services. But as it turns out, that individual had some tax problems and that nomination was withdrawn before it ever got to the confirmation vote in the full Senate. So we were left without a Secretary of Health and Human Services for several months, no health care bill.

Suddenly, it was early summer. There was a letter sent from the other body from the two committees of jurisdiction, the Health, Education, Labor and Pensions Committee over in the other body, and the Senate Finance Committee in the other body, they sent a letter to the President and said, We will be producing a health care bill within the next couple of weeks. In fact, the Health, Education, Labor and Pensions Committee did produce a bill. The coverage and cost numbers were quite startling when they were revealed: A cost of $1 trillion. It left a lot of people uncovered as the original plan was unveiled, and then several weeks were spent in what was called the markup of that bill over in that committee over in the Senate.

Then the three committees of jurisdiction in the House had a health care bill that was rapidly brought forward. We didn't really get a lot of time to look at it. There was certainly no subcommittee markup. It came straight to our Committee on Energy and Commerce for a markup. And to give credit to the chairman of the Energy and Commerce Committee, we did get a little more time than the other two committees, the Committee on Education and Labor and the Committee on Ways and Means. They each had a day, a 24-hour period, to mark up this bill. Think of that. This bill, this legislation that's going to affect the lives and livelihood of Americans for the next three generations was allowed 1 day in markup in Ways and Means, 1 day in markup in Education and Labor. We at least had 8 days in Energy and Commerce. Four of those days were spent recessed because we couldn't agree on some things, but we did have more time in the Committee on Energy and Commerce than in any other committee in the House.

Think back, Mr. Speaker, to the Clean Air Act in the early 1990s. I'm told it was an 8-month markup for the Clean Air Act, 8-month. Think how the people on those committees must have hated each other at the end of those 8 months. But what did they get? What did they get for that 8 month investment? They got a bill that had support from both Republicans and Democrats, eventually passed the House, eventually passed the Senate, eventually was signed into law by George Herbert Walker Bush, and the Clean Air Act became the law of the land and arguably has been successful since that time. So that's the way the process is supposed to work.

Let me take one step back. The House passed a bill, the Senate passed a bill, they went to a conference committee, had a continuation of that long and drawn-out process, but the conference committee produced a conference report that was endorsed by the Senate, endorsed by the House, again bipartisan majorities on either side, the bill then went to the President for his signature, and that's what we now know as the Clean Air Act.

But think of the difference between that major piece of legislation that had a great and far and reaching affect on the lives and livelihood of every American, contrasted with what we've done over the past year.

And quite honestly, Mr. Speaker, it's not that we didn't have time. It's not that we didn't have time. After all, we have been working on this thing nearly 15 months. We actually had time to do a real markup in each of the three House committees. We had time to do a real markup. We had time to do a real conference committee.

Look at the timeline of this bill. We got it in Energy and Commerce in the middle in July. We didn't have a lot of time to deal with it before, but when we got it, we worked on it, we worked hard. I offered a multitude of amendments. I had 50 amendments prepared in committee. Five of those were accepted by the time the bill passed out of committee, all of those on a voice vote, so presumably a unanimous vote, and every one of those amendments was stripped out when the bill went to the Speaker's Office before it came back to the House, to the House floor in late October, and then we had the vote in the House in early November.

The Senate had their bill. The Senate Finance Committee completed their work in the fall. They brought their bill to the Senate in the month of December. It was voted upon, famously, on Christmas Eve, and then the normal sequence of events would be for the bill to go to a conference committee. And there in the conference committee, yes, the Democrats have substantial majorities in the House and the Senate. The Democrats would have had a significant advantage in the conference committee. The idea of the conference committee is to meld the differences of those two bills to create a product that can be endorsed by both Houses in the Capitol.

But they didn't do that. They thought, well, that was hard to get that one through the Senate. Let's not go through regular order. Let's try something different. And that something different was, maybe we can just get the House to pass the Senate bill because the Senate bill was, in fact, a House bill. It has a House bill number. In fact, it was our appropriations bill, I think, for Treasury Department appropriations last year. It did pass the House as an appropriations bill, went over to the Senate for work on their appropriations bills. That never happened, but the bill was then used as a shell. The legislative language for appropriations was stripped out, the health care language was put in, so the Senate passed a House bill on Christmas Eve, and then that bill can come back through those doors, come into the House, and the Speaker of the House will say, the business of the House is now, will the House concur with the Senate amendment to H.R. whatever it is, the House agrees by a simple majority, at that time 218 votes, and the bill goes to the President's desk.

But House Members didn't want to do that. They didn't like the Senate bill. For some it didn't go far enough. For some it went way too far. But the Senate bill was not seen to be an acceptable product. So while all of that discussion was going on, there was a little-noticed, to that point, election that took place in the State of Massachusetts, and the election was to fill the vacancy that was created when Senator Kennedy died. And that election was won by Scott Brown, who is a Republican who said he would be the 41st Republican vote against this health care bill.

Whoa. Now, a lot of doors are closed over in the other body. They can no longer go to a conference committee and expect that they will have their 60-vote majority to pass anything they want. In fact, to take any bill back to the Senate now, and under Senate rules where you need to have 60 votes to cut off debate, that is going to be a pretty tall order because they only have 59 votes, 41 votes on the Republican side.

So what to do? We do still have the bill that was passed by the Senate. That Senate bill passed with a 60-vote margin, so it is still quite viable. If there is just some way to convince the House to vote for that bill. Now the Republican side, we didn't vote for it in the first place, we are not likely to vote for it in the second place. But on the Democratic side, if they can put together enough coalitions and enough votes, now the number is only 216, with some unfortunate deaths we have had on this side and some people who have left the House of Representatives, so 216 is the simple majority in the House. That is all that is required. So, well, look, maybe if we could do some technical corrections, we can't really do them to the bill because the bill has already passed the Senate, and if we took those corrections back to the Senate, we would have to have 60 votes to cut off debate. But there is a Senate process called reconciliation to deal with budgetary and fiscal matters. And under reconciliation, only a simple majority is required in the Senate. Maybe we could do those technical considerations in the Senate under reconciliation and pass that through the Senate with 51 votes.

And if we, the Senate, do that, will the House then agree to pass our bill with the understanding that these technical corrections would quickly be instituted? That is the big question right now. And are there going to be any problems with any of those technical corrections to be done under reconciliation?

Well, there might be. There might be. Because, remember, reconciliation is to pass those very tough budget and fiscal bills that are really hard to get the number of votes because sometimes you are actually cutting spending, sometimes you are actually irritating a constituency back home because we are reducing Federal spending in some of those reconciliation bills.

If it deals with budgetary issues and spending issues, then it could pass under reconciliation with 51 votes. The Vice President gets to vote in the case of a tie over in the Senate. So 50 Senators plus the Vice President would actually pass any of those reconciliation provisions, unless, unless someone makes a point of order over in the Senate that they don't deal exclusively with budgetary issues, that they are in fact changes in policy that are outside the budgetary process. Then the Senate has rules that say if a point of order is made, that it would require 60 votes to put that provision into the reconciliation bill, the so-called Byrd rule initiated by Robert Byrd, the dean of the Senate many, many years ago, to keep just this type of problem from happening. Didn't want the Republicans if they got in charge to be able to do things like this.

So the Byrd rule has been in effect for a number of years; and the Byrd rule would say, well, say you have a contentious issue in the House bill. Say there is some issue with the language regulating the Federal funding of abortion. Say there is some question of what do we do as far as dealing with people whose legal status in this country may be in some question. Well, those issues are beyond budget and may in fact be subject to a point of order and may require 60 votes to then be included in the reconciliation bill.

So it is not a given that everything that is wanted by House Democrats in changes in the Senate bill for the House to agree to pass the Senate bill, they may not be there when those technical corrections are finally voted on in the Senate. And that will take some time, because every amendment in the Senate may not necessarily be debated, but every one will be voted on; and all of that is going to take some significant time.

So where we are in the House tonight is that my understanding is the Rules Committee is to meet soon, if they are not already meeting, and the Rules Committee will come up with the language for that reconciliation bill. None of us have seen that yet. It hasn't really been scored by the Congressional Budget Office, so no one really knows what this bill will cost yet. So all of that is still hanging out there.

Then there is one more wrinkle thrown in. The Speaker of the House said it very well the other day: no one wants to vote for the Senate bill.

Well, that is a problem if you are going to need to get 216 votes in the House for the Senate bill to allow the reconciliation bill to then go forward to fix the technical problems in the Senate bill. I know this gets a little confusing, but no one wants to vote for the Senate bill.

Is there a way around voting for the Senate bill? Probably not. But, wait. What if we voted on a rule that allowed us to go forward with reconciliation, and within that rule we kind of made it like the Senate bill had already passed without actually having to vote on it?

Mr. Speaker, I would just ask the question: Do you really think the American people are not paying attention? The last Democrat who spoke here in the well of the House said it is time for the American people to pay attention to this process. I would submit that is exactly right.

Now, many people will recognize this icon, the Capitol Rock figure from when my children were young. This was the individual who was just a bill, and one day he hoped to be a law but today he was just a bill. But you can see today he is mad. He is angry. And why is he angry? He is still a bill. He wants to be a law. But he doesn't want to be deemed, and he doesn't want to be ``slaughtered,'' referring to the Slaughter rule that the House may vote on. By this time on Sunday the House may vote on the Slaughter rule which would deem acceptance of the Senate product.

Well, you can see why Mr. Bill is upset. He wants to go through regular order. He wants to go through committee, he wants to be voted on by the House, he wants to be voted on by the Senate. He really would have liked to have gone to a conference committee and have those two products melded together and then come back for an up-or-down vote in the House or the Senate. But as it appears tonight, he may not get his wish.

And is there a consequence to doing this? Now, you are going to hear people say that, oh, things have been deemed for a long time. This is nothing new. I will tell you, this is different. This is new. This is not something that, certainly in my short tenure, I have seen.

In fact, I recall a reconciliation bill in 2005 when the Republicans were in charge, it was called the Deficit Reduction Act, a very contentious bill, because we were trying to bend the cost curve on Medicaid spending. Does that sound familiar? You have heard the term ``bending the cost curve.'' We were trying to bend the cost curve on Medicaid spending from an increase of 7.7 percent year over year to 7.3 percent growth year over year. Not a heavy lift in anyone's book, but it was a big lift here in the United States House of Representatives.

Now, we were coming to the end of the calendar year 2005. In fact, it was coming up on to the Christmas holidays. People were anxious to get home and be with their families. We voted on that bill, as I recall, early on a Monday morning. We had been here through the weekend, up all night, debates, debates, debates. A lot of changes, a lot of moving things around on the chessboard. And then, in the final analysis, the bill passed very early in the morning on a Monday morning. I think it was December 19, so it was getting very close to that cutoff for Christmas.

