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Mr. COBURN. Madam President, I have a question for both the Senator from North Carolina and the Senator from Nevada. Can the State of Nevada or the State of North Carolina or the State of Nebraska or the State of Oklahoma be healthy if our country doesn't flourish? So no matter what we do for our own States, if, in fact, we are not thinking about the country as a whole, the best right thing for the country as a whole, none of our States can flourish.
Mr. ENSIGN. I think the Senator from Oklahoma has made a wonderful point. Right now, my State is suffering terribly, not because of anything individually, such as we didn't get our fair share of something; my State is suffering because the whole economy is in the doldrums and because we are such a tourist economy, construction oriented, the housing industry, all of those things, and because the general economy went down, my State is suffering.
So the Senator is exactly right. We should be looking at what is best for the entire country. As John F. Kennedy said: A rising tide raises all boats. Well, if the whole country is doing better, whether it is on health care or whatever it is, instead of looking for something individual for our States, you are exactly right. I think our individual States will do better if the whole country does well.
Mr. COBURN. Madam President, I ask unanimous consent to have printed in the Record an article that appeared today. It is a quotation from the founder from the Daily Kos Web site. I will give it to the clerk in a moment. I wish to read a quote from it:
I don't think this is a reform bill. I mean, I think it is very clear this is not insurance or health care reform. What it is is allowing more people, 30 million people, to buy into an existing broken system. It is very important to keep in mind that health insurance is not the same as health care. If you go up to Massachusetts, they have a mandate as well. Last year, in Massachusetts, 21 percent of the people who are insured could not get health care because they could not afford it.
That is somebody who is very well respected on the majority side, and it is something we have been saying, and they are saying the same thing. The fact is, what we are going to do is put 15 million people into Medicaid that we know has worse outcomes, we know is an unfunded mandate on the States, and we know 40 percent of the doctors refuse to see them. So you are not going to get to choose the doctor you want to see. You are going to have State mandates in terms of what is available to you and what is not. So we have violated two of the key promises with which to reform health care.
There being no objection, the material was ordered to be printed in the RECORD
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Mr. COBURN. Madam President, I wish to also quote from what I think is a brilliant letter by a Dr. Robert Geist from St. Paul, MN, that was written as a letter to the editor in the Wall Street Journal today. The title of his letter to the editor is, ``The First Cost Controller Will Be Your Own Doctor.'' It is something I have been talking about since we started this. The last thing we want to do in health care in America is to make it where the doctor is not a 100-percent advocate for the patient's best interest.
He quotes very directly the transfer. He said a previous article written:
..... doesn't emphasize a potential stealth cost-control aspect proposed in the bill. It will start pilot programs that would transfer the gatekeeper role to doctors at the bedside, a role currently held by ``payers'' (HMOs and government-agency insurers, including Medicare and Medicaid).
The transfer will be via capitation fee payments, making clinics ``responsible'' for the cost of care of ``insured lives'' for one year. ..... The illusion of many pundits and policy makers is that mini provider gatekeepers can control costs after the very powerful payer gatekeepers--
That is, Medicare, Medicaid, and the large insurance companies--
have failed for decades. The problem for patients is the dilemma of all managed-care gatekeepers: cost, quality, access; pick any two. It is not pleasant to think that one's gatekeeper doctor will have to decide whether to order surgery for your painful [worn out] hip or only to increase the dose of--
Anti-inflammatories because they are worried about costs.
That is the key point. We are going to now separate physicians in this country for doing what is best for the patient to meet the demands of the government.
Mr. ENSIGN. If the Senator will yield.
Mr. COBURN. I will be happy to yield.
Mr. ENSIGN. As a practicing physician, isn't this what the Senator saw in his practice with HMOs?
Mr. COBURN. That is exactly why I am not a member of any HMOs.
Mr. ENSIGN. Because we have kind of an insurance center system today, to a large degree, and now we are going to make that worse. Instead of going more toward a patient center, we are going to go from an insurance center to a government center to where these government bureaucrats now start being in control of eventually what kind of care you are going to get, what is paid for, and all that. We need to put the doctor and the patient back at the center of our health care system.
Mr. COBURN. Let me finish this for a minute, if I might. Here is the summarizing paragraph:
The economic reality is that no rationing of care supply will ever control costs, when the problem is demand inflation driven by popular insurance tax subsidies too sacred to repeal. Consider that when federal fiscal ``necessity'' overwhelms empty slogans,--
Our empty slogans--
scores of new bureaucracies created in [this bill] would be able to implement Draconian rationing in collusion with subservient insurance and ``provider'' corporations. The high costs, as well as the rationing powers included in the more than 2,000 pages of the ObamaCare Senate legislation are very real.
Which is the point I have been making all along. I am going to spend 30 minutes tomorrow talking about the rationing aspects of what we are about to do as we pass this bill.
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Mr. COBURN. What we also know from the Congressional Budget Office is that between 9 and 10 million people who today have insurance through their employer will actually lose it. They are going to lose their insurance. That may be good or bad for them. But if you look at the incentives, the subsidy for people who do not get insurance through their employer, if you make $42,000 a year, today with your health insurance through your employer you get a benefit of about $5,749 from the tax system. But under this bill, you will be eligible for $12,500 worth of subsidy.
