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Doctors Caucus Special Order

Floor Speech

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Date:
Location: Washington, DC

Mr. FLEMING. Madam Speaker, it's a pleasure to be on the floor once again to really talk about my favorite subject in Congress, and that is health care.

I am a physician and have been a physician for 36 years. I am a family physician. I still have an active practice and practice when I get a chance, which lately has not been very often.

We'll be talking about ObamaCare, the repeal of ObamaCare, and we'll be talking about Medicare. I say ``we.'' That is only if I'm joined by some of my colleagues who may be making their way here this evening.

I want to in the way of introduction just let everyone understand, Madam Speaker, how we got here in the first place. Why are we here this evening talking about this? Why are we talking about the repeal of ObamaCare?

I take you back to 1965 when there was a recognition that health care insurance was becoming something more than just insurance; that is to say, that insurance, of course, in theory is to protect against catastrophe. We see that, of course, in our homeowners insurance and our car insurance. So it seemed a good idea to have some form of insurance where you would not be bankrupted by a sudden and severe illness and have your lifesavings taken away.

So the idea of insurance came up, and it was mostly a catastrophic policy. Then that sort of evolved over time into more and more comprehensive concepts, and it really has become today extremely comprehensive, perhaps even a health management type of system that you pay into and hopefully the system takes care of you. It was a recognition that a robust market did not exist for insurance for the elderly.

From that sprang the idea of Medicare, health care insurance for the elderly, which is really not insurance, per se. It's really a 100 percent single-payer government program. Then also insurance--again, a single-payer program--for the poor, and that is Medicaid. That began around 1965. It began with a promise to the health care system and to the elderly that this would never usurp the relationship with the patient, that the decisions would be made by the providers and the patients, and that Medicare--of course, the government taxpayers, if you will--would be picking up the bill, no questions asked. There was also a recognition that even though patients would get help with their bills, they would still have to pay something into that.

I will also interject that there was the belief, actuarial estimates, CBO, the Congressional Budget Office, that predicted that a program that would be maybe $3 billion annually would maybe top out at $12 billion.

Of course we know now that it's in the hundreds of billions of dollars many times over what it was initially promised to be.

In that evolution, we saw where government and insurance companies began to take a larger and larger role in covering for various things. For instance, beginning in the early eighties, Medicare began to see the physician charges becoming a problem, and from a budgetary standpoint they weren't really going up that fast, but because of the growth of the elderly out there it was running the cost up.

That led to restrictions put on what doctors could charge. Then came EMTALA, which is an acronym, a long acronym, that basically says regardless of your ability to pay, if you show up to the emergency room, the doctors and hospital have to treat you.

These are all things that began to add up over the years, and it's made Medicare, of course, balloon into an extremely expensive program, as is Medicaid as well. In fact, for most States that is the largest budgetary item that they have.

Well, fast forward to 2008. As a physician, I became very concerned that we needed health care reform in this country. Why? Because government had become such a large part of the health care system and the so-called insurance thereof, and with the price fixing that went along with that, that it began to actually have a perverse effect on health care. That is to say that as reimbursement to hospitals, doctors, and other providers were going down, that costs were actually going up just as fast, which is just the opposite you would expect intuitively.

Why was that happening, and why is it happening today? Well, the answer is this: a physician, a hospital, anybody, the first thing that they are going to do, the first thing a business or a factory is going to do is when the reimbursement per unit goes down, that is a reimbursement per patient goes down, you make it up on volume and you keep working harder and you keep seeing more patients, and you find more things to do to drive up that, and I'm saying this in a generic way.

I do not ascribe to that, but many doctors have been put in that position to just stay solvent in their practices. They have run faster and faster, seen more and more patients, done anything they can. While they make an extra dime to keep up with their costs, they're running the system up by a factor of 10. They make a dime for themselves, but the system costs a dollar for that.

As a result, we have had severe inflation. It was my belief that the way to solve this problem was to begin to move government out of health care and begin to move the private sector back in, put together robust and healthy markets, give consumers choices once again. Patients have skin in the game--that is to say, they have to pay a little something into it.