Later in the week, that bill was voted on in the Senate. And this was a

conference report. We had voted on the regular bills, it had gone to a conference, so these were the conference reports that we were voting up or down on.

The House passed its version. The Senate passed its version on Tuesday or Wednesday, quickly left town, and were gone. The House had already vacated the premises. And it was found that there was a little discrepancy. There were some differences in wording between the two bills.

Well, as they should have done, the Democrats that were then in the majority went nuts and they said, You cannot send that bill down to the White House for a signature because the House and the Senate did not pass the same bill, the same identical language. And it was a big deal.

The reason I remember this so well is, remember the doctor fix that we talked about a lot? In fact, we did a little doctor fix today. We extended the time before the doctors get their big pay cut; we moved that from April 1 to May 1. Well, there was a doc fix in the Deficit Reduction Act. At that point, I think the doctors were facing a 6 percent reduction in Medicare reimbursement, and that clock ran out at midnight on December 31.

We fixed it in the Deficit Reduction Act, but there was a problem. The House bill and the Senate bill were not word for word identical. I don't even remember the number of words that were different. It was not many. It seemed like an awfully picky process. But in order to comport with all of the laws in our Constitution, the House and the Senate had to pass identical bills for the bill to be regarded as passed and be available to go down to the President for his signature. So the clock ran out on Medicare and the doc fix.

Now, everything else that was in the bill was not perishable, and it would keep until the House came back in January of 2006 and could fix the damage. In the meantime, there was much wailing and gnashing of teeth here in the House on the then-minority Democratic side: this is unconstitutional. We will go to court. We will take this down. So the bill did not go to the President for his signature. It stayed and languished. And then, when the House came back, they passed identical language to the Senate. The bill was passed and went off to the President for his signature. The doc fix was taken care of a month late.

Dr. Mark McClellan, who was then the administrator for the Center for Medicare and Medicaid Services, told the country's doctors that he would make good and retroactively supply that difference in the bills that they had submitted; they would not have to resubmit. He tried to paper over the problem and make it as painless as possible.

But it was a big deal. It was a painful deal for the country's doctors. That is why I remember it so well, because so many were calling me in my district office and my staff here in Washington and voicing their displeasure that Congress really couldn't have gotten this right and passed the identical bill through the House and the Senate. But the fact is they didn't. And the fact is that that was a problem as far as passing a bill and getting it signed by the Senate.

Well, what are we doing today or this weekend? What are we doing? We are not even going to pass the bill. We just deem it as having passed. Because, you know, a lot of the things that are in the Senate bill are things that we have talked about a lot here in the past 14 or 15 months, and some of them we may have even voted on a time or two. So we can just deem it as having passed.

Well, no wonder, no wonder Mr. Bill is so mad. That is not what he signed up to do. He didn't want to be deemed or Slaughtered. Slaughtered refers to the chairwoman of the Rules Committee who has created the so-called Slaughter rule, which means that the rule that allows us to take up the reconciliation bill is a self-executing rule and will deem passage of the Senate product that passed on Christmas Eve.

Do you think the American people can't see through that, Mr. Speaker? Do you think there are many phone calls going into Members' offices over the past couple of days about this? I think so, because I have heard from a lot of people. They are not happy about a lot of things right now, but they are really upset about this, and I think rightly so.

We are supposed to do things by the book. That book is called the Constitution. And when we stray from that on something like this--and this is no small matter--this is going to affect one-seventh of the Nation's economy. This is going to affect the lives and livelihood of every American not just this month, not next month, not the month after that, but for the next three generations.

Think of Medicare, passed in 1965. How has that affected people's lives, for good or for ill? But this is sweeping legislation that has a long half-life and is going to affect the way of life in this country from this day forward, really long past my time on this Earth, and I suspect a long time past the life expectancy of almost everyone who is serving in this body.

So it is so important that we get this right. It is our obligation. It is the oath that we swore on this floor the early part of January of 2009 after those very famous elections, those historic elections that created the new Presidency, created a supermajority for Democrats in the House, created almost a filibuster-proof majority in the other body. A historic election.

We were signed in, we put our hands on our hearts, we put our hands on the Bible, we swore an oath to protect and defend and uphold the Constitution.

What happened to that, men and women who are here with me tonight? What happened to that oath? Did you not believe it then, or has something happened that you don't believe it now?

This is critical. I know it looks lighthearted. I know I have copied a figure from a children's musical. But this is critical. This is going to change the way of life for every American, not just now, but for far into the future.

Now, we don't even know yet the cost of this bill. There are multiple iterations of the reconciliation package that have been floated around the Congressional Budget Office. You call them up and try to get them to do anything at all and they will not because they are working on health care. Unfortunately, it has been that way now for well over a year. It is almost impossible to get any piece of legislation scored by the Congressional Budget Office, but we don't even know what this thing is going to cost.

We talk about bending the cost curve. The Commonwealth Foundation, the good folks at the Commonwealth Foundation, I attend a number of their seminars. I think they do a good job of trying to educate Members of Congress. They will talk in lofty terms about bending the cost curve. Well, we are just bending the cost curve, all right. We are just bending it in the wrong direction.

Now, this bill is supposed to cost on the order of $800 billion and change. I think it was $824 billion. But anyone will tell you that is not the real cost. In fact, when this reconciliation stuff gets scored, it is very likely that we are going to see a number in excess of $1 trillion.

You know, just a lot of this stuff people look at it and say, What is the plain truth here? You say that you are going to raise taxes by $500 million, you are going to cut expenses in Medicare by $500 billion, and you are going to cover 30 million more people. How is that not going to affect me? You say if I like what I have, I can keep it, but how in the world is it possible to do all of those things and it won't affect me?

And the President said this several times during the summer. He said: Many people look at this bill and say, What is in it for me? What do I see differently, either positively or negatively, after this bill has passed?

For one thing, we know what they will see is a lot of new Federal regulations. We're going to see new fees on insurance companies, new fees on medical devices, new fees on prescription drugs, new fees on insurance plans. All of those, of course, have to, by definition, drive up health care costs.

One of the things that we're not doing--and you've heard me reference the ``doc fix'' in the Deficit Reduction Act. We had a baby ``doc fix,'' if you will, for just the next month. But there is a looming 21 percent reduction in reimbursement for physicians who practice in the Medicare system, doctors

who take care of some of our sickest patients, our seniors who might have multiple medical comorbidities. We've asked them to do this, and yet we come at them every year with a formula that says we're going to pay you a little less this year than we paid you last year.

Now maybe that's okay if you're fortunate enough to practice medicine in a location where energy prices are falling by 5 percent every year, labor costs are falling by 5 percent each year, cost of capital is no concern because the banks are just giving away plenty of money at a zero percent interest rate. Maybe if you live in that area, this is not a problem.

But most of the doctors who live in the real world, the same world as you and I, know that their costs of labor are going up. Their cost of capital is going up. In a doctor's office, you don't make a great many large capital purchases, but you sometimes hire a new doctor; and in order to do that, you sometimes have to go down to your friendly banker and secure either a loan or a line of credit. So the cost of capital goes up for those physicians' offices year after year.

Energy costs go up the same as they do for every other American. Even the cost of the doctor buying the health insurance for their employees will go up. Believe it or not, the insurance companies don't come into the doctor's office and say, Doc, you know what? You've done such a good job at taking care of all the people enrolled in our insurance company that we're going to enroll your employees for free or at a very reduced rate. It doesn't happen.

In fact, what happens in doctors' offices across the country every year is the insurance underwriter comes in and says, Hey, you've had some claims activity. Your rates are likely to go up in your small business here. And the doctor says, Well, maybe that's okay because maybe my reimbursement rates are going to go up enough to match it. But then most private insurance companies actually peg their reimbursement rates in the private sector to Medicare. So if Medicare is reduced by 5 percent, 8 percent, 21 percent, as we're scheduled to do this year, guess what? Insurance reimbursement rates go down. So the poor doctor is left scratching his or her head, saying, How come it costs me more to insure my employees and my reimbursement rates are going down? How's that going to work out for me?

The cost of doing business in a medical office is no different than any other small business in America, and doctors' offices simply cannot continue to survive if we continue to impose this draconian pay formula upon them, and yet nothing in this bill fixes that problem. We had a temporary fix today. We talked in grand terms about this great and wonderful fix that the House passed last fall, but we all knew over here in the House, even those of us who voted for it, we knew that the Senate was never going to take it up and pass it. In fact, they had already rejected it. As a consequence, this provision has been left out of this big, gargantuan health care bill, this 2,700-page bill, and there is no fix for the problems that the doctors face in the Medicare reimbursement system. There is no fix in the bill.

It's a simple arithmetic problem. The simple arithmetic problem is that it costs somewhere between $280 billion and $350 billion to fix that problem. Well, clearly, if you're trying to keep the cost of your bill under a trillion dollars, and I'm not sure that they have done that, but if you're trying to do that, a $350 billion addition to the price tag is not likely to make your life any easier.

There is a cost for simply repealing the sustainable growth rate formula, as it's called. Medicare part B has an additional problem in that, by law, seniors are charged 25 percent of the actual cost of their premium. The Federal Government picks up the other 75 percent very generously. But if the cost of the Medicare part B program increases, then Medicare part B premiums, by law, have to increase, and they have to increase by a formula which, again, is 25 percent of the actual cost.

Now we hear a lot of talk about insurance companies raising the rates. They do. Can they justify it or not? There are supposed to be State insurance commissioners to oversee that process. I know we had a big hearing in my committee on Energy and Commerce a few weeks ago on the Anthem, WellPoint rate increases that occurred out in California, but I honestly don't know where the California insurance commissioner was when all of that was going on. And the people at Anthem did say they submitted their paperwork to the insurance commissioner. I don't know what happened there. I honestly don't know what the disconnect was, but there are rules in place where these types of increases are supposed to be justified.

But the fact is that part B recipients will likely get a big increase in their premiums this year because the cost of paying for the part B program goes up every year, and, just interestingly enough, that increase is likely to be somewhere in the order of 12 to 16 percent. The President is very critical of private insurance companies that will do that but, wow, he is the CEO of the biggest insurance company in the world. It's called Medicare. And he's raising his rates by 12 percent this year. In fact, over the last decade, over the last 10 years, those premiums have increased almost 150 percent. Again, it's by law. It's no one doing something that they shouldn't be doing. It is just the cost of delivering that medical care has, in fact, increased over time, more people making claims on the system. And as a consequence, those costs have gone up, and, by law, the seniors who are participants in the part B program are obligated to pay 25 percent of the cost of the program in their premium.

So when people tell you that the cost of insurance is going to increase, that's true whether you're talking about a Federal program, such as Medicare, or programs in the private sector.

