Madam President, we, unfortunately, are in a period where we are going to be redebating health care reform. We had long debates on health care reform in the last couple years. I cannot think of…
Madam President, we, unfortunately, are in a period where we are going to be redebating health care reform. We had long debates on health care reform in the last couple years. I cannot think of legislation that has occupied so much time in this body, as well as the other body. But, regrettably, we are going to redebate health care reform, even though legislation was passed last year, and even though the legislation was signed by the President. The law is enacted. Nevertheless, this body, regrettably, is going to spend, it looks like, a lot of time redebating health care reform. Why? Basically, because the other side of the aisle wants to do so--wants to not admit health care reform is the law of the land. It wants to repeal it.
The other side knows there are not sufficient votes to repeal health care reform. That is a well-known fact. The other side knows and those who have covered health care debate reform know the votes are not there. It is the law of the land, signed last year, and it will remain the law of the land.
So then, you might ask, if it is the law of the land today and if everybody knows Congress will not repeal health care reform, why in the world are we going to debate this for another who
knows how many weeks, months or maybe even years? To be honest, I think it is because the other side thinks--and I will pick the charitable explanation first. They don't like health care reform, for whatever reason, even though I strongly disagree with their reasons. But in addition to that, they think it is a political issue. They think they can score political points by mentioning points which, in the main, are not accurate but say them anyway, and they will say it over and over, and unless those points are refuted or those myths are busted, many of the American people will start to believe some of that stuff.
There is another reason, which is a bit regrettable, and that is because there have been lawsuits filed in Federal district courts around the country, alleging that the law is unconstitutional--the health care law. It looks like those decisions will eventually make their way up to the Supreme Court of the United States, and I expect the Supreme Court will not rule for, I don't know, maybe 1 year, which means we will further debate health care reform, waiting to see the outcome of the U.S. Supreme Court.
I heard one that I think is a very ill-advised argument a few minutes ago, which is that because the Supreme Court has not yet decided on the constitutionality of health care reform, we should, in effect, pass a moratorium. We should forget the provisions of the law because we don't know how the Court will rule.
That is one of the most specious and inadvisable arguments I have heard in a long time. That, in effect, means that whenever any law is passed and there is a lawsuit filed, that law is invalid because the suit is filed. If we are to follow that line of reasoning, then anytime we enact a law, anybody who doesn't like it could rush off and file a lawsuit, and that would mean we don't follow the law. I think the better course, by far, is to assume the law is the law of the land, until it is overturned on a statutory basis or a constitutional basis. That is the way we should operate.
The Senator who suggested, about one-half hour ago, that we should enact a moratorium, in effect, I think should rethink her position. If she wants that to be the precedent, I think she would recognize that pretty soon the country could not function because anybody could file a lawsuit on maybe something passed 10 years ago. They could say: I don't like that law, so I will file a lawsuit. Following the Senator's line of reasoning, we can't enforce that law because somebody doesn't like it. That makes no sense.
One of the myths that has been discussed many times, and as was said by the previous speaker in his argument for repeal of health care reform, is that repeal will save money. He thinks the health care bill adds to the deficit.
You and I have been around here long enough, Madam President. We have lived long enough to know that anybody can come up with any set of figures or statistics that he or she wants. That is a fact of life. So if somebody asserts this and that, I think it is wise to see what that person's authority is. Who says that? Where does that come from? Who verifies or validates that? We well know there is one organization that has studied health care reform and has concluded that health care reform saves, I think, about $240 billion; it reduces the deficit by $240 billion in the first 10 years, and it reduces the deficit by north of $1 trillion in the next 10 years. That is the Congressional Budget Office.
The CBO, I remind my colleagues--and for anybody listening--is a nonpartisan, professional organization that analyzes legislation for both Republicans and Democrats for the House and the Senate. They are a very professional outfit. They work very hard. No one has ever even hinted that this outfit, the Congressional Budget Office, is unprofessional or that it has a partisan bias. Nobody has suggested that. Everybody knows they work very hard and do the best they can, under difficult circumstances--I say ``difficult'' because it is difficult to predict the future, to know exactly how any request they are given will actually score. It is a complicated process. You have to build models. It takes a long time to build a model and to know what goes into the model.
