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Deficit Reduction Omnibus Reconciliation Act of 2005--Resumed

Location: Washington, DC



Mr. COBURN. Mr. President, I thank the leadership for giving me an opportunity to express some concerns with the version of ``value-based purchasing'' for physicians in the Medicare program, as presented in the Senate reconciliation legislation. While I commend the committee's efforts in finding budget off-sets to stop the Medicare payment cuts facing physicians next year I believe the committee, and Congress as a whole, has accepted the idea of ``value-based purchasing'' with little discussion, vetting and evidence that it will actually do what people say it will do.

We have a big problem in the Medicare system. Our physicians, the bread and butter of the Medicare program who provide millions of services each year to Medicare beneficiaries, are facing unprecedented cuts in their reimbursement at a time when their own costs are skyrocketing. We have known about this problem for years, have taken action to prevent previously scheduled cuts and once again we must take action this year to prevent more cuts. I commend the Senate Finance Committee's efforts for at least preventing these cuts for a year and recommending that physicians receive a modest one percent increase instead of a 4.4 percent cut. I know the physician community is grateful for this effort in a time of budget deficits, hurricanes and other problems.

I am concerned about another provision included in the bill--specifically, value-based purchasing, a.k.a. ``pay-for-performance.'' My concern is that this concept is not ready to be codified and be taken to prime-time. In the last decade, we have already declared two Medicare physician payment systems--the current sustainable growth rate formula and the volume performance standard--dysfunctional and unworkable. I do not see the value of diving so quickly into adding a new, untested and unproven system on top of an already declared disaster--the sustainable growth rate or ``SGR.''

As a physician, I can attest that most doctors are dedicated to improving the quality of care they provide their patients. The concept of continuing medical education and continuous quality improvement is engrained in our medical culture. For years, physicians have been involved in peer review, the development of clinical guidelines and best practices, and outcome measurement. The concept of value-based purchasing is to turn these practices into a payment system that pays higher performers more and pays less to those who cannot make the grade. In theory, this has great promise and I believe it will improve the quality of care provided to all Medicare beneficiaries while increasing efficiency in the system.

However, I am concerned that the language included in S. 1932, the ``Deficit Reduction Omnibus Reconciliation Act of 2005'' will not achieve these goals. While it does give physicians a 1 percent update for 2006, it does not address the impending cuts scheduled for January 1, 2007. The proposed legislation does not fix the SGR, it instead places cuts on top of cuts, and infuses a system that mandates greater volume on top of one that penalizes physicians for volume increases. Value-based purchasing and the SGR are not compatible and cannot work together. In exchange for a one percent increase in 2006, physicians could receive cuts of up to 7.5 percent in 2007, 2008, 2009, 2010 and 2011. If you think your physician constituents are frustrated now, wait until they understand this.

Under the suggested program, some physicians may have the opportunity to earn back that additional two percent cut if they meet specific ``quality'' and/or ``efficiency'' measures. Many of these measures have not yet been developed, have not yet been vetted by consensus building groups like the National Quality Forum and may or may not be evidenced-based. Before there is value-based purchasing, there must be agreed upon, comprehensive quality and efficiency measures for each medical specialty developed by the specialties themselves. In this proposed legislation, bureaucrats in Baltimore would primarily develop the measures that physicians across the country--with limited input from the physician and specialist community. I can tell you as a doctor that I am not interested in having some bureaucrat in Baltimore tell me how to deliver a baby in Muskogee, OK, and my patients are not either. Physicians must be the ones to develop these measures if they are going to be held accountable and if it is really going to improve quality and not just be another layer of paperwork and bureaucratic administration.

I believe pay-for-performance is critical to improving quality in our healthcare system. But we must get it right. Our physicians are facing year after year of cuts and beneficiaries are facing a loss of access to the physicians they know and trust. I believe the correct course is to deliberately and methodically build up toward a new physician payment system that accurately accounts for the cost in providing care to beneficiaries while encouraging and rewarding high quality and improvement.

Mr. DODD. Mr. President, I rise today to express my opposition to the spending reconciliation bill, which has been misleadingly titled the ``Deficit Reduction Omnibus Reconciliation Act of 2005.'' As some of my colleagues have mentioned, the spending bill before us today is only one-third of the budget reconciliation picture--the other two pieces are a tax cut bill and a bill to increase the debt limit. Taken together, this package of reconciliation legislation would increase the budget deficit and impose greater costs on some of the most vulnerable members of our society. It would also allow for drilling in the Arctic National Wildlife Refuge, which would be environmentally damaging and do nothing to reduce our dependence on foreign oil. The bill fails to reflect the priorities of the people of our nation and it fails to seriously address the major challenges we face as a Nation.