One of the things that concerned a lot of us as the debate was going through the House this summer was the appearance of what was called a public option. At the time, a lot of concern by, actually, Members on both sides of the aisle--probably voiced more consistently by people on the Republican side--about what this public option was going to do to pay for insurance coverage in this country. Many people on the Democratic side said, Oh, it'll be competition for the insurance companies so it'll bring their prices down.

Well, here's part of the problem. One of the reasons that the insurance companies are raising their prices is because there is a cross-subsidization, that there is a shifting of cost from the government sector onto the private sector. Medicare reimburses at a rate that's far lower than most of the private insurers for both doctors and hospitals. In order for those doctors and hospitals to keep their doors open, that means they need to charge a little bit more to those patients who come in who have actual insurance coverage. So that cost shifting or cross-subsidization exists because the government isn't actually carrying its share of the load today. So if we expand that part, how are we going to help keep the costs low on the private side? Because, again, it's a cross-subsidization that we're already doing in the existing public plans--Medicare, Medicaid, SCHIP, and the variety of other programs that exist. Those public programs are not filling the holes that are being dug, the overhead holes that are being dug at hospitals and doctors' offices, and those holes have to be filled with dollars from private insurance.

So right now it's about a 50-50 mix. Well, that's not fair. Fifty cents out of every health care dollar that's spent in this country today is already spent on one of those public options--Medicare, Medicaid, SCHIP, add the VA, Federal prison system. It's about fifty cents out of every dollar that is spent on health care, and it is going up. The other 50 percent is not all private insurance. Some of it is paid out of cash flow for some families; some of it is paid out of savings for some families, and some doctors and hospitals just simply have to write off some debt because it will never be paid. They certainly do contribute more than their share of charity care.

So the government, which has about 50 percent of the health care dollar right now, is not carrying its load, which drives up the cost for people with private insurance. So we're going to expand that part and expect that the cost for private insurance is somehow going to go down. You're talking about magical thinking. That's just never going to work out. There's no way it can work out.

And sometimes you step back and you look at this and you think, Wow, the people who want a single-payer, government-run system have really set the wheels in motion to accomplish just that. Let's create another public option, bleed off more dollars from those greedy folks on the private side. Their prices go up. The President, whoever the President is at that point, says, Well, I tried. We tried to keep the private sector involved, but look what they've done to you. There's nothing we can do about it. We will just have to take over everything. At that point, you have a completely nationalized health care system in the United States of America.

A lot of people look at that and say, No, that's not what we want. You said, if you like what you have, you can keep it. That's what we want.

Sixty-five percent of Americans have insurance either through their employer or in the individual market, and they like what they've got. They're concerned about cost, to be sure. They want costs to be held down, but they like what they have and they want to keep it. So it does concern them when they look out over the horizon and say, What might have happened with this public option?

Now, the Senate bill, at least in theory, does not have the public option written into the bill. It does. It's kind of hidden. You kind of have to look for it a little bit. The Senate bill sets up insurance exchanges across the country in order to ensure that everyone has access to at least two products in an insurance exchange. The Senate has said that the Office of Personnel Management, OPM, will ensure that there is at least one for-profit and one not-for-profit insurance company in each of those exchanges. Well, what happens if no one shows up on the day they hold the auction to sell the insurance? Office of Personnel Management will find a for-profit company and a not-for- profit company, and if they can't find one, somehow they will make one.

Now, the Office of Personnel Management right now is a relatively small Federal agency. It administers Federal benefits. It administers things like the Federal Employees Health Benefits Plan. It does a good job with that, arguably, but this is a vast expansion of their mission, a vast expansion of scope to then put them in charge of these various exchanges that are in place all around the country. The Office of Personnel Management could become the de facto public option, and in fact, as it was looking like this bill was getting very close to being enacted in the early part of January before that famous election in Massachusetts, the Office of Personnel Management was indeed gearing up to take on that responsibility.

So whether you get the House bill or the Senate bill, there's still a possibility that you're going to see a public option. It may not be the so-called robust public option that you heard talked about here on the floor of the House ad infinitum last summer, but it will be a public option nevertheless, and it remains to be seen what happens to that over time. It may always stay a small part of what is available to the insurance market or it may grow significant.

What has been mystifying to me about that process, and you heard the President say earlier or last year in the fall, he cited there's a part of Alabama that you go to and you have only got one choice of an insurance company; and if you've only got one choice of an insurance company, there's not a lot of competition, so let us put a federally administered program on the ground to compete with that one insurance company.

But there's well over 1,000--in fact, over 1,300 insurance companies--in business right in the United States of America. What if we changed the regulations such that more companies could, in fact, sell in that market in Alabama? It looks to me like a market that companies might be interested in because, after all, there's not much competition there. That's the way to get robust competition in the market, and that is the way to get the types of cost controls that we would all like to see that could be delivered more efficiently by a competitive marketplace than it can be by government regulation and price-fixing.

We know what happens when you fix prices. Those of us my age who are old enough to remember gasoline purchases in the 1970s, when you put price controls on gasoline, you end up with gasoline shortages. You remove the price controls, and miraculously there's enough gasoline for everyone to buy. And as more gasoline becomes available, then the price comes down. It was a wonderful study in just how markets were supposed to work. You put the price controls on, it becomes very scarce and very expensive. And I can remember as a young resident at Parkland Hospital waiting for hours in line at a gas station because I did not want my gas tank to be empty and risk running out of gasoline on the way to the hospital in the middle of the night. It's something I couldn't afford to let happen to me. So I missed a lot of family time sitting in those gasoline lines. Fortunately, that didn't last long because the folly of that decision was recognized, the price controls were removed, and the price went up temporarily, and then it came back down as the supply of gasoline increased.

We don't know where we're going on the cost of this bill that's before us. The one charge that the American people gave us was, We want you to do something about the cost of health care. The one thing that we're not doing in this legislation is moving in a sane way towards doing anything that would get control of those costs. In fact, some of the things we're doing may, indeed, lead to a reduction of availability, and that means a reduction of access for patients to medical care.

An interesting little article that I found online on the way over here tonight was about what will happen to health insurance premiums under the bill that has been proposed. And what got this reporter's attention was a Presidential speech where he said that the cost of insurance if the bill was enacted would drop by 3,000 percent. Later on, the White House clarified and said the President meant to say the premiums would drop by $3,000, and that is money that could be returned to the worker.

The next quote in the story is, `` `There's no question premiums are still going to keep going up,' said Larry Levitt of the Kaiser Family Foundation, a research clearinghouse on the health care system. `There are pieces of reform that will hopefully keep them from going up as fast. But it would be miraculous if premiums actually went down relative to where they are today.' '' So next line in the story is, ``It could be a long wait.'' Indeed, it could.

I do urge people to pay attention. I do urge people to dig a little deeper in the story--don't necessarily accept what I am saying here tonight. But do look carefully into this story and understand what your Congress is doing because if it doesn't affect you the day after the bill passes, it will affect you at some time.

Now convincing reluctant Members to vote on this bill by doing the Slaughter rule and deeming the bill passed may be a way to trick some wavering Members into voting for the bill. But I promise you, it's not tricking anyone out there in America. You hear stories of people going to the supermarket at the checkout line, and the person who's checking their groceries will say, You are not really going to deem that bill as passed, are you? They get it. People understand it. They've been watching this. We've been working on this for 14 or 15 months. Goodness knows we're tired of it. The country is tired of it. People do understand and are watching.

Now tomorrow in The New England Journal of Medicine, it's been widely reported that they're going to have an article detailing the attitude of America's physicians towards this legislation that the House of Representatives is likely going to try to pass sometime this weekend. The numbers were somewhat startling, and I don't have the exact numbers in front of me. But if the bill were to pass, around 30 percent of practicing physicians would consider concluding their practice and finding something else to do with their time. And if a public option is included, that number gets significantly higher--45, 46 percent.

People who have been working in the trenches, who have been delivering the health care, understand how pernicious

it has been with the constant reduction in rates for Medicare, to be sure, Medicaid in some States. In most States, physician reimbursement is just an easy target. When those State budgets start getting stressed, that's one of the first places that the State legislatures will go to try to pull some of those dollars back in. They'll reduce reimbursement rates to physicians. And as a consequence, if it was difficult to keep your doors open and pay your overhead costs with the reductions that we were seeing in Medicare, it becomes an absolute certainty that those doors are not going to stay open if Medicaid rates are vastly curtailed.

One of the things we're going to do with this bill is significantly expand Medicaid. The cost to the States right now is somewhat in flux. Nebraska got a pretty good deal on the Senate floor right before Christmas that would kind of protect them against some of the dollars that the State would have to match into the Medicaid program. Now there's talk of extending that to every State and not just making Nebraska a special case but extending that to every State. I promise you, I promise you that is not going to make the cost of this legislation go down. It is going to make the cost of that legislation go up significantly.

If we don't do that, right now there is a Federal share and a State share of Medicaid expenses that are paid. It varies from State to State. In some, it's a 50-50 proposition. In some, it's much more generous from the standpoint of what the Federal Government contributes. On average, about 57 percent of the Medicaid cost is contributed by the Federal Government. The State pays 43 percent. In this bill, the language might be more generous than that, but there would still--unless the so-called Cornhusker kickback is applied to every State, then States are going to be hit with additional Medicaid expenditures.

I have received communications from senators and legislators back home in my State where that number could approach $20 billion for the 2-year budgetary cycle that we have in Texas. And although many people in Washington would consider that so small as to not even be worthy of consideration, in a State budget, it is significant, and that is why the legislators and senators have written to their Members of Congress to advise them of this that's occurring. That means money that's not going to be available to fund transportation projects in the State. That means money that's not going to be available to pay for educational activities in the State. These will be real dollars that are taken out of circulation in the State to pay for the expansion of Medicaid that the Federal Government is going to require.

The whole question of making everyone buy health insurance, the question of an individual mandate that is contained within the Senate policy, is something that this country has not done before. That is a new phenomenon. Now I know you hear people say, Well, look, look Massachusetts has a mandate, and it's working okay up there. Well, maybe. Maybe not. I think the costs went up a little bit because the insurance companies are now under no--there's no reason for them to try to hold costs down to attract customers because, hey, you've got to buy it. It's the law. But still, if a State wants to pass an individual mandate or an employer mandate, for that matter, within their State to cover health care costs, that's their business. They can do that under the 10th Amendment, that those powers not taken by the Federal Government are reserved to the States. That's one of those powers that are reserved to the States. So if a State wishes to do that, and the people who elect the Governor and State legislators and State senators in those States are saying, Well, that's okay with us, then good on 'em. That's what they should do.

But what's working in Massachusetts likely wouldn't work in Texas. It's a different demographic, different problems. So we can't apply a one-size-fits-all solution across the country, and the Founding Fathers recognized that. You will hear people say, Well, look, it's a mandate that you've got to have car insurance if you drive your car. But you are driving your car voluntarily on a public road, and that is a State mandate for the purchase of that insurance. Not every State has them. I think there are two States that don't have an insurance mandate. Texas didn't until a few years ago. I don't know if it's actually increased the number of people who carry insurance because you are forever hearing about some poor soul that was hit by someone else who carried no insurance. But that's a State issue. And the States make that requirement.