I wish to make it very clear to anybody listening that repeal of the health care law will actually increase the deficit by about $240 billion over 10 years and increase the deficit by over $1 trillion in the next 10 years. That is what the CBO says. That is the organization that all Members of Congress must live by. Different Members of Congress might have different points of view. They may belong to some different organization--very liberal or very conservative--that has an ax to grind, and they can come up with some other figure. But they usually have an ax to grind, a bias they want to perpetuate.
The one arbiter in the middle, which is professional, the one organization nobody has ever accused of being partisan or unprofessional is the CBO. They conclude, again--and they have written letters to us in the Congress--that repeal would essentially add about $\1/4\ billion to the deficit over 10 years. It would add; that is what repeal would do. It will add to the deficit over $1 trillion in the next 10 years.
That should end the argument right there because it is the one neutral professional organization that has looked at this. Other organizations can have their points of view, but the one that is professional, the CBO, has ruled, and we have to go by those numbers anyway in passing legislation here. That should be the end of the argument. That has been settled. That is what the effect of repeal would be. That is it, as anybody knows when he or she is spouting off numbers that are not the CBO's but some other organization--I don't know which--maybe Heritage or some other organization. First of all, they are not neutral. They are not unbiased. Second, we can't go by those numbers anyway under the rules of the Senate. So it is kind of silly, frankly. They may be scare tactics. That is one of the scare tactics used on this floor to try to score political points, but it is inaccurate. It is just plain simply inaccurate.
Now, a couple of other points. What do we spend on health care in America today all together? We spend about $2\1/2\ trillion a year on health care, we Americans do. About half of that is public--that is Medicare, Medicaid, children's health insurance--and about half of that is private--the commercial insurance industry. That is the American way. That was the division before health care reform was enacted.
What is the division after health care reform was enacted? It is about the same. It is about 50-50. So this is no government takeover. This is no government takeover. It is still about the same. Maybe it is a percentage point or so different, I don't know, but it basically is the same. There is no government takeover. Half of it is still private commercial insurance, as it always has been.
Also, in America we spend much more per person on health care than the next most expensive country. I don't know the exact number. I think it is 50 percent, 60 percent more per person on health care than the next most expensive country, but we are not 50 percent to 60 percent more healthy per person than the next most expensive country.
In fact, all the international health care data ranked us pretty low. We are not No. 1; we are not No. 2 in health care. We are way down there. I have seen statistics--I haven't looked at it recently--that show us being maybe 14th and 20th in terms of health. Our infant mortality rate is much higher than many countries. Our death rate is higher than many countries. I don't know about our diabetes rate, but I expect that is high compared to other countries, and maybe cardiac and other chronic care is high compared to other countries. But we are not No. 1 in terms of health care. We are No. 1 in per capita cost of health care.
So I would think we should begin to reduce the rate of growth of health care expenditures in our country, and that is what this legislation does. It starts to reduce the rate of growth of health care costs in this country. That is probably why the Congressional Budget Office reaches the conclusion that it actually reduces the deficit by $\1/4\ trillion over 10. It is probably why the Congressional Budget Office says it reduces the deficit over $1 trillion over the next 10 years. And it is probably also why the Congressional Budget Office says that compared with prior law, I think it is 90 percent of Americans' premiums will be lower--90 percent of people's premiums will be lower.
Again, that is the Congressional Budget Office. That is a neutral organization. They do the best they can. They are professionals. Some Members of Congress criticize them because they do not come to the conclusions they like. Other Members of Congress criticize the CBO because the CBO doesn't come up with the conclusions they like. It is tough what they do, but they have always been praised for doing the best job they can, and they have never been criticized for any partisanship or unprofessionalism. They are a very good outfit.
I have had my problems with the head of CBO, Mr. Elmendorf. I have talked to him many times on the phone. Most of the time it is saying: Can't you get your numbers to us more quickly? Why does it take so long?
He does his best. He is very professional. He says: Senator, I am just doing the best I can. And I know he is, but still I am a little frustrated, but I know he is, and I think he does a pretty decent job.
Now, you might ask: Why are American health care costs so high? Why is that? Why are American health care costs so high? Well, there are a lot of reasons for that. Essentially, it is waste. It comes down to waste. There is a lot of waste in the American system, and this legislation, among other things, is designed to root out a lot of the waste.