Because, remember, back in the eighties, patients' out-of-pocket expense, for instance, in Medicare for laboratory and many other items went to zero, which meant that instead of having to negotiate with the patient, what is the best ideas in terms of a list of tests that must be performed to get to the answer, I can just simply make out a list as long as I want. Somebody is going to pay for it, but it won't be the patient, and therefore, again, health care inflation.

I came to Washington after being elected to work on this with the other side of the aisle, because I saw that we had two major giant entitlement programs that are bankrupting this country, Medicaid and Medicare. I remind folks that Medicare runs out of money, according to whichever actuary you want to listen to, in 5 to 12 years. But they all agree that it runs out of money and the services will have to be sharply curtailed.

What we found was that the other side of the aisle, our Democrat colleagues over there decided that instead of solving the problem by bringing the marketplace, they wanted to take government another step. It reminds me of a story that was told to me once about two farmers. They were on a wagon, a mule, and they are going down the road, it's an old farm road, and one of the wheels breaks and they come to a stop.

Now, the mule can't pull that wagon, it's just too hard to pull it on one wheel. So the two farmers get off, one starts fixing the wheel and the other one starts going back home. The first farmer says to the second one, where are you going? He said, I'm going to get another mule, because that's the way we're going to go forward. We're just going to hitch a second mule and keep dragging this wagon down the road.

You see, in my opinion, that's precisely what happened with ObamaCare. Instead of fixing our health care crisis and the inflation and costs, the inefficiencies in the system and the fraud, waste, and abuse, by bringing the marketplace back into sanity and back into balance once again, and letting patients be the decisionmakers, what we really did is double down on the government control of health care and, as a result of that, we're going to have an even more expensive, more burdensome and bureaucratic system that we won't be able to control.

Anyway, this is the Doctors Caucus Special Order. We're going to be talking in the next 30 minutes, and we're going to be talking about the repeal of ObamaCare.

We have voted on this, you probably already heard, several times already. Of course, we have never got it past the House of Representatives because the Senate won't take it up and, of course, it's doubtful that the President, our current President, would ever sign it.

There are a lot of things that we hear about ObamaCare. Let's talk for a moment about taxes. We just had a Supreme Court decision handed down, and there has been this debate, this battle, within the Supreme Court and outside, on this individual mandate where government under this bill literally forces and requires you to purchase a product or service that is created by government, rather than making it more affordable and attractive and you opting in and you buying it on your own.

The decision has been handed down that, yes, the

decision is constitutional, but not by the way of the commerce clause. But government can, Congress can now, according to the justices, Congress can basically make you do anything Congress wants to do. It has to force you through taxes. While we could debate whether I agree or not agree with that, that is the law of the land now.

This means that if we in Congress decide that we want to make citizens do things, we do have a pathway now to do that, and that is to tax you. Even if you're not in an activity or buying something we can still tax you.

I prefer that we go the market route. I would much rather people buy insurance because they see a need, they see a desirability, and they see that it's cost-effective, rather than forcing Americans to do that. Our colleagues on the other side, would rather just simply force you to do that.

But now we have to also admit that this is a tax, and our friends on the other side of the aisle I think would admit that had this been advertised as what it turns out to be, a big tax increase on the middle class, that it never would have gotten passed because they would have been voted out of office for having raised taxes on the middle class. That's a big political no-no these days.

But there are many other taxes, and I'm just going to hit on a few here. One is a 156 percent increase on the Federal excise tax on tobacco. Another is the employer mandate. The Supreme Court says that you can, Congress, you can make employers buy insurance or you certainly can penalize them if they don't.

But, interestingly enough, one part of the bill that was termed unconstitutional was coercing, or forcing States to expand Medicaid eligibility. That's a part of the Supreme Court's decision that actually is going to impact the cost of this bill.

There is a surtax on investment. This is something that you're going to hear more and more about, and the way you're going to hear about it is that one day you're going to sell a home, you're going to sell a property or an investment or something like that, and the IRS is going to demand 3.8 percent of those profits.

On the subject of the IRS, remember that it's estimated that 16,500 new IRS agents will need to be hired and are funded in order to require or force the taxation into ObamaCare. This will certainly bring the IRS much more intimately into your life, regardless of whether you own a business, or you're simply an employee, or really don't even have a job.