Again, those State governments have to be responsive to their citizens in the State. If the citizens get too upset by the liberties that are being taken from them by a State government, they are free to react against that. And that's what a democratic process is all about. That's what elections are all about. But never in the history of this country has there been required the purchase of a product just as a condition for living in the United States.

Now we do have to pay income tax, it's true. You don't have to earn any money. And if you don't, then you don't have to pay taxes. But in order to ensure that this program is administered effectively, we go to the meanest, biggest Federal agency of all, that very same Internal Revenue Service, and say that they're going to collect--they're going to enforce this individual mandate that you buy health insurance.

Just a thought on that in some of the moments that are remaining to us this evening. Does putting an individual mandate on people increase the number of people who carry, say, health insurance? Putting an individual mandate on for the requirement that everyone have health insurance, does that increase the number of people who have health insurance? Right now in the country with a robust employer-sponsored insurance program, people who are employed in the individual market, small businesses who provide insurance in the individual market for their employees, the compliance rate or the insured rate is about 85 percent. We hear the figure of the number of people uninsured in this country, and it works out to be about 15 percent.

In the Federal tax system, does everyone file and pay taxes who should? The answer is no, they don't. By the IRS' own estimates, by their own estimates, 15 percent of the population decides not to file or not to pay their income taxes. Now that's a pretty stiff mandate that the IRS puts on us. Most people don't know exactly what the penalty is, but they're pretty darn sure that they don't want to find out firsthand because they do know it to be severe. So with this very severe penalty hanging over people's heads, you still have 15 out of 100 who will say, No, thanks, I'll still take my chances. How many more people are going to buy health insurance who don't already have it if we put that on as a requirement?

And then one of the other considerations is, if the fine is not as much as the insurance policy itself, then someone who believes themselves truly to be at zero risk for any medical condition says, You know what, I'll just pay the fine if it's less money, and I'll worry about insurance if I get sick. Of course under the plan that's over in the Senate now, they can do that because there will be what's called guaranteed issue. If they get sick, they can literally purchase the insurance policy from the back of the ambulance on the way to the hospital.

You know, we heard a lot during the course of this debate on health care over these past 15 months. One of the things that I will never forget is the energy and enthusiasm that I encountered this summer in doing town halls during the month of August. As you will recall, we passed the bill out of the Energy and Commerce Committee sort of at midnight Friday night, July 31. We all went home to our districts. We started seeing the stories on the evening news of vast throngs of people showing up at Representatives' town halls, both Republicans and Democrats. Whether they had come out in favor or in opposition to the bill. We hadn't voted on the bill on the House floor at that point. Because I was sitting in the committee that voted on the bill, I could tell my constituents back home that I voted no in committee, and I would vote ``no'' when it came to the floor, unless there were substantial changes. And people supported that decision overwhelmingly in the town halls that I did this summer.

But it doesn't mean that they said, We don't want you to do anything.

They had some rather specific things that they would like to see Congress do to help them with the problems that they were having with either insurance companies or with their doctors or with their hospitals. There were some things they thought that Congress could do. Now bear in mind the approval rating for Congress is somewhere south of 20 percent. We do not enjoy a significant amount of political capital. In order to do something this big, you really have to have the American people behind you, but we don't. And therein is the trouble that the Democrats are having passing this bill. Right, they've got no Republicans, but then they really didn't try. They weren't interested in having any Republicans a year ago when this process was beginning.

So it's no surprise that at this point, a year later, they don't have any Republican support for their proposals. Their problem is within their own conference.

Now, they've got 40 seats on us. It really shouldn't be a problem. I'm sorry, they have 40 more seats than they need to pass this bill, because in the House it's a simple majority. It really should not be a problem. All you've got to do is keep 40 people from leaving you. That shouldn't be that hard. These are people who feel the same as you. They're members of your same party. They believe the same things you do. That shouldn't be a hard lift.

Why is it so hard?

It's hard because there's not the popular support for this bill that everyone assumed would be there shortly after the 2008 election. We had an election. President Obama won the election. Health care was a big deal during the election, so it was just naturally assumed that the American people would be with the Democrats no matter what they did, with, to or from health care. As a consequence, they didn't need any Republicans. They really couldn't be bothered. We were noisy and inarticulate in meetings, and they just wanted to write the bill they wanted to write, and they'd get it passed without any Republican votes.

Now they're up against an impasse with their own side. Very difficult to pass something this large that affects this many people without at least some input from both sides. That's never been done before, to my knowledge, in this country; and that's what we're trying to do tonight. You might be able to do that if you had the popular support of the American people behind you. You could say, well I've got the people with me. I don't need Republicans. And that would be true, but they don't have the people behind them.

So the fact that the Republicans are not supporting the Democratic bill is actually of no consequence. Their difficulty is the people don't believe what they're doing. And, quite frankly, I don't see how there is a way to change that equation between now and Sunday, the day we're supposedly going to vote on this monstrosity.

I did hear from people in town halls about things they do want done. I maintain a Web site that's devoted to health care policy. It's called healthcaucus.org, @healthcaucus.org. ``Healthcaucus'' is all one word. Healthcaucus.org. Under the issues tab, you see Dr. Burgess' prescription for health care reform. And I've listed there the nine things that people told me most consistently during the summer and fall that they wanted to see us do.

Number one thing, people sure do want some help with preexisting conditions. There are things we can do to provide some help, and it doesn't mean an individual mandate. It doesn't mean guaranteed issue. It means helping those people who need help. It does cost some money. The Congressional Budget Office scored an amendment that Ranking Member Joe Barton had on our committee. It scored at $20 billion. Nathan Deal, the ranking Republican on the Health Subcommittee and I have introduced legislation that captures the spirit of that amendment. We erred on the side of being more generous. That's a $25 billion authorization for that program. The Congressional Budget Office said $20 billion over 10 years. We plussed it up by $5 billion. Let's start it and see what happens.

After all, that Senate bill comes over here and becomes law, no one gets any help tomorrow. It's 4 years before they get help. Preexisting conditions are a problem today. We heard this over and over again in the summer time. This is something people actually wanted us to work on. We could work on this in a bipartisan fashion. We never even had a hearing on how to approach the problems of preexisting conditions without a mandate. We never even had one word of testimony about that in our committee leading up to this.

Does there need to be some fairness in the Tax Code? You bet. Why does someone in the individual market who's paying for their health insurance out of pocket have to pay with after-tax dollars when someone who works for a large multi-state corporation gets their insurance paid for with pre-tax dollars by their employer? That fundamental unfairness is something that has to be fixed. I'm not sure that I know the best way to fix that, but I know we haven't even tried. We haven't even had those discussions.

We do need some medical liability reform. It's working in Texas; it could work in other places around the country. It does help keep costs down, in spite of what congressional Democrats and the White House tell you.

Portability, the ability to carry insurance with you through life, is extremely important, especially to younger workers. Think of the relationship with your insurance company if you had a longitudinal relationship with that insurance company.

There are some things that we could be doing that are not that heavy a lift and don't cost that much money. Most importantly, we can show the American people we can deliver real value and work together while we're doing it. Then we could improve those approval rates, that low esteem that the country holds us in.

Dr. Burgess' Prescriptions For Health Care Reform

1. Insurance Reform

We should eliminate the bias against patients with pre-

existing conditions, outlaw rescissions except in cases of

fraud, and ensure states have well-designed high-risk pools.

H.R. 4019--Limiting Pre-Existing Condition Exclusions in

All Health Insurance Markets (Deal)

H.R. 4020--Guaranteed Access to Health Insurance Act

(Burgess)

2. Tax Fairness

Providing individuals the same tax benefits no matter where

they want to get their health insurance, and tax credits to

help individuals purchase insurance in the individual market.

H.R. 3218--Improving Health Care for All Americans Act

(Shadegg)

3. Medical Liability Reform

The success of Texas' 2003 reforms: Texas has licensed over

15,000 new physicians and Texas hospitals have delivered more

than $594 million in charity care.

H.R. 1468--Medical Justice Act (Burgess)

4. Portability

Allowing patients to shop for health insurance plans across

Thank you, Mr. Speaker.

Well, we have had quite a day here in Washington, D.C., in your Nation's capital. The 6\1/2\ hour health care summit that was held down at the Blair House right adjacent to the White House has mercifully concluded. And as the saying goes up in Washington, everything's been said, everyone has said it, so it was time to go home. But for those who haven't had quite enough discussion about health care today, maybe we can spend just a little while longer talking about some of the things that we heard today and some of the things that we maybe perhaps didn't hear today.

One of the things that I do want to stress, we heard several times in the past several weeks that the Republicans don't have ideas. In fact, that was one of the admonitions of the President on starting this summit was that the Republicans didn't have ideas, and he wanted to in fact show the country that the Republicans were devoid of ideas. But nothing could be further from the truth. If anything, we saw today abundant Republican ideas. Some may say there are too many Republican ideas, too many to fit in one room.

I wanted to spend a few minutes tonight talking about some of those ideas on our side. I have a Web site, Mr. Speaker, that is devoted entirely to health care policy. It is from the Congressional Health Care Caucus. The Web address is www.healthcaucus.org. And under the Health Caucus Web site, under the Issues tab, I think it is the second heading, is a Prescription for Health Care Reform. Anyone is free to go to that site and click on the Prescription for Health Care Reform, follow the links, and they will be taken to a one-page description of nine different bullet points on health care reform.

In fact, there is even a little segment to record comments if someone would like to leave their ideas or their thoughts on the paper. Or if someone thinks of other things that might in fact be included, we welcome those comments on the Web site.

I am just going to briefly go through this list, and then I have got some other observations that I want to make on the summit that occurred today. And we will be joined from time to time by other Members of Congress, and I want to give them an opportunity to speak. But under the Prescription for Health Care Reform, certainly everything I heard this summer was, we don't want a 1,000-page bill. People really didn't want a 2,000-page bill after we came back and revamped it after the summertime. But what did people want Congress to do on health care?

There are people who have legitimate concerns that the system is not functioning in an optimum fashion. We do have great health care here in America, but there are distributional issues. The employer-sponsored insurance system does work well for the 60 to 70 percent of the population that is therein covered, but in fact there are problems for people who are outside the employer-sponsored insurance system, and there are certainly problems that all of us face with the advancing cost and complexity of health care.

So just running down the list, insurance reform that would include limitations on insurance companies excluding people for preexisting conditions, and guaranteeing access to insurance. Now, one of the fundamental differences on the Republican and Democratic approach to this is that the Democrats want to have, and the President wants to have, a mandate. That is, you are required to buy a product, an insurance product.