We are living today in an increasingly global society, one that presents tremendous opportunities. But with those opportunities come challenges. Today, countries like China and India are becoming increasingly desirable for venture capitalists interested in investment, for students interested in higher education, and for companies interested in labor that is not only inexpensive but well-educated and well-trained, too. With economic development and expansion have come greater competitive pressures.

Our labor market is under strain--real wages are stagnating, health care is becoming increasingly unaffordable, and pension benefits are being eroded and cut. The science and math scores of our high school seniors are at the bottom of the pack of industrialized nations. And we are the only nation in the developed world where literacy levels of older adults are higher than those of young adults.

Our Nation faces a choice. Are the administration and Congress going to respond to new challenges in a sensible and progressive way or will they continue to ignore the facts and adhere to policies that have brought Americans higher deficits, higher unemployment, and lower incomes? Will they continue to hold to the primitive philosophy that lower taxes on the most affluent, higher taxes on everyone else, and less investment in education, research, and business growth will somehow magically restore us to our place of economic preeminence in the world?

This view is naive and betrays a fundamental misunderstanding of our history. Our economic success has not been achieved despite investments we made in our people, but because of them. The not-so-benign neglect that characterizes much of our current national economic policy is not a strategy for success. It's an excuse for complacency, and ultimately a recipe for mediocrity.

Regrettably, this reconciliation package continues failed policies that will only continue to erode our Nation's place in the world.

First and foremost, the budget reconciliation package takes the worst fiscal record of any president in history and makes it worse. It takes procedural rules specifically designed to reduce the deficit and uses them to increase the deficit by $30 to 35 billion over the next 5 years. Part one of this reconciliation legislation may be cutting spending by $35 billion, but part two will provide tax breaks costing even more--$70 billon.

This fiscal irresponsibility is not an isolated case. Under President Bush, the Federal budget has gone from a surplus of $236 billion in 2000 to a deficit of $319 billion in 2005. The national debt has risen by nearly two and a half trillion dollars since 2000, totaling roughly $8 trillion as of this morning. That amounts to $27,041.81 for every man, woman, and child in the United States. Every minute in 2005, Republican budget policies have added $1,048,952 to the national debt.

As we have borrowed more, we have been forced to rely increasingly heavily on foreign lenders--particularly the central banks of countries like China and Japan--to fund our profligate ways. Foreign holdings of U.S. Treasury debt have more than doubled under the Bush administration from $1.01 trillion in January 2001 to $2.06 trillion in August 2005. Japan now holds $684 billion of that debt and China now holds $248 billion. We are playing a dangerous game here by relying so heavily on borrowing from abroad.

Some in this administration have reportedly argued that deficits don't matter. I strongly disagree. By blowing a massive hole in our budget, this administration and the Republican majority in Congress have seriously jeopardized our ability to meet the needs of our nation's other critical priorities.

The cost of the Bush administration's deficits is reflected right here in this spending reconciliation bill. In order to pay for just a small piece of the Bush tax cuts for the most affluent, this legislation would impose harmful cuts that would fall disproportionately on working Americans and the most vulnerable in our society.

For example, this bill cuts funding for Medicare and Medicaid, which provide health care to poor children, working men and women, the disabled, and the elderly. It cuts funding to rehabilitate FHA-insured multi-family housing. It dramatically increases the premiums paid by pension plans to the Pension Benefit Guarantee Corporation, the Federal pension insurer, making it more expensive for companies to offer defined benefit pension plans for their employees.

While many of the health care cuts in the Senate's reconciliation bill are less severe than what is contained in parallel House reconciliation proposal, I remain concerned that even under the Senate plan Medicare beneficiaries will have to pay more for critically needed services and access to Medicaid services could be limited for some beneficiaries.

As bad as the cuts are in the bill before this body, the companion legislation in the House of Representatives is much, much worse. It contains food stamp cuts for roughly 300,000 people, most of them in working families. It contains Medicaid cuts that would reduce health care benefits and increase health care costs for roughly 6 million children, as well as many low-income parents, the elderly, and people with disabilities. And it contains cuts in child support enforcement, child care assistance, and Federal foster care assistance.