There will be an excise tax on comprehensive health insurance plans that will go up over time, ObamaCare hike in the Medicare payroll tax. There will be a medicine cabinet tax, if you will. But what that really is removing is the tax deductibility for the pretax dollars from health savings accounts that you have been able to enjoy before, that if you go and buy cold medicine off the shelf, that you could buy it with your pretax dollars under your health savings account, that's gone. If you want to get cold medicine and use your pretax dollars, you have to get a prescription from a doctor. So one of two things are going to happen: Either you're going to have to see the doctor, which is going to cost you more, or the doctors are going to be spending a lot of their time, again, wasted in paperwork, writing prescriptions for nonprescription drugs. That really doesn't make much sense.

There will be an ObamaCare HSA withdrawal tax hike, an ObamaCare flexible spending account cap, ObamaCare tax on medical device manufacturing. It's estimated that many of the domestic medical device factories will simply go out of business or go offshore. The cutting-edge innovation that we have today in health care devices, we're going to lose that has a result of ObamaCare. That will go to other countries.

The itemized deductions, the exemption is going to go from 7.5 percent to 10 percent of adjusted gross income. There will be a tax on tanning. That's got to be a middle class tax. ObamaCare elimination of tax deduction for employer-provided retirement drug coverage in coordination with Medicare part D, ObamaCare Blue Cross Blue Shield tax hike, an excise tax on charitable hospitals, a tax on innovator drug companies, a tax on health insurers, a $500,000 annual executive compensation limit for health insurance executives, ObamaCare employer reporting of insurance on the W-2, the black liquor tax, the ObamaCare codification of the economic substance doctrine. Again, a long list of taxes.

So, Madam Speaker, it seems to me that in a time that we have the worst recession since the Great Depression, we're now facing perhaps the largest tax increase that's occurred in our lifetimes, both through ObamaCare and through the expiration of the Bush tax rates, which are much lower than the Clinton tax rates.

Of course, you have heard some about that as well in recent days. In fact, the President himself said in 2009 the last thing in the world we want to do is to raise taxes in a recession. And everybody knows we're in 41 months of a recession and no end in sight.

Now, there's also been some discussion and debate on the impact on small businesses. And I'm segueing to small businesses because, let's face it, taxes have an impact on all of our pocketbooks, but taxes also have an impact on the ability for small businesses to hire people. If you take money off their bottom line, that's less money, less capital to invest, less money to hire more people. And that is precisely what is going on with ObamaCare.

In fact, I would say, based on studies that I have read, one said that 70-plus percent of small businesses are saying that the main reason that they're not hiring people is because of their fear, the uncertainty of ObamaCare and its impacts on them, and the people I speak with throughout my district and throughout the country who say that ObamaCare is probably the worst threat to the survival of their businesses and, therefore, they're not going to expand their businesses.

We know there's trillions of dollars sitting on the sideline right now, both small and large businesses, ready to be invested to grow jobs, and yet the job creators, the employers, are fearful. They don't want to put that money in.

Why would somebody want to put, say, $10 million into a new factory not knowing whether they can make a profit and making the calculation that perhaps I should stand up that factory overseas someplace where, in fact, I can make a profit. I don't have to deal with ObamaCare and all that comes with it.

Now, that's just part of. We also know the hyper-regulatory atmosphere that we've evolved into, where regulations are not being written by Congress but by people in the buildings that surround the Hill here, many of which we do not yet know. 106 new major rules being written out of this administration, the worst proliferation of regulations.

So this, on top of other things--the direct hostility and attacks on energy and the job creators themselves--has just put a complete wet blanket over our economy and the creation of jobs. And I would say that ObamaCare is the lead in that entire process.

Now, there's also something that I get asked about a lot, and that is, well, what about what you Republicans say about ObamaCare and what the Democrats say about ObamaCare? And it seems--at least it appears to them--that one of us is lying about some of these things. And, of course, one of the things that is important that we do when we come to Congress, what we understand and learn, is that we should never presume ill motives of the other side. And that's exactly what I will do tonight is not presume ill motives by the other side. So I will give you an example of what I'm talking about.