It is interesting because during the campaign in 2008, President Obama, when he was a presidential candidate, actually moved away from mandates. Candidate Hillary Clinton during her candidacy was in favor of mandates. Barack Obama was less enthusiastic about mandates. He did feel that there should be a mandate for children. We don't hear much discussion about that anymore. In fact, I don't think I heard that during the 6\1/2\ hours of debate today.

But mandates really have no place in a free society. There's some argument as to whether or not it would even be constitutional for the Federal Government to require someone to purchase an insurance product that they might

not want. So there are legislative products out there. And this is the point I want to make. When people say, oh, we can't start all over, this would be too taxing. There are a couple of bills out there that I would encourage, Mr. Speaker, people to look at. H.R. 4019, a bill introduced by Nathan Deal of Georgia; H.R. 4020, a bill introduced by myself. Those two bills, taken in conjunction, would go a long way towards eliminating the problems with preexisting conditions.

Another bill to address the tax fairness or the tax inequity that exist in the health insurance market today introduced by John Shadegg, H.R. 3218, the Improving Health Care for All Americans Act, that would allow the same benefits, no matter where you get your insurance, whether it's through employer-sponsored insurance or in the individual market, the same benefits should accrue to an individual as accrue to a business.

Medical liability reform. Texas and California have taken big strides in medical liability reform. So why do I care? If Texas has fixed their problem with medical liability, why would I care about that? Well, I care because the cost of defensive medicine is significant. And since the Federal Government is the purchaser of about 50 percent of all the health care in this country, the costs of defensive medicine that drive up the price of Medicare and Medicaid, those costs need to be brought back under control, and medical liability reform is a way to do that.

Portability. Allowing patients to shop for health insurance across State lines, again, a bill introduced by Mr. Shadegg is H.R. 3217, the Health Choice Act.

To back up for just a moment to medical liability reform, H.R. 1468, the Medical Justice Act.

We're about to bump up against an important deadline on Sunday night, and that is the expiration of the prevention of a reduction in payment to doctors who take care of Medicare patients. We go through this time and time again. It is time for Congress to fix the physician payment reform, and H.R. 3693 would do just that.

Do we need to be worried about if there are going to be doctors there to see us when we get sick in the future? I think that is a concern, and I think that is something where Congress might play a role. Doctors to care for America's patients, the Physician Work Force Enhancement Act, H.R. 914. People ought to be able to know what the cost is when they go to the doctor or the hospital.

How about a bill for ensuring price transparency? H.R. 2249, the Health Care Price Transparency Promotion Act. Prevention and wellness programs, we all agree, during the hearings this summer, the individuals that come in who worked at Safeway and talked about how health promotion and wellness was saving them money, firms like Allegiant in Omaha, Nebraska, brought in great stories about how they had involved their employees in living healthier lifestyles and reaped the benefits from lowered insurance costs.

An odd thing about the way we do things at the Federal Government, we're actually going to have to change the HIPAA laws, the privacy laws, a little bit in order to have this type of legislation be passed. But that's certainly within the purview of Congress and within the ability of Congress to do that.

But prevention and wellness programs, although I do not have the bill number attached to this, we had several amendments in committee and in the Rules Committee leading up to the passage of the Democrats' bill this fall that dealt with prevention and wellness. The legislative language is written. It is not in bill form right now because it would require a simultaneous modification of the HIPAA laws in order to allow that to happen.

And finally, I mentioned before, mandates. No place in a free society. And this is one of the fundamental differences between the President and myself. He wants to force everyone to buy an insurance policy. He said that's the only way to bring costs down. I would submit that if the insurance companies know you have to buy their product, their prices are not likely to go down. In fact, if you're required to buy their product under the penalty of law, with the IRS as the enforcer, it is very likely that the cost will go up because no one wants to run afoul of the Internal Revenue Service.

And then we make insurance companies lazy. Why bother to compete with a better product? Why try to create a program that people actually want? You've got to buy it anyway. The government's going to force you, you're going to buy my product, I don't even have to make it something that you want, and I can charge you more for it. Mandates make insurance companies lazy.

We actually have a model for what works in this endeavor, and that is when the Medicare part D program rolled out, then Administrator of the Center for Medicare and Medicaid Services, Dr. Mark McClellan, required, out of six classes of pharmaceuticals, there were six protected classes of drugs. Within each class, an insurance company had to offer two choices, and using that as the parameter, the companies did produce the plans that people wanted. The product, part D, has been very popular. Ninety-two percent of seniors now have credible drug coverage under Medicare because of the flexibility and the desirability of these programs. The cost came in way under budget, and 92 to 94 percent of seniors are satisfied or very satisfied with their prescription drug coverage, so a program that indeed worked. And the whole emphasis was to make this look more like insurance and less like an entitlement.

Creating products people want is a better way to go about getting meaningful change in the insurance market than giving the insurance companies a license to steal, which is what a mandate would be, in my opinion.

I have some other observations on the day's activities, but I wanted to yield such time as he may consume to my good friend from Pennsylvania, Mr. G.T. Thompson, who in a former life was a health care administrator. I know it's odd that a doctor and a health care administrator would get along, but the two of us do get along very well.

G.T., I will yield to you such time as you may consume.

I thank the gentleman for his work on these issues. I thank him for always being willing to be involved in these. These are tough problems. These are complex problems.

You know, the activity today, I referred to it earlier today on a radio show as the Blair House project, not to be confused with the Blair Witch project. There were times when it did seem to be that there probably were some spells being cast.

The other thing that really had to strike you in watching the discussion today is that there are fundamental differences as to the role in government, fundamental differences as to the involvement in government.

You know you can't help but be struck. Here we've worked on this concept now for 13 months. The President was sworn in the 20th of January of last year. Here we are at the end of February, and still no bill is across the finish line. Boy, I thought it would have happened much, much more quickly. In fact, had the energy that was put into the stimulus bill been put into a health care bill, in all likelihood they could have passed whatever they wanted in February of last year. Instead, they chose to work on the stimulus first and then cap-and- trade and then gradually, gradually, gradually, their capital bled away to where they did not have the votes necessary on their side to pass one of these bills.

And this is the fundamental problem that is happening with the President's plans and the Democrats' bills in the House and the Senate right now is they do not enjoy popular support. Pick your number: 56, 58, 75 percent of the American people who do not support this 2,000- page monstrosity that literally required bribes to bring Senators down to the well to pass this bill Christmas Eve. The American people saw that and they rejected it.

They might trust us--I am not sure that they will--but they might trust us to work on some of these individual concepts one at a time. But at the very end of the summit today, the President decried incrementalism and said we have to be bold and we have to move forward with a large bill.

Why? Why do we have to do that? The programs to deal with preexisting conditions would involve risk pools to be sure. Reinsurance options for States, yes, it's going to require some Federal subsidy. The Congressional Budget Office has estimated $25 billion over 10 years. They may be a little bit light on that, but still we're nowhere near a number like a trillion dollars, which is scaring Americans to death.

We could provide some help in that market. The States could provide some help in that market. We could ask our partners in the insurance industry to voluntarily or by law cap their premiums at some level so that the person who was in this market did not find the costs so daunting that they simply gave up and did not get insurance.

Now, all of these great programs that the President and the Speaker talk about that they're going to give to the American people at no charge, none of these programs start for at least 4 years.

Now look, here we are 13 months into a new administration and the administrator at the Center for Medicare and Medicaid Services is not there. He hasn't even been appointed, much less confirmed by the Senate. That is the individual who is going to be responsible for taking this 2,700 pages of legislation that we give them and turning the legislation into rules and the Federal rulemaking process. That is going to be an enormously difficult task. It is going to take 4 years to work through all of that and impugn all of the legislative intent and make those Federal rules and leave the rulemaking period open long enough so that people can comment on it. That is an enormous task. It's not going to happen overnight.

So the people that come to us and say, My premium's going up too much, I want you to take it over, they're not getting anything for at least 4 years.

Now, in the meantime, what if we took an approach--and, in fact, it was an approach that was talked about by

Senator McCain in the fall campaign of 2008. What if we took the approach of we're going to take existing risk pools of the States--34 States have already created. We're going to emulate the best practices of the best States. We're going to allow for some reinsurance options if companies are willing to take on higher-risk individuals so that no individual insurance company is tasked with too much in the way of financial loss, and we're going to cover this group of individuals.

I heard it over and over and over and over again this summer at town halls, Stop what you're doing. We don't want you to destroy the system that is working well for 65 or 75 percent of the country. We want you to concentrate on those individuals who, through no fault of their own, have suffered a tough medical diagnosis, have lost their job and employer-sponsored insurance, couldn't keep up with the COBRA payments and now find themselves having fallen into that dreaded category of uninsured with a preexisting condition.

While we're at it, we might look at the COBRA system. COBRA was placed as a protection to help people who had employer-sponsored insurance but they lose their job. So employer-sponsored insurance means the employer generally pays about two-thirds of the premium; the employee pays about one-third of the premium. When you lose your job, you can't continue that insurance. But in all likelihood, your employer is not going to pay their two-thirds any longer because you're no longer their employee. But for 18 months, you can pick up the whole premium and pay that with a small administrative charge--I think it's 102 percent of the premium--and you can continue your insurance for 18 months and not fall into the category of uninsured. And if you have a preexisting condition, you continue to be covered at that cost.

But that's a tall order for someone who just lost their job to continue to carry that degree of premium. What if we allowed people-- instead of you had to keep that same insurance your employer provided you, what if we allowed them into a lower-cost, high-deductible plan for those 18 months and still preserved their insurability during that time, so that when they found employment, they would not fall into that same category again. Or they might even decide to continue that high- deductible policy with a lower premium and continue to have the protection of health insurance without falling into a preexisting category.

But we never really worked on those issues. We just decided we were going to do this big bill, and it was going to have mandates, and it was going to have a public option, and this is the way it was going to be. But to tell you the truth, for 4 years there is no help. There is taxes. For 4 years there is the immediate Medicare cuts, but the benefits don't start until year 4 or 5 or possibly even 6. We don't even know how long it's going to take to set up those programs. And again, we don't even have the administrator at the Center for Medicare and Medicaid Services. The President needs to nominate one. The Senate will then have to confirm them. We may still be months away from filling that very important bureaucratic job over at the Department of Health and Human Services.

I'll yield back to my friend from Pennsylvania

I was criticized on a news show earlier today referring to this exercise as a 6-hour photo op. Probably I would fall into the category as a ``plummet.''

Isn't it interesting that, yes, premiums for the average family may increase for 10 to 12 percent, but that's okay. Instead of an apple, you get an orange, so you're coming out better in the deal.