So let us not be under any illusions: any conference agreement with the other body is likely to be even more harmful to the well-being of Americans.

The reason for these cuts is to pay for a small portion of President Bush's tax breaks for those who need them least. More than 70 percent of the benefits of the Bush 2001 and 2003 tax break packages have gone to the 20 percent of taxpayers with the highest incomes, according to the nonpartisan Tax Policy Center of the Urban Institute and the Brookings Institution. More than 25 percent of the tax-cut benefits have gone to the top one percent. I believe these priorities are seriously out of step with the values of this Nation.

In addition to cutting assistance for the poor to pay for tax cuts for the wealthy, this legislation would open the Arctic National Wildlife Refuge to drilling. Not only would such drilling be incredibly damaging to the region's fragile ecosystem, it would do nothing to reduce our Nation's dependence on foreign oil. Reasonable estimates project that drilling in the Refuge would provide only enough oil to satisfy U.S. demand for 6 months. Moreover, this supply would not even come on-line for 10 years. The belief that our country can drill our way out of dependence on foreign energy sources is misguided.

As a nation, we face significant challenges in both the short and long term. Americans are concerned about finding and keeping good jobs, paying for soaring energy prices, and whether they will have good health care when they need it. They are concerned about hurricane disaster relief and rebuilding assistance, and preparedness for the threat of an avian flu crisis. They are concerned about the war in Iraq and protecting the homeland from terrorist attacks. They are concerned about our education system and our competitiveness in the global economy.

The budget resolution--and the reconciliation legislation that carries out its instructions--is a statement of priorities. Unfortunately, the bill before this body today fails to seriously address the concerns of American families and businesses.

We can do better than this legislation. We can do better than harmful cuts for the poor and for children and for seniors. We can do better than using these cuts to pay for tax breaks for the most well-off in our society--who are, by the way, hardly clamoring for the kind of tax largesse that this Administration and its allies in the Congress insist on heaping upon them.

We should be investing in our society--in our education system and our knowledge base. We should be investing in science and technology and research and development. This legislation is not about investing in America. It is about fiscal irresponsibility in the name of tax breaks for those who need them least. Therefore, Mr. President, I cannot support this bill.

While I am unhappy with this reconciliation package overall, I am pleased that this bill does contain lifesaving legislation that I have introduced the past two Congresses that will provide Medicare coverage for screening for a dangerous condition known as abdominal aortic aneurysm--or AAA--a silent killer that claims the lives of 15,000 Americans each year. AAAs occur when there is a weakening of the walls of the aorta, the body's largest blood vessel. This artery begins to bulge, most often very slowly and without symptoms, and can lead to rupture and severe internal bleeding. AAA is a devastating condition that is often fatal without detection, with less than 15 percent of those afflicted with a ruptured aorta surviving. Estimates indicate that 2.7 million Americans suffer from AAA. Further, research indicates that when detected before rupturing, AAAs are treatable and curable in 95 percent of the cases. And while most AAAs are never diagnosed, nearly all can be detected through an inexpensive and painless screening.

I want to thank my colleague Senator JIM BUNNING for joining me in supporting this important and lifesaving legislation. When we first introduced this legislation in the last Congress, we were joined by patients who had suffered a ruptured aorta as result of an AAA and their families. At this event these patients shared with us their harrowing and personal stories of battling this deadly condition. It is because of struggles like theirs that we are here today at the outset of an effort to prevent abdominal aortic aneurysms from advancing to the point of rupture by providing coverage for a simple yet lifesaving screening. Simply put this legislation is about saving lives and I am pleased that it is contained in the bill passed today.

Finally, I would also like to say a brief word about the amendment being offered by Senator Byrd that deals with the issue of H-1B and L-1 visas. His amendment would strike the text in the underlying bill dealing with immigrant worker visas and replace it with a $1,500 fee for employers who file a petition to hire a foreign worker under the L-1 visa program.

Immigration reform is a critical issue that this body must address. It is a matter of national security, of overall economic well being, and of protecting American workers. Simply put, the underlying bill is not the appropriate place to address such critical and complicated immigration issues as the H-1B visa. So I thank Senator Byrd for offering his amendment. I strongly support it and I hope that my colleagues will as well when it comes to a vote.

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