We Republicans have contended all along that $500 billion will be ripped from Medicare. Again, I said earlier that Medicare runs out of money, becomes insolvent, in 5 to 12 years. Everybody agrees it's in that window someplace. And we have the Ryan budget plan, which would save Medicare. The other side of the aisle refuses to engage on that. But the question is: Does ObamaCare take $500 billion out of Medicare?

I have a lot of Medicare recipients who are very worried about that, and they ask me because they hear and read things. They read something from PolitiFact or all these fact checkers, and they say, no, this isn't happening, or it's not happening the way you think it does and so forth. Well, we had a discussion with Douglas Holtz-Eakin, who is the prior CBO, about this 2 days ago, and he confirmed a lot of my beliefs about this, and here's the way it goes.

Madam Speaker, the way laws are written, oftentimes what is in the four corners of that law says one thing, but when you add the omissions and the unintended consequences and sometimes intended consequences, the effect of that is completely different. And so, for instance, the idea that Medicare does not lose $500 billion that is dumped into ObamaCare, well, I think the nuance in there is that you have to understand that the cost of Medicare goes up progressively every year. Now, in some years it goes up higher than other years, but it always goes up.

And so in Washington, oftentimes you can say that something is cut when, in fact, it's just the increase is reduced. And so that's really what happens here, is what Democrats did in crafting ObamaCare is they cut the increase in Medicare spending and they took those so-called savings and they spent it inside of ObamaCare.

Well, where is it coming from? Is it going to have an impact? Well, of course it will. Because as things get more expensive, if you reduce the amount of increases that nominally occur, it's going to have an impact because there isn't an underlying inflationary rate that has to be recognized.

So while one can make the legalistic case that, no, there isn't $500 billion removed, in reality, yes, it is removed because you have got to go from point A to point B. And if you don't allow that nominal increase, that inflationary rate in Medicare spending, if you don't allow that, it's a cut. It's going to be a cut in services.

And where are the services? About half of it is going to be in Medicare Advantage, which is the private type of Medicare which people really love. It's very popular in a lot of States. And the other is going to come from providers. That would be doctors, hospitals, medical device providers, and so forth.

Now, the Democrats were very careful not to take that money from beneficiaries. And, in fact, in the sequestration that occurred last year and that we're still debating, where money is taken out of defense and it's also taken out of Medicare, the money is taken out on the provider side but not the beneficiary side.

That is, we're not taking away from patients, we're only taking away from the people who are providing the care. Well, that's all well and good. Well, not so fast. You have to understand that as you reduce reimbursement of services, the ability for providers to provide those services goes down. And it has been going down progressively. Certainly, a relatively small percentage of physicians today accept Medicaid for payment and reimbursement. So even if you have a Medicaid card, which, by the way, half of the so-called increase in coverage under ObamaCare will be on Medicaid. Well, that will be very good. You'll have a Medicaid card. But when you shop around and you go to various doctors' offices and you say, I'd like to see the doctor today, there will be a lot of the assistants at the desk that will say, I'm sorry, we don't accept Medicaid.

Now, you might be critical of the doctor on that, but you have to understand, doctors have to make payrolls, and they have to pay rent like everybody else. And if it comes to a point where they can't do that, then they either have to stop seeing Medicaid patients, or they have to go out of business. Either way, you're not getting in to see him because the reimbursement is not there.

Well, the same phenomenon is now happening across America in Medicare. If you're on Medicare, if you're 65 and over and are disabled and you're on Medicare, there's been such a flattening and ratcheting down in many cases of reimbursement that just because you have a Medicare card does not mean you're going to be seeing doctors when you want to see them.

And, in fact, that is precisely what I was talking about in the beginning of the discussion--that if we just simply take the same entitlement programs that are making the cost problems worse, and through the price-fixing mechanism actually perversely incentivizing fraud, waste and abuse, if we're doing that now and then, we expand yet another entitlement system, we're only going to aggravate the same problem. So what's going to be the net result? We're going to have more people, more patients, searching out care from fewer and fewer providers.

And what will that lead to? It will lead to long lines, and it will lead to rationing as a natural thing, not a planned kind of rationing. That just will be the imbalance that we're going to have in the system.