Now, yesterday, in our Committee on Oversight and Investigations, we hauled in Anthem Insurance Company in California. And Anthem, to their great discredit, chose right now as a time to increase their premiums, and they have become the whipping boy and the poster child. And I will concede, I think they raised their premiums too fast. They were tone deaf. Their highest premium increase was 39 percent. Their average was 25 percent. Twenty-five percent. Okay, that seems high, but the President's already said 12 percent. Yeah, that's okay because you get an orange instead of an apple, so after all, you're good in that transaction.

So I guess if Anthem wanted to raise their rates, they probably should have stayed at that 12 percent rate. They would have been right in line with the President of the United States. They could have raised their rates and all been happy about the transaction. Instead, they overshot. They hit an average rate of 25 percent and, as a consequence, found themselves sworn in under oath in our committee having to absorb the ordeal that we put people through when they come before our committee.

It's interesting, perhaps the one thing that would provide the right impetus in the competition to hold down those costs we are not going to do, and that's the ability to buy across State lines.

In the individual market, buying a policy for a family of four in New Jersey is $10,000 a year. Your State of Pennsylvania, $6,000 a year, my State of Texas, $5,000 a year. As long as people know what they are purchasing, I don't see why it is reasonable to restrict someone from having a policy that may be more affordable.

My insurance premiums have decreased by about 50 percent over the last 2 years. Not because I am a Member of Congress and I get a special deal, but I said, you know what, I can no longer afford this high option PPO insurance that is available to us in Congress, so I have elected to go into what's called a high deductible health plan with a health savings account. I actually had one several years ago when I was in private practice. I liked it.

I liked the fact that I was the one who got to choose which doctors and facilities I got to use. I didn't have to call 1-800-California to get an X-ray preapproved. I wrote the check and I controlled the money, and I made the decision about who I saw and when. So I have gone back to that type of policy, and I will tell you I am very satisfied.

We have improved from the old medical savings account in 1986 to the Health Savings Account improvements that started in 2003 and continue to this day. Preventive care is now included as part of the benefit in a high deductible health plan because the insurance company has an interest in making sure if you have a problem that it is diagnosed early, while it is less expensive to treat, and I think ultimately that's a good thing.

I have chosen a plan that does not have prescription drug coverage because after we passed the prescription drug benefit in Medicare in 2003, one of the unintended consequences was we changed the market so that now many generic medicines are available at Wal-Mart for $4 a month. I try to find those bargains for those medicines if I should need one. I try to find those bargains at Wal-Mart or go to an over- the-counter variety, which is much cheaper than the name brand that is bought at the pharmacy, and you can actually achieve significant savings.

I am motivated to do that because it's my money that I am spending for those compounds. Yes, I could have paid more for PPO insurance and then, yes, I could have had a nice mail order, even gone down to my pharmacy and gotten brand names, but I have found that, hey Prevacid is over the counter now. It costs a fraction of what it used to cost a few years ago. Even before that, Prilosec was a similar medicine, not quite the same thing, but that was available in a generic form over the counter at that time at a fraction of the cost of the 30-pill bottle of Prevacid that I was taking before.

So it makes the consumer more informed and motivated. Here is how you hold down health care costs: Let me be the decisionmaker about that. Don't tell me from a comparative effectiveness board that, hey, this medicine is just as good as this medicine, and so this is all you get because this is what we are buying for you this month.

Let me have some of that money back to spend myself, the premium that I pay every month, a portion of that goes into the medical savings account. Every year that it accrues and grows larger it's tax deferred until--if I don't spend it on health expenses I would obviously have to pay taxes on it when I took it out. As long as I spend it for legitimate medical purposes, hey, that's pretax dollars. That's probably the best deal you could do in the individual market. So these are changes that we actually ought to encourage.

I was stunned today to hear the Democrats admit, you know, we agree on a lot of this stuff that we have got here on these sheets, but, well, we don't do the health savings account thing. My goodness, that is the one way to really start to bring--you talk about bending the cost curve, that's one way. Get a motivated patient, educate them about some of the options that they have, and, oftentimes, not oftentimes, almost always they will make the right decision. I cannot tell you how many times in my medical practice if I recommend a test, a CT or MRI scan, a CAT scan or an MRI scan, and the next question from the patient back to me was not, Doctor, is it really necessary, or, Doctor, is this safe to do this, the next question was, well, does insurance cover it? If it did, there were no more questions. Go ahead and have the test.

I, on the other hand, with the type of policy that I have, yes, I may have hurt my knee or shoulder bad enough to go get a CAT scan, or I may make the decision that, Doctor, with a little ice and tincture of time would this not perhaps resolve on its own? Yes, it could, and if it doesn't get better in a week we could still do the CAT scan and we won't have delayed beyond the therapeutic interval, so it is okay to do that.

I am happy to take that advice and not have the test. If I don't feel better in a week or 10 days or whatever the prescribed time limit is, fine. Go get the test, and I will still be able to write the check and have that done. Here is how you bend the cost curve down. You get the patient involved, put the power back in the hands of the patient. Let the patient and the doctor make those decisions.

Don't make them buy the insurance at 1-800-California, but don't make them buy across the street at Health and Human Services. Let the patient and the doctor make those decisions. Every doctor has had the unpleasant experience of having called a preapproval number and have their patient denied a test or a procedure or a surgery, and then you have got to go to bat for them and prove all of these things. It is an enormous nuisance, and I hated it every time it happened.

On the other hand, in the Medicare and Medicaid system, they go ahead and cover that, but maybe 3 or months from now, maybe a year from now, they call you back and say, you know, we don't think that hospitalization was actually necessary, and we are going to deduct what we pay to you from the next round of payments that we give you for your next round of Medicare and Medicaid patients.

That is beyond frustrating because at that point you may not have at your immediate disposal the documentation that you at least would have had with a preapproval process. Neither is a good occurrence in a doctor's office. We need to come to some sort of consensus. But, as much as I hated the preapproval process, I see now, dealing with these large, large Medicare and Medicaid outlays, why it is necessary sometimes to assess medical necessity and why it is necessary sometimes to seek that preapproval, perhaps in our Medicare system.

If we really were serious about bending the cost curve, instead of just cutting doctors' payments--and that's what we do, we say, well, we will pay 20 percent less this year than we did last year--what's the practical effect of that? Well, the doctors' costs are fixed. He is not paying less for electricity to light his office this year than he was last year. His office help certainly didn't come in this year and say, hey, you know what, we can all take a pay cut because we love working for you.

That doesn't happen. His costs go up every year. The reimbursement rate goes down because Congress says, hey, we are spending too much money. What is the practical effect of that? The practical effect of that is, you know, I was able to pay my bills and take something home last year seeing 18 patients a day. But you know what, this year I have got to see 25 patients a day. And maybe if I can squeeze an extra procedure or two out, maybe I should do that because I have got to make up that difference somewhere.

So we have gone about this the wrong way. We are ratcheting down costs at the provider, and yet the doctor, he or she is the one who picks up the pen and writes the prescription, orders the hospitalization. The most expensive item in the doctor's office is their ballpoint pen most of the times because the doctor is the one making the decisions about that medical care.

Wouldn't a different way to look at this might be to say, Doctor, we are not going to cut your pay this year. We are, in fact, going to pay you a little bit more. We hope you will see fewer patients and maybe take a little bit more care and a little bit more preventive medicine and education with those patients along the way. It would be a phenomenal thing to look at but we never tried. We just cut the doctor's pay and said, whew, we got through it this year, the doctors are all mad but maybe they won't remember come November, and we will cut them again at the end of the year.

We are probably going to bump up against the clock. I do want to make this point from what we talked about the cost of insurance at the hearing we had yesterday.

It is important to understand, I think, that Speaker Pelosi, Harry Reid, President Obama, their health proposals would not make health insurance significantly cheaper for America's families. Under the bill passed by the House in November, H.R. 3962, a family of three making just under $55,000 a year and buying now a plan in this new exchange that's going to be set up and created by the bill, they would have to personally contribute after a tax credit about $5,500 a year in premiums. Additionally, this family would also pay $4,000 of out-of- pocket costs exclusive of the premium--copays and drugs that weren't covered--so this family would pay about $9,500 for a family of three that earns $55,000 a year in the Health Insurance Exchange.

I think it's important for people to understand that when we pass these bills and it's all settled and done, it doesn't mean free insurance. It doesn't mean free health care. It means, yes, you have got a government option here for buying insurance, but it's still going to cost something. It is still going to be an expensive item in that family's budget every year, and we are misleading people by telling them that, hey, we need to pass this bill because too many people don't have health care.

True enough, the person who has no income and no job will now have access to Medicaid, which they may not have had before, but the average person earning a reasonable salary is still going to find that the cost, the expense they paid for health insurance, is going to be significant. Here is the rub: If we pass this bill, this won't be an optional expense in their budget. They will be required to buy this, and the enforcer is going to be the Internal Revenue Service.

Now, Mr. Thompson, you brought up the online purchase of insurance for automobiles that has the cute little lizards and cave men on the logos. People will sometimes bring up to me, well, why, why not have a mandate. After all, there is a mandate to buy car insurance in your State, so, what would be the matter with having a health insurance mandate?

Here is the key. In my State, this is a State decision that in the State of Texas, people have to carry insurance if they are going to exercise the privilege of driving on the roads of the State of Texas. Health insurance is a different animal, and for the Federal Government to require, not a State government, but the Federal Government to require the purchase of health insurance is taking us in the direction of loss of liberty that none of us have really ever encountered before. It is a new concept.

So if a State wishes to exercise a mandate, which they have done in Massachusetts, then that's a State decision and that decision will either be supported or rejected by the voters in that State, but for the Federal Government to create for the first time a mandate, a requirement that a person purchase a product just for the privilege of living in this country, again, we are going down the road of loss of freedom that, again, I don't think people really want to go there.

Now, you will also hear, and it's so strange to hear the comparison of we have got to have a mandate as you do with automobile insurance, and you know what, you can buy that consumable insurance online. What if, instead of, if we had our thinking right, we would let the health insurance be available online, let the plan finders be available online and, if people think it's necessary to have a mandate, let that be a State decision. Let that be a State decision if the exchange is--right now you have, and I don't know the precise number, 30 or 34 States whose attorney generals are drawing up legislation to prevent their States from or prevent their citizens and their States from being required to follow an illegal Federal mandate.

It just shows you the type of tension that we are going to set up between the State and Federal Governments if we were to pick up and pass either the House or the Senate bill and send it down to the President for his signature.

Mr. Speaker, I thank you. And I thank our side of the aisle for having the opportunity to speak to our colleagues, both Republicans and Democrats tonight, about a very, very important issue. The team that just spoke, Mr. Speaker, on the floor of this House about much of the spending and the plans and the too much spending, too much taxing, too much borrowing theme, which is absolutely what the American public, Mr. Speaker, needs to know about, including the plans and the spending and to have a comprehensive health care reform plan that we would vote on, we literally, Mr. Speaker, would vote on before this body and the other body goes on the traditional August recess. That is what, just barely a little more than 4 months away. And the big question is not do we need health care reform? I think my colleagues, and particularly my colleagues on this side of the aisle, who are doctor Members of this body, who are with me tonight to discuss this, the issue of health care reform, we do not disagree, Mr. Speaker, and my colleagues, that this needs to be done.