What is some of the waste? I am not going to go into great detail, but I am struck with an article written by Dr. Guandi on June 1, 2009, in the New Yorker magazine comparing El Paso, TX, with McCallum, TX. What conclusion did he reach? This is an article that many in the health care industry cite because most people think this fellow got the nub of the issue right.
Health care costs in El Paso are about half per person as compared to health care costs in McCallum, TX. They are both border towns so it has been adjusted for immigration and so forth. The outcomes in El Paso are higher. People do better in El Paso than they do in McCallum, TX.
Why, one might ask. The basic conclusion of this article is that it is because of the way we in America reimburse doctors and hospitals and providers. It is a way which allows a culture in a community to spend a lot of dollars on health care, if it wants to, and it is a way it allows a culture in a community to spend fewer dollars and focus more on a patient, if it wants to. That is the culture of a community. That is because we pay providers in America; that is, doctors, hospitals, the pharmaceutical companies, medical equipment manufacturers, and so forth, on the basis of quantity and volume, not on the basis of quality.
So there is a bias in the system. Doctors want to do the right thing, but there is a bias for a doctor to order an extra procedure. There is a bias to order an extra drug for this or that. There is a bias to get this new equipment, and I might say, too, though it is awfully technical, but when we reimburse hospitals there is something called DRGs, the DRG purp, and it is according to procedure in a hospital, but it does not include the medical equipment. So there is no real fix on what is the cost of that medical equipment. So the medical equipment manufacturers can charge virtually what they want, and they charge a lot.
We have read lots of stories about how you can go to Walmart and get the same little small whatever it is for about one-tenth of the cost that a hospital is going to charge, and it is because the providers are purchasing through DRGs. That is an example of a lot of the waste that occurs in the system.
Let me give another example. I think there are excessive procedures in America. You can do a lot with anecdotes, but this is one that I think gives some indication of one of the problems we face in America.
I know a doctor, he is a neurosurgeon, and a very reputable, very good one. He said to me: Max, you know, there is another neurosurgeon group that wanted me to join their practice. So I went to talk to them. We talked a while. I have my own practice, and they have their practice. After a while, the negotiations kind of cooled a little bit. Why? It turned out the group who was seeking to have my friend join them did an audit on my friend's neurosurgical practice, and it was that audit which kind of cooled the ardor of the group having my friend join them. Why? Well, the group said: Our hit rate is 2 to 1, and your hit rate is only 20 to 1.
Those were the exact words they used--``hit rate.'' What does that mean? That means in the practice of the several neurosurgeons, for every two patients they see, they perform one procedure. They have a hit rate of 2 to 1. My friend's hit rate is 20 to 1. For every 20 patients he sees, he performs 1 procedure. Those doctors in that group love procedures. They want to do everything under the Sun. You have a back pain, it is an operation, a procedure, and all that; whereas, often you don't have to have the most expensive procedures.
But our system in America, because it compensates doctors and hospitals on the basis of volume and quantity, has a bias toward excessive procedures. That is one reason we have waste in America today. Nobody disputes that. It is one reason we have waste in America today.
Something else. There is something called the Atlas study by a guy named Jack Wennberg. This is from a few years ago. He looked at health care costs across the country, and what did he conclude? By the way, this study has not been refuted in any significant way over the years. He concluded basically--and I am exaggerating now--if a person lives, say, in a Wheat Belt State, say Montana, the Dakotas, or the Northern Plain States, that person's health care costs per person are roughly one-half of what they would be if that person were in a Sun Belt State--you know, Miami, Denver, Los Angeles, Phoenix, or Dallas. The outcomes in the Wheat Belt States versus the Sun Belt States are better. People have better outcomes; that is, they are cured better, faster than are people in the Sun Belt States where the cost is twice as much per person.
Well, you might ask, why is that? The reason is because, basically, it is supply driven; that is, in the South there are a lot more doctors per person. There are a lot more hospitals per person. People like to live in the South. They like the sunshine weather. When you have more doctors and more hospitals, that is supply driven, and that tends to push up costs because those doctors and those hospitals want to do things. They want to order procedures for their patients, to make them worthwhile, and that is what happens.
Now, most doctors around the country, including the South, are good doctors. They want to do the right thing. But I can tell you, I have run into individuals--one cataract surgeon, an ophthalmologist, told me--and I couldn't believe it because he was very upset--he was only getting paid $2 million a year. Basically, he had people come in and rotated people in his office to do more cataract procedures--more cataract--and he was upset that he was only getting paid $2 million a year.