Now, how do I know that's going to happen? Well, as I mentioned, it's already happening, but it's not showing up to the level you might expect just yet. But let's look at Massachusetts. Remember, Massachusetts and also Tennessee have comprehensive State programs, and since the comprehensive plan started in Massachusetts a few years ago, the waiting lines for doctors have grown now to an average of 6 weeks. Over 50 percent of primary care doctors are not accepting new patients. The reimbursements are going down, and so are the number of doctors. The waiting lines are getting longer.

The same happens in other countries that have single-payer systems such as Canada and Great Britain. And as a result, how do these people get care? They go to the emergency room. And where is the most expensive care? In the emergency room.

So you see, Madam Speaker, when you have a highly structured, bureaucratic, top-to-bottom system that micromanages behavior of individuals and providers, all you're going to get are higher costs. And ultimately, the only way you're going to control costs is through long lines and rationing.

Now, in ObamaCare, Democrats did something very clever. They didn't want to depend on Congress to make those tough decisions to cut reimbursements. So they created something called IPAB, the Independent Payment Advisory Board, which will be 15 unelected bureaucrats, not necessarily health care providers, appointed by the President. Again, they are unelected, and they will not be answering your phone when you call to complain. They will literally have more power than Congress itself in order to cut the benefits that you'll receive. They'll do it by way of reducing the types of services, the quality of services, and the payment for those services. It will happen in a lot of different ways, and it will begin to show up in delays, in more paperwork, misdiagnoses, and ultimately some very unfortunate outcomes that I can see coming down the road.

Now, Congress will have the responsibility of meeting certain targets of spending. But if they fail to meet those targets--and Congresses never reach those targets, that is, to cut spending by so much in Medicare--then it falls back to, it defaults back to IPAB, and IPABs will be the ones making those decisions. So call it what you will, there will be members of government, people who are on a governmental payroll, who will be making decisions about what services you will have.

Now, a lot has been said today about all the free services that you're going to receive, free Pap smears, free breast exams, free preventive health services. Madam Speaker, I have never seen anything free in this society. Somebody is going to pay for that service. Somebody has got to pay somebody for doing it. Somebody has got to pay the secretary, somebody has to pay the provider, somebody has got to pay the rent. Nothing in this society is free. And I will tell you that any time somebody tells you something is free in ObamaCare or any other kind of health care insurance, they're just not being straight with you. Let's just be honest. Somebody is going to pay for it at one point or another.

Let's talk about the social conscience part of ObamaCare, which has a lot of us who are in the pro-life community very concerned. Remember, the President said that he would preserve conscience rights; that is, providers would not be forced to provide abortions or abortifacients, that is, pills that will create abortions, or anything that is against our conscience. And, in fact, the first version of ObamaCare that passed the House passed only because the pro-life Members of the Democrats said those protections have to be in there, the so-called Hyde amendment that says that no taxpayer dollars will be spent on abortions or abortion-like activities. However, when it came back from the Senate, another trick was pulled and that was pulled out of the legislation. But the President said, well, look, I'll write an Executive order, which really has very little meaning, certainly in the long term. Any President can rescind that. There are many different ways to end-run an Executive order if it's not something that's in statute. So, as a result, there are plenty of holes in ObamaCare like Swiss cheese that allow taxpayer funding of abortions.

Now for the first time in many years, a majority of Americans are pro-life. But I can tell you an overwhelming majority today and always has been against the taxpayer funding of abortions. But what we're dealing with today is not the taxpayer funding of abortions, that's already in law, and that's part of the reason to repeal it, but the fact that the President is now forcing religious institutions such as the Catholic Church to provide certain services that are against their conscience, such as abortifacients, abortions, and sterilizations. And so their choice is either to get out of health care entirely or to go along with the government and run into heavy fines.

So, where are we today with ObamaCare? Is it going to be repealed? Tomorrow ObamaCare will be repealed in the House of Representatives. That you can bet on. However, we all understand that there is a problem with the Senate, which is controlled by the very people who voted it in to begin with, and a President who, though he supports it and would not sign a repeal, says very little in defense of ObamaCare. But why? Because there's very little that is desirable to defend in it.

So I look forward to another opportunity to vote for the full repeal and look forward to next year when we'll have the ability to repeal it lock, stock, and barrel, pull it out by its roots and start over again with step-by-step reform in health care with patient choices, as it should be.


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