Nobody, whether Republican or Democrat, whether majority or minority, would want to see 47 million people in this country to have no health insurance whatsoever, and maybe another 25 million that are underinsured. And, yes, indeed, it could happen to one of my adult children and their young families. They all have decent jobs, but one major illness away from being under-insured and possibly ending up in a bankruptcy court, facing foreclosure on their homes and these kind of crises that we all agree we need to avoid.

So the reform of the health care system is not really a question of whether or not this side of the aisle agrees. We do agree. It is a matter, though, of how we do it and when we do it, and what we can afford to do. And I think that what the President has proposed so far is, just as we hear about his overall budget in a 10-year projection, and the numbers that we received over the weekend from the Congressional nonpartisan budget office, of unsustainable debt, deficits that will lead to possibly doubling of the national debt within 10 years. It is something that really has to be addressed.

Well, Mr. Speaker, tonight, we are here with, I am leading the hour, but I am very pleased that some of my colleagues on the GOP Republican Doctors Caucus have joined with me. And I wanted to set the tone for what we will talk about during this hour, and that is about physician work force; and will we have the manpower, when those 47 million hopefully do have health insurance, and the under-insured are fully insured, where are we going to come up with the doctors, the health care providers, to be able to provide that care?

Having a plastic card, Mr. Speaker, that says you are covered and you have access doesn't guarantee any individual that they are going to be able to have a provider who is going to see them.

And my fear is that they will not be able to have that access, particularly if the majority is successful in their plans to have a government default option to go along with, let's say, Medicare and Medicaid and TRICARE and veterans' health care benefits and the CHIP program. It is just adding one more responsibility of the Federal Government to control all of health care, and that is really what we are going to talk about tonight.

As I walked over here, Mr. Speaker--I was walking in the building, into this great Capitol House Chamber, the people's House--there was an emergency, and I saw physicians from the office of the House physician--paramedics, nurses--sprinting to the ambulance that is parked right outside this building for just such an emergency. I thought to myself, you know, thank God for the health care system that we already have. We definitely can improve upon that, and we will talk about that tonight, but thank God that we have that ability to respond in that manner.

It makes me think, Mr. Speaker, of the tragedy that occurred up in Canada in regard to this famous actress--and I will not mention her name--the tragic death of that actress after what seemed like a fairly routine, snow-skiing fall in which she got up, dusted herself off and said: I am fine. I do not need any medical care. Let me just go back to my resort hotel room. I am fine. Of course, that is what she did, and we all know now that 2 hours later, when she began to get into trouble and, maybe, passed out and a 911 call was made, it was 4 hours later that she was finally seen at a major medical center that could respond to this subdural hematoma that she obviously had developed. By that time, she was brain dead, and a life was lost, not just a life of a famous person and a prominent person but a mother of young children and of a devastated family.

So when we, Mr. Speaker, hear this talk about a single-payor system, of a government-run system not unlike the Canadian system--I am not necessarily picking on Canada. They are our good friends and neighbors to the north, but the same thing could be said, I think, about the system in the U.K. or in Taiwan or in any of the other countries that have a national health insurance, government-run program. If this accident had occurred, I think, out in Colorado in the United States, that young mother and famous actress would be alive today.

So these are some of my thoughts as we begin to discuss. I call on my colleagues, the doctor colleagues, who are with me tonight. I want to ask my colleagues to focus their attention on this first poster. It is titled ``A Second Opinion,'' and then, of course, it is subtitled ``Strengthen the Doctor-Patient Relationship.'' That is what we want to do, and that is what we will talk about.

With this second opinion theme, I think, most people associate a second opinion with a medical opinion, and understand that, when they go to the doctor, sometimes a second opinion is very, very valuable. In fact, I think almost always it is very valuable. So it is important when the other side of the aisle--when the majority party--says or some of their news media, coconspirators, if you will, who support a

national health insurance program or any major issue that the majority party is promoting says, well, the Republicans, all they are is a party of ``no,'' they do not have another alternative. They are just saying, well, we are going to stand in the way of something that we do not like because the majority party has presented it, and this is all political.

Mr. Speaker, nothing could be further from the truth, and that is certainly true in regard to the health care of this Nation. This second opinion theme could apply to energy; it could apply to what the previous team was talking about in regard to the budget and spending. We do have a plan on the Republican side on all of these issues and, if you will, a second opinion Republican plan on health care.

So, with that sort of setting the theme, I want to go ahead and recognize my colleagues. I am going to first call on the gentleman from Pennsylvania, my classmate who has been with me here in the House--and we are now serving our fourth term--and that is Dr. Tim Murphy from the great State of Pennsylvania.

Dr. Murphy, I would like to give you an opportunity to talk about some of the issues that you have been focusing on, not just as part of the Republican Doctors Caucus but since you came to Congress some 6\1/ 2\ years ago. I will yield to the gentleman from Pennsylvania.

I thank my colleague, my co-chairman of the GOP Doctors Caucus and of all of the important points, Mr. Speaker, that Dr. Murphy brought to us. That point he made about the doctor- patient relationship being paramount I think is the most important. And that is our concern that if we go to a government-run, totally government-run system, that that will be sacrificed and that will be sacrificed badly.

Before I yield to my colleague, Dr. Fleming from Louisiana, Mr. Speaker, I wanted to draw my colleagues' attention to this next slide in regard to the supply/demand crisis.

Even if nothing changed under the current system, we already have a shortage. And it will only get worse as we approach the year 2025. There are a lot of reasons that. Growth in an aging population. There is an immense physician shortage on the horizon. It is expected by 2025 to be a shortage by 125,000 physicians, and the demand for care by that time will increase by 26 percent.

Now, the bulk of the shortage--and these are statistics from the Association of the American Medical College; this was a center for workforce studies back in 2008, so just a year ago--but the bulk of that shortage, in fact, 37 percent of the projected shortage, is in primary care physicians. And I don't disagree with President Obama and the majority party in regard to the need to get more primary care physicians, to have these medical homes that we talk about, to stress wellness. And that is so important.

So it couldn't be more timely for me to call on Dr. Fleming, who--he specializes in family practice, and has for a number of years, in south Louisiana.

And it is indeed a pleasure to yield time now to Dr. John Fleming.

I thank the gentleman from Louisiana, the good doctor.

And, you know, again, stressing this theme of going forward, the shortage of manpower, it has a lot to do with physician satisfaction in their chosen profession. And I think that is basically what we want to make sure, Mr. Speaker, that everybody, all of our colleagues understand on both sides of the aisle, that as Dr. Fleming was saying, if you have access to an affordable health insurance policy, as we all hope and pray for those 47 million, if it's a system that is run by the government and we crowd out the private market completely--and that is one of my big fears and I think that of my colleagues--then these young men and women that normally would--our best and brightest who would normally want to go to medical school and maybe become a family practitioner and provide this care, they are not going to do it. They are going to choose another profession. They are going to maybe become lawyers, but not doctors. And I think that is a big concern.

And I don't think anybody knows more about this than the next person that I will yield to, Dr. Phil Roe, a fellow OB-GYN physician, who has provided women's care and delivered lots of babies in the Tri-City area of Tennessee--Kingsport, Bristol, Johnson City--and he knows of what he speaks. And I think he's going to talk to us a little bit about what probably everybody in this Chamber is aware of, and that is something called TIN care in Tennessee, and I am happy to yield to my colleague, a freshman representative doing a wonderful job, Dr. Phil Roe.

Well, I thank the gentleman from Tennessee and the words of the wisdom that he brought us to.

Before I yield to my colleague from Georgia, I want to just make a few comments, Mr. Speaker, about some of the statistics in regard to physician workforce shortage. Any my State, my home State of Georgia, it's ranked 40th in the Nation with respect to active physicians per 100,000 people. In Georgia, there are 204 per 100,000. National average is 250.

Georgia also has the dubious ranking of 44th in the Nation with respect to active primary care physicians. You just heard that from Dr. Fleming, and you will hear it in just a minute from Dr. Paul Broun, a family practitioner in Georgia.

Seventy-three primary care physicians per 100,000 in Georgia; the national average, 88.1. Eighty-nine percent of job seekers graduating from Georgia medical residency programs received and accepted job offers in 2004 but only 54 percent of them stayed in my great State of Georgia.

So just kind of bringing home some of the statistics from where we live and represent.

At this time, I'm proud to yield to Dr. Paul Broun, the gentleman who represents my hometown of Augusta, Georgia, and Athens, Georgia, the home of the University of Georgia, the great bulldog nation and many, many wonderful counties in between.

I yield to the gentleman from Georgia, Dr. Paul Broun.

I thank my colleague, Dr. Broun, for joining with us in this hour, talking about the issue of strengthening the doctor-patient relationship and not destroying it.

And as Dr. Broun pointed out in some of his statistics, those shortages that he was talking about in the State of Georgia--and this is applicable to 49 other States as well--we're talking about under the current system. But once we cover the 47 million uninsured, and these numbers just get that much more difficult, and actually the shortage increases by 4 percent, and these statistics are frightening.

And before I introduce the next speaker, my colleague from Texas, my fellow OB/GYN colleague, I wanted my colleagues to see this next slide. And part of the reason of this physician shortage--and as I say, it will only get worse in the future--is declining reimbursement ranked as the number one impediment to the delivery of patient care.

Sixty-five percent of physicians surveyed said that Medicaid pays less than the cost of providing that care, and 35 percent of the physicians surveyed said Medicare pays less than cost of providing that care. Nobody in this House of Representatives has worked harder than my classmate, the good OB/GYN doctor from Plano, Dallas-Fort Worth. He has worked so hard to try to provide a reimbursement based on a reasonable formula and not this current sustainable growth rate.

Nobody can really understand how that's ever figured, but doctors know that every year it's figured in a cut in their reimbursement, and that indeed, Mr. Speaker, is not sustainable.

And with that, I yield to my colleague from Texas, Dr. Burgess.

I thank my colleague on the Energy and Commerce Committee, Dr. Burgess.

I want to yield to another of my physician colleagues from Georgia, Dr. Tom Price, an orthopedic surgeon who represents the district adjacent to mine, the Sixth District of Georgia.

Dr. Price is going to tell us a little bit about these 47 million uninsured, many of whom are employed and simply cannot afford what is offered by their employer, their portion of the premium, and many of them of course work for very small employers that can't afford to offer coverage at all.

At this point, I am proud to yield to my colleague, the chairman of the Republican Study Committee, Dr. Tom Price.

Dr. Price, thank you so much.

Mr. Speaker, I realize that we are running very close to that witching hour. Maybe I saved the best until last. He probably thinks that I'm shorting him on time because his LSU Tigers whipped up pretty badly on my Georgia Tech Yellow Jackets in the Bowl game. That's is not the case at all.

I'm proud to yield to the internist and gastroenterologist from Baton Rouge, Dr. Patrick.

Mr. Speaker, I thank Dr. Patrick. And I thank all of my colleagues. You can see the level of interest of the GOP Doctors Caucus. But we want to work with the physicians, the medical providers, the nurses on the other side of the aisle, and work in a bipartisan way.

In this area of a second opinion, we will continue to bring other issues forward as we continue in the 111th Congress.

Mr. Speaker, with that I yield back.

Thank you, Dr. Burgess. I really appreciate what my good friend from Texas is doing in terms of his leadership with the Congressional Health Care Caucus. It's refreshing in this Chamber to deal with folks who have the facts and have the experience to make informed decisions when it comes to such important topics like health care. I think of all the issues that come before this Chamber, there are probably few things as intimate to our individual lives as health care. And to observe this process over this past 14 months, where bills are written as I look at these bills, 1,000, 2,000, 3,000 pages, which has been special agendas for, you know, just misled government-run health care, it's apparent to me that those who are writing those bills have very little experience, if any experience in health care. And so it's been a real privilege to be able to work with you and under your leadership to really look at the solutions that we need to have.

Now, as I travel around, and I did, my background was 28 years nonprofit community health care where I, in the hospitals, the health systems I come out of, we work very hard to be partners with our physicians.

And so what am I hearing? As I travel in my congressional district and I listen to folks throughout the country, I haven't met anyone that says, just don't do anything. The commitment is that, as I talk with folks, that they feel that they like the health system we have. Can we improve it? I think there's an acknowledgment that we can do that. And I've certainly spent my professional career serving my patients first as a therapist and a rehabilitation services manager and ultimately as a nursing home administrator. And looking at four dimensions of health care that we should always continue to strive to improve. Number one is cutting cost. And that's just not cost for a certain segment or a certain group, but cutting cost of health care for all Americans, which we're committed to that with the solutions you've talked about. It's about improving access, increasing access and improving quality and strengthening that decisionmaking relationship between

the patient and the physician, not allowing government or a bureaucrat to be that wedge in between.

As I talk with people about health care, and I've been doing that since I came to Congress, that's what they're asking for. The people I talk to, they like the solutions. They like the bills that we've introduced as far back as last July that dealt with medical malpractice reform, tort reform that drives the cost of the health care up for all Americans through both the premiums for medical liability insurance that has to get absorbed into the cost of doing business, those premium costs get passed along as a part of the fees, and not just the premium fees, but then there's the cost of defensive medicine that occurs, with extra tests that are ordered, not so much maybe to serve our needs and whatever particular illness or disability we come to the doctor for, but to provide a record that shows that the physician has exhausted every possibility.

It's things like many of the solutions you talked about, allowing to purchase across State lines. It fascinates me that you can go to the Internet and you can go on a Web site, some of them got little critters like lizards on them, and you can purchase car insurance and get the best value, the best product for the best cost. You make that decision as an individual. And yet we are barred from purchasing health insurance across State lines.

In States like Pennsylvania, especially rural Pennsylvania where I'm from, if you have choices, you have just a couple of choices. Maybe if you're lucky, you have three choices to pick from. And a lot of people say, well, I want the insurance that you have as a Member of Congress. Well, I'm quick to tell people, I worked nonprofit community health care for hospitals for 30 years. I'm paying more today as a Member of Congress than what I ever paid for health care. But what I would like every American to have, certainly every constituent in my district that I have today are just lots of choices. And we do that by allowing purchasing across State lines, more competition. That's a good thing. Competition brings the cost down and raises quality. I don't care what you're purchasing, that's a principle that lasts.

Certainly, a formation of association health plans, and preexisting conditions, as you've talked about. I mean, those are all just a few of the different parts of the proposals that Republican Members have introduced and are pending bills that are right here that the Speaker could elevate to the floor at any moment so that we could actually take an up-or-down vote on these. I think the American people would vote yes. I see a thumbs-up from the American people as we talk about these different proposals.

Preexisting conditions, that's a tough issue, but we're addressing that within the proposals we have. Just because you're born with a preexisting condition or you happen to have the misfortune to develop a disease such as breast cancer or prostate cancer in the course of your life doesn't mean that you shouldn't be able to afford to be able to purchase affordable health insurance. We address that in the solutions that we put forward. I'm so very proud of all of the representatives from the Republican Caucus who were at the Blair House today. I thought they did an outstanding job of representing the American people and ideas that the American people are looking for.

You mentioned about workforce issues, and to me that was something that I came to Congress just looking as a crisis. Starting with rural America and underserved urban areas first, the baby boomer generation, my generation, we're beginning to retire in tremendous numbers. And in those areas where our physicians, our nurses, therapists, technicians are retiring, this payment system will get changed if we don't proactively address those workforce issues. If you don't have a physician in your community to provide services, you do not have access to quality care. And so because we've been misled with these 1,000, 2,000, 3,000 pages, all the attention's been drained in the wrong direction, we're missing the bigger issues that, frankly, we've been talking about. We've got bills that address some of the workforce issues, and so it's time to get beyond the misinformation and the misdirection that my Democratic colleagues have been putting together in these 1,000, 2,000-page bills, and get to the business of really addressing the real health care issues.

Some of the observations of just watching the summit, as I guess it was called--I have a question for you. I will come back to you for that.

Some observations of the proceedings that I watched today when I had an opportunity to tune in in my office--I wasn't on the invitation list to be there. It was pretty limited invitations. But I heard--and I don't know which leader it was, whether it was the President or the Speaker or whom, made comments there were absolutely no Medicare cuts that are involved in this. And yet the fact is the Congressional Budget Office Director, Doug Elmendorf, back on December 19, just a month ago or 2 months ago, noted that there were Medicare cuts, and those Medicare cuts built into this impact all areas of health care from hospitals to skilled nursing to home health to hospice. Hospice, which is a wonderful service for people who are in the final stage of dying, where they have the support of compassionate health care professionals surrounded by family to be able to die with dignity, and yet that is an area, one of many areas of Medicare cuts that are slated for under these proposals.

In my responsibilities across many different settings of health care, I have to say that there is a lot of reasons why commercial health insurance is expensive. Tort reform I would put right on top of the list.

But maybe even higher on the list, I would say, is the Federal Government. The Federal Government pays--underfunds and has systematically underfunded the costs of health care--the physician, the hospital for Medicare payment. For every dollar of cost of providing care, the Federal Government pays 80 to 90 cents. For medical assistance, it's maybe, if you're lucky, 40 to 60 cents. It depends on the State. The commercial health insurance pays, on the average across the Nation, 135 percent of costs. And the primary reason for that is the hospitals' physicians have to negotiate at that rate. If they don't, they can't make up for what the government does not pay.

So what are some of the other costs that I heard today that really intrigued me?

I heard the Democratic leadership claim that it was going to bend the cost curve, meaning it's going to bring the cost down for everyone. Yet, what we saw was the administration's actuarial--the professionals that work for the White House, that look at those numbers and do those cost projections--have found the Senate bill, in fact, will not decrease health care costs. The Center for Medicare and Medicaid Services, who you just talked about, the Medicare professionals, their finding was that those were going to increase expenditures by $222 billion, with a ``b,'' billion; not hold costs, not cut costs, but will expand the costs of health care.

And the President today was very up front in his comments where he said that, yes, this proposal will increase premiums for the average American and American family by 10 to 13 percent. Well, I thought the number one thing we were looking at here is decreasing the cost of health care, making it more affordable. How do you truly get access to greater health care? Well, you bring the costs down so people can afford it.

So I was curious to get my good friend's opinion. This morning when I woke up and I knew this was going to occur, it struck me as I was walking to the Capitol, was this going to be a health care summit today or a health care plummet? And to me, the indicator was whether the President showed up with either a white board, a large white board that was blank that we could start over and do what the American people want, and that would be what today's events would be--it really would be problem solving, because that is what Americans are looking for, problem solvers--or would he show up with a rather large hammer and really try to hammer through, push through Big Government, bad ideas that the American people, in a large majority, have rejected.

So I yield back to my good friend just to get your impressions of do you think it was a health care summit today or a health care plummet.

I have to wonder with that because I see premiums like announcements, and they are going up. And this is why we're committed to doing the right type of smart government solutions to bring the costs of health care down, the premiums down. Giving a license to 12 to 13 percent additional increases, that's unacceptable to me for the American people.

I have to wonder how much of what's going on in Washington and these health insurance companies as America is watching the debate here, that--you know, giving this approach that the Democratic leadership, my good friends and colleagues on the other side of the aisle are taking, how much is that driving up premiums right now because they don't know what's coming. They don't know the premiums. There is a lot of uncertainty.

I mean we, not too long ago, passed a credit card bill under similar circumstances. It was going to provide all kinds of limitations and impose new conditions on really what has been kind of a free market type of process, and what I have seen, actually, as a result one of the unintended consequences, is some of those interest rates--before the new regulations kicked in, some of those interest rates went way up as an unintended consequence of government overreaching, government-run approach.

I have to wonder if what we are seeing with some of these more recent--like the situation you just talked about, may be an unintended consequence of just the wrong-minded direction that our Democratic colleagues are taking this health care debate in, as a reaction by the health insurance industry.

Pennsylvania being one of those, absolutely.

Well, you have touched on so many very important issues during that time, during the course of this hour. I certainly want to come back to--you know, when I started in health care, I mean, the patients were not a part of the treatment team, they were, you know, everyone kind of focused their energies on the patient, the individual, the consumer, but they weren't included in health care decisions. So much has changed in at least three decades.

Today, I don't know of any health care professionals that don't consider the patient themselves a very important part of the treatment team, and it's so important that individuals take that, exercise that self-responsibility to be informed and to make decisions and to take control of their health care, extremely important.

You also talked about, you were talking about the stress on physicians, and it's significant. In Pennsylvania, the average age of physicians in Pennsylvania is 50. Many that I talk with, they look at the challenges of practicing medicine today. In Pennsylvania, we have terrible medical malpractice costs. We export our physicians. We train a lot of them, but we export them to States like Texas. You know, we don't keep them. And many of the physicians I talk with that are 50 and older, they look at what they have accumulated in their lives, and they look at how much they are spending each year, whether it's medical malpractice, these additional costs or regulations that are coming, the extra costs they had to put into practice to comply with Federal mandates like the HIPAA law from the 1990s.

And they are saying, you know what? Why don't I retire now while I

can at least retain a little bit of what I've earned so I can have some type of future enjoyable retirement? That would contribute so much to our access issue in States like Pennsylvania where citizens are not going to have access to quality care. I see that as a significant unintended consequence as a part of what my friends across the aisle are proposing and pushing at us.