So this health care bill is trying to address that basic problem, and it is called health care delivery reform. We are going to move slowly toward reimbursing doctors and hospitals a little more on the basis of quality as opposed to quantity. It is hard to measure quality. How do we measure quality? It is hard, very hard. But there are some provisions in this legislation--which have been criticized by people unfairly--designed to help both the doctor and the patient have a better idea of what the right procedure is and how to get the highest quality health care. That is what it is designed to do. There are lots of names for it--bundling, ACOs, and all kinds of things--but that is the whole purpose of it.
The key is this: It is not at all intended to tell the doctor or the patient what to do, as has been claimed. It is not that at all. Rather, it is just the opposite. It is to help the doctor and the hospital have better, more information so the doctor and the patient can decide for themselves what procedures should next be performed or not. It is more information to the patient, it is more information to the doctor so the patient and the doctor can make their own decision.
There are implications by some on the other side of the aisle that this legislation destroys or significantly undermines the doctor- patient relationship. There is not a whit of truth to that. It is just the opposite. It helps with information to the doctors and information to the patients so they are
in a lot better position to know what they should and should not do.
I have talked to a lot of doctors. They want to learn more. Right now, the drug rep comes into their office and pedals this drug, and the doctor wonders: Gee, is this the right drug? We are trying to get a little more objective source of information so that the doctor and the hospital and the patient have better information.
Let me go back to the earlier point. I mentioned that health care costs, according to the Dartmouth study, are much lower in the Northern High Plains States than the Southern States. The Congressional Budget Office--people don't like this because it is the Congressional Budget Office. People on one side of the aisle may not like it because it is the Congressional Budget Office. But they concluded that if the entire country's health care system were applied, nationwide, in the way that it is applied in Wheat Belt States; that is, Montana and other Northern High Plains States, the cost of health care in America would be reduced by 29 percent. Remember, the outcomes in the Wheat Belt States are better than are the outcomes in the Sun Belt States.
I said earlier that we spend $2.5 trillion on health care. Thirty percent of $2.5 trillion is a lot of money. What is that--north of $800 billion a year? I do not stand here to say we are going to save all that money, but I am saying that is some indication of some of the waste that occurs in the current system. Others will say there is waste because too many doctors have to practice defensive medicine. I do not deny that. I think too many docs do have to practice defensive medicine, and that has to be addressed. But that is waste. That, by and large, is waste. It must be addressed.
I know there are other Senators who wish to speak, but there are a couple of points I want to make.
Preexisting conditions is really a big deal. In my State of Montana, about 425,000 people have preexisting conditions. That is nearly half the population. That means that without health care reform, most of those 425,000 would not get quality health insurance. They would not get health insurance--certainly not quality health insurance. They may get it, but they will have to pay too much in premiums to get coverage.
This legislation moves us toward that day where a health insurance company cannot deny coverage based on preexisting conditions. We have already done it for kids. We have a pool for kids. In a couple of years, all Americans will be able to get quality health insurance. They will not be denied coverage based upon preexisting conditions.
What is the consequence today of denial based on preexisting conditions? Part of it is people do not have health insurance, but also it is this: In my State of Montana--this is true in all States--a lot of people go to the emergency room. They go to the doctor--they get hit by a truck or get cancer--and they don't have insurance. If you don't have insurance, what do you do? You go to the ER, that is what you do. You have a good ER doc, and he or she takes care of you, and you see another doc.
If you can't pay the hospital bill because you don't have insurance, what happens? You get the care. But the cost of the doc, the ER doc, and the other physicians and the drugs in the hospital--somebody has to pay for it. So who pays? All the rest of us who have health insurance, we pay. It is all transferred to the rest of us who pay. Our health care bills, our premiums, are higher today because of the people who do not have health insurance. It is called uncompensated care. In Montana, the bill is about $2,100 a year--the premium in Montana, $2,100, family health care premium in Montana, due to uncompensated care. If people had health insurance, if the whole country had health insurance, we would not have that cost transfer to the rest of us who have to pay for you.
Then you say: Gee, how do you get those other people to pay for health insurance? That is one of the questions that comes up in this bill. It is an honest question. This bill says two things. People must have health insurance. They can do two things. If they are poor, they can go to Medicaid. That is expanded a little bit. Then there are issues such as, that costs too much, aren't States having to pay big bills, and so forth. The answer is, there is no increase in bills to the States for 3 years. Then the match is reduced from 100 percent down a little bit--that is after several years--which is much higher in Federal dollars than it is for other Medicaid. We can have that discussion and figure out ways to help States legitimately needing help. But still it is more insurance for people because if they need health care, those bills are not passed on to the rest of us.
The other way is to give assistance to people who cannot afford health insurance. It is through a rebate in the Tax Code. That is where a lot of the money goes. But it is clear that some people who would have too much money to qualify for Medicaid but not enough to buy health insurance are going to need some assistance, so this legislation is designed to help those people get assistance, and the wealthier they are, the less assistance they get. Some say that is why this bill costs so much.
I think it is important to remind people here that according to the Congressional Budget Office--again, the neutral group that we trust. Nobody questions their integrity. It says this bill does not cost a thin dime. A lot of people like to say it is $1 trillion. It does cost $1 trillion, but it raises $1 trillion, so on that basis it doesn't cost anything. The dollars are raised because the rates we pay providers are cut back a little bit. There are also some fees on some of the providers. That is true. That is true. That is how this bill is paid for.
But let's remember, almost all those providers, all those people who are paying a little higher taxes, and all those groups whose reimbursement rate is a little lower favored the bill. They are in favor of it. You might ask, why in the world do they favor this bill? The answer is, because more people have insurance. If more people have insurance, their margins might drop a little, but their volume will increase. They can make money. They figure they are going to make money under health insurance reform. Hospitals, pharmaceutical, medical equipment manufacturers, most of the insurance industry, you name it, they think they can make some money.
I don't want to take too much of my colleagues' time here, although I do have one other point, and that is Medicare. It is stated on this floor: This hurts Medicare. It takes money out of Medicare. That is a red herring--a red herring in the sense that somebody says something that on the face of it is true, but it is irrelevant to the main point. It is true that reimbursement rates to providers is a little lower, but it is also true that this legislation extends the life of the Medicare trust fund by about 120 years. The trust fund under this legislation is extended. The life of the trust fund is extended by 12 years compared to what it would be before this law was enacted. Some people want to repeal that. They want to cut back the life of the Medicare trust fund.
What else do they want to cut back with repeal? Repeal gives many seniors--4 million Americans I think is the number--a drug benefit in the doughnut hole of $250 a year. In my State of Montana, it is 9,000 Montanans. After a period of time, that doughnut hole will be closed, so seniors will not have to pay for excessive costs on prescription drugs. Repeal would repeal that. Repeal would say: Oh, all you seniors, 4 million seniors, we are going to send you a $250 bill. We want you to pay $250, in effect, for drugs. We don't want you to get any break. That is what repeal does. I don't think Americans want health care reform repealed--certainly those 4 million seniors do not want it repealed.
I have a lot to say. I will finish up. All I ask is this. We are going to have this debate, regrettably, for about a year until the Supreme Court finally decides. I ask that we all stick with the facts. Stick with the facts and don't indulge in histrionics, scare tactics, and so forth. ``Just get the facts, ma'am,'' because facts generally control. You can't change facts. The fact is, what does CBO say? There are lots of facts here. I urge us to stick with the facts. We could argue what they mean, but let's stick with the facts. Let's not manufacture the facts. You can't manufacture facts and have a good- faith debate. I assume this is going to be a
good-faith debate, so let's stick with the facts.
I have one more small thing. A person once stood here years ago in the Senate--it was Mike Mansfield from Montana. He was majority leader in the Senate for 17 years. No other leader served for as many years as Mike Mansfield. I ran across a statement by him which he gave in 1989 to a bunch of wide-eyed students. I can't remember exactly what he said, but the main point of it is this--he was a very reasonable guy, revered in Montana--in all efforts to be constructive, you have to listen. Listen very well, very closely to the other person's point of view. He went on to say: You are not always right. They are not always wrong. The more you listen and the more they listen, you will see where you are not right and you will see where they are not wrong. You also see where you are right and they are wrong. But you have to listen to try to find that common ground where somebody is right and somebody is not right in an objective sense of the term and then use that information constructively and with knowledge and with good faith.
I ask all of us to do just that.