What do you think an employer is going to do? They are going to look at their employees and they are going to say: I have to pay this penalty if I don't offer this, but it is a significantly smaller amount than what I am paying today. Therefore, I am going to make a decision to no longer offer health insurance, give my employees a small raise because the government is going to come in with $12,500 worth of subsidies to put them in a ``private'' plan inside the parameters of what is in the exchange. How many people do you think it is going to shift?
What we are going to get is adverse selection. So the individual--let's say I am working and I am making $42,000 a year and my employer decides to do that and let's say I am 35 years old and I know available to me is $12,500. Even though my earnings may go up, I am still 2 1/2 times better off.
I also know I will have to pay $3,000 or $4,000 of my own money to get that benefit. I will not cover myself because I know I can cover my little incidentals. If I get sick, they have to cover me in the exchange.
So we are going to see adverse selection in the insurance market, people who are between 40 and 64 who are sick are going to pay far more for their health insurance and people who are sick who are younger than 40 are going to pay far more for their health insurance and everybody who is healthy under 40 is going to say: This is an economic bonanza for me. I am not going to buy insurance.
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Mr. COBURN. Well, the disappointing thing--and I have worked on this for 5 years, since I have been here--is we are not honest with the American people about how we account for things, and this bill is another example of that. Let me give you the quantifications.
If you read the CBO report on this bill, they talk about it is highly unlikely we will ever actually make the Medicare cuts, because they have never seen it done, and every time we have said it in the past, we haven't done it, like the sustainable growth rate formula in the Balanced Budget Act of 1997. So if you match up revenues and expenses, what you see is a $1 trillion tax increase, a $1 trillion cut in Medicare, and an increasing cost to the economy.
But because there is not the sustainable growth rate--the doctor fix in the bill--that is $247 billion not accounted for, and that is if you keep physician wages frozen over the next 10 years. That is $247 billion, probably closer to $300 billion. So that is $300 billion. The fact is we know the taxes that are going to be collected, people are going to pull down the cost, which is one of their hopes, and they are going to pay for it out of their pocket.
So we are going to see that insurance plans not reach the Cadillac level, and we are counting on revenues from that in terms of billions and billions and billions of dollars. But what they will do is change the deductibles--and that is a hidden tax. Because if your deductible goes up to keep your insurance from going too high, your tax goes up in actual expenditures. So your ability to invest and create additional jobs--in other words, it cascades. The honest accounting for this is that there is no way this saves any money. It will cost money.
The final point I will make is they won't put forward the cuts in Medicare that they are claiming in this bill. Because they know if they truly do put forth the cuts, and patients feel it, they won't be back here. So it won't happen.
I will go back to what Senator Burr started this out with. If you are going to start tomorrow and fix health care, what would you do? You would attack costs. Why are things so costly? One is because there is no transparency in markets. There is no real connectedness to your pocket. No. 3, there is no incentive for prevention of chronic disease or the management of it. In other words, we don't pay people to have less expensive outcomes. We won't incentivize better care in that way. We won't incentivize prevention.
We have done a lot of this on Medicare--and I will talk about it tomorrow--but they have three different agencies within this bill that are going to ration care. They are going to make the decisions for you, and not just on Medicare and Medicaid. Everybody needs to understand that. It doesn't just apply to Medicare and Medicaid, it applies to your choice of your private insurance. The government is going to ration your care.
We know that is true because they wouldn't allow an amendment to prohibit rationing. They all voted against the amendments in committees when we offered amendments to limit rationing. So we know the intention is to ration care. If that is how we are going to control costs, then Bernie Sanders is right--go to a single-payer, government-run system. Bernie Sanders' system is far better than this one--far better than this one--if that is what we are going to do. If we are going to ration care, let everybody know it upfront. Let's be absolutely honest about it.
If you are 75 years of age and need a hip replacement but the quality of your life is not all that great, we are going to say you can't have it. That is what we are going to do, because that is exactly what they do in England. They have the National Institute of Comparative Effectiveness which makes an evaluation of what your worth is. And no matter what your history, no matter what your family situation, no matter your income, you can't have it.
Canada is getting around that, because they have said you get the right to buy what you want. Their Supreme Court ruled on that 2 1/2 years ago. So we are seeing a two-tiered system developing in Canada, which ultimately will happen in this country--worse than what we have today.
Mr. ENSIGN. If the Senator will yield, though, if America does this with our health care system, where will the Canadians come for their health care when they need it? When they get it rationed up there, they usually come to the United States.
Mr. COBURN. They will go to Thailand or India.
Mr. ENSIGN. But where will Americans go?
Mr. COBURN. I thank the Senator for holding this colloquy, and I will make one final point before I stop.
I don't doubt the motivation of our colleagues on the other side of the aisle. They want us to fix this problem--the problem in health care. But the problem is cost. If you don't fix cost, and you expand the same broken system, you haven't fixed anything. You have added to the cost.
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