Remarks by Senator Bob Graham at Iowa Health Care Forum

SENATOR BOB GRAHAM (D-FL), DEMOCRATIC PRESIDENTIAL CANDIDATE REMARKS AT HEALTH CARE FORUM

MODERATOR: IOWA GOVERNOR TOM VILSACK (D)

LOCATION: DRAKE UNIVERSITYSEN.

GRAHAM: Good afternoon. I will tell you that your health must be in good shape if you have managed to be here all afternoon. (Laughter.)

I appreciate very much, Governor, this opportunity to talk about health care to such an informed audience in a state which cares so much about the quality of its health. Earlier today I was in Marshalltown, and one of the administrators of the local hospital proudly announced that in Marshalltown they have the lowest-cost, highest-quality health care. I don't know if he was constraining it just to the United States or to the world. (Laughter.) But he made a very convincing case.

I know that you've been hearing our thoughts on a set of interconnected issues. I would like to share my feelings and then hear your questions or comments.

Clearly one of the challenges facing America is to make health care affordable and accessible to all of our citizens. The consequences of the fact that today about 15 percent of Americans, 40 million people, do not have access to affordable health care includes the fact that preventive care, particularly preventive care for children, is frequently unavailable. And when a person does become ill, they use the least appropriate and most expensive health care facility in the community, which is the local hospital's emergency room.

We have tried over the last—since Harry Truman was president in 1948 to achieve the goal of universal coverage. That is the goal to which we should all be committed. The question is, politically and economically, how do we get to that goal?

I would propose that the lesson to be learned from the efforts of two very bright, persuasive people, Bill and Hillary Clinton, to reform health care in one step is that it is politically very difficult, if not impossible. The system is too complicated. There are too many stakeholders in the status quo.

So I would suggest that we proceed to achieve the goal of universal coverage in a step-by-step basis. And I would—my own value systems are to assign that step by step based on degree of vulnerability and the capacity to use an existing health care mechanism to provide affordable health care.

So my step one would be children. Twenty percent of the uninsured Americans are under the age of 18. There is an existing program, the children's health insurance program, which could be expanded to include all children who do not have access to health care from some other source.

The working poor—we could expand Medicaid to a higher level with a co-payment based on levels of income to assure that all American families, particularly those who live at the margin and who typically work for an employer which does not provide health care, will have that opportunity.

And third, the early retirees, those persons who retire at the most-used date in America, which is now 62, and have a three-year gap before they are eligible for Medicare.

Those are the three that I believe should be the first steps. It would cost $70 billion a year to cover those three groups of Americans, and we would have cut the number of uninsured Americans by two-thirds. That, I think, would be a significant accomplishment and one that is within our capability.

The issue of access to affordable health care relates directly to the issue of the cost of health care. One of the things that causes us to have 40 million Americans without health care is they can't afford the health care that is available.

I think that there are a number of steps that we should take to provide some restraint on the growing cost of health care. One is a greater emphasis on prevention. We know that early diagnosis and intervention is an effective means of the maintenance of health, and therefore the avoidance of health care. Many of us in this auditorium today take drugs to regulate cholesterol or other heart conditions which have had enormous savings in human suffering and medical cost.

Prescription drugs, the fastest-growing component of our health care system, need to be constrained in part by competition. We should make it easier for generic drugs to come to the market. We should allow Americans, under appropriate safety and health conditions, to reimport drugs from countries, such as Canada, where the cost is substantially lower. We should encourage purchasing groups, such as the Veterans' Administration is doing today, to assist all of our citizens in being able to have access to less-costly prescription drugs.

A particular target of our concern should be those Americans who represent the largest share of our health care cost, the frail elderly. The reality is that a significant percentage of lifetime health costs are spent in the last 12 months of life.

What can we do to try to maintain quality but reduce the cost for elderly Americans? One is, within Medicare, we need to encourage more use of case management to assure that the proper health care is being provided but not excessive.

Second, we need to look for community-based alternatives to institutionalization. My wife Adele joins us this afternoon. She led the fight in Florida to achieve a program called Community-Based Care for Older Floridians, which had a tremendously positive effect on the quality of life and the cost of health care for older Floridians and will have a similar effect on a national basis.

We also need to encourage Americans to prepare for their later years by making long-term care insurance, which would cover both community-based and institutionally-based long-term care more affordable through providing tax deductions and other incentives, to purchase it while it is still reasonably affordable. Senator Chuck Grassley and myself have introduced legislation for that specific purpose.

The third component of the interrelated system is improving the quality of health care. Medicare is an example of a system which has improved the quality of life for millions of Americans. But there are some nagging problems within the Medicare system. One is the need to recognize efficiency and quality of care within the reimbursement program of Medicare.

The gentleman in Marshalltown wasn't making that statement just to announce the good health care in Marshalltown, Mr. Governor. He actually had a political purpose. He wanted to impress upon me the importance of reform within Medicare to raise Iowa above being 50th out of 50 states in Medicare reimbursement. (Applause.)

It's an irony that the very fact that Iowa has such an efficient system now has the perverse effect of costing health care providers important funds which would allow the system to be even more valuable and effective for Iowans.

Some of the things that we need to do to improve quality across the system, Medicare and elsewhere, is to reduce errors that occur in a health care environment that can be reduced. The Institute of Medicine has estimated that every year in America, 44,000 to 98,000 Americans die unnecessarily in a hospital because of some medical error, frequently an error in the medication that is administered, and that the cost of those deaths is $17 billion to $29 billion.

We need to have a major emphasis on—can I take a couple more minutes?

GOV. VILSACK: Okay. (Laughter.)

SEN. GRAHAM: We need to have a major emphasis on making hospitals a safer place. We need to increase the use of chronic-care management for all Americans, but particularly for the elderly and the disabled. And we need to have a new emphasis on the public health system.

We just are watching this afternoon as the power grid has gone down in much of the Northeast. That is going to put an immediate pressure on the public health system to see that those people who have spent several hours underground in a subway have access to appropriate medical treatment.

It's been said that the 19th century was the century of public health. The 20th century was the century of private health. The 21st century needs to be the century in which we find the proper blend. (Applause.)

On the private-public health care partnership, again, I would say that on the whole, Medicare has been the model of success. In its some 30 years of existence, it has almost doubled the life expectancy of Americans who reach the age of 65, so that today the average American woman has 20 years of life expectancy after 65; the average American man, 15 years. I will not make any comment on the cause of that difference. (Laughter.)

But Medicare is a program which is financed by the federal government, uses private-sector providers and private-sector financial intermediaries. It is one of the least-costly programs to administer in American health care. The Republicans, if I could be partisan for a moment, want to break that contract of public-private in the Medicare system by privatizing important parts of Medicare, starting with the idea that the new prescription drug benefit, which I hope will soon be available, should be more available to those who use an HMO, a system that's almost unavailable in Iowa, than those that use the traditional fee-for-service system.

Finally, we need to, in Medicare, begin to introduce a greater level of depoliticalization. I remember the debate we had over providing colon cancer screening. You wouldn't have wanted to have been there, because it was a squeamish discussion of the various modalities to determine if you had colon cancer. That is not Congress's business.

What I have proposed in the area of preventive care—and I think this could be applied on a more extensive basis—is that we ought to have the best medical science determine when procedures, such as tests for colon cancer, are both safe and efficacious. And then those should be submitted to Congress for inclusion in the Medicare program, and they would be included unless Congress affirmatively rejected the recommendation of the best medical science.

Finally, friends, I want to share with you a personal experience. For the last 28 years, like Tom Harkin, I have been taking jobs. I took my 390th job at the Little Sue ethanol plant. I've taken probably 30 or 40 of those jobs in health care. One of them was at a nursing home in DeLand, Florida. I was working with a middle-aged African-American man named Johnny Denton (sp). Working as an orderly in a nursing home is not a pleasant task. You're changing soiled sheets. You're taking people to the bathroom, feeding people, doing all the necessities of life.

At the end of the day, I told Johnny, "Johnny, I'm going to be 100 miles away from here tomorrow morning. You're going to be right back here performing your job as an orderly. What is it that gives you the motivation to want to come back day after day and do this job?" Johnny's answer was, "I figured that if God loved these people so much that he would let them live for such a long age, that I could love these people.

"

That, I think, is the spirit with which we need to approach the provision of adequate, affordable, quality health care to all of the citizens of America. If one among us can have that access, then, as one nation, undivided, under God, indivisible, with liberty and justice for all, we can afford to provide health care to all of our family of America.

Thank you. (Applause.)

GOV. VILSACK: Senator, thanks for joining us today. I was intrigued, during your comments, your reference and mention briefly to long-term care health insurance. Perhaps you could share with us a little bit more detail about your thoughts about the need for such a program, what the federal government's role would be, and how it could be implemented.

SEN. GRAHAM: Well, the legislation that Senator Grassley and I have introduced would have two parts. One, it would be a tax credit which would go to the in-home provider of services to a disabled or elderly member of the family, and it would provide a deduction of up to 50 percent of the cost of long-term care insurance as a means of encouraging more Americans during their working years to begin preparing for what many of us will likely experience.

That is a proposal which I think would represent a significant step towards making those services for older Americans more qualitative and more affordable.

GOV. VILSACK: You mentioned briefly the role that dedicated health care workers have in the system. Taking a slightly different approach, in terms of technology, what role does the federal government have in encouraging the development of additional technologies that could ease the worker's burden and perhaps improve the quality of care?

SEN. GRAHAM: I think the federal government has and continues to have a significant role in that. Many of the major breakthroughs in medical science were the result of organizations like the National Institute of Health and the Institute of Medicine. They deserve to have continued sustained support.

I have an overall economic program that is called Opportunity for All. One component of that is a series of areas in which America should be making a greater investment for the future. One of those areas is in the field of medical research, innovation, as well as the basic sciences. That is a national responsibility because it is for our nation's benefit.

GOV. VILSACK: Your remarks also centered on the importance of prevention. And I'm interested in knowing whether or not the approach would be focusing on specific diseases and a single focus on a particular disease until it was essentially reduced, or would you see a broader approach in prevention?

SEN. GRAHAM: I would see somewhat of a blend of that, Governor. There is an entity within the federal government which has, as its responsibility, to evaluate for safety and for efficacy and for cost various preventive modalities.

What I have suggested is that the Congress ought to defer to that scientific panel, and when a particular procedure, such as a procedure on colon cancer, has proven to be safe, effective and cost-effective, that it would automatically be added to the list of benefits of Medicare unless Congress specifically rejected that modality.

Congress has been unfortunately very slow to adopt preventive measures. For that reason, our Medicare program is often called a sickness program; that is, it will give you substantial help if you're sick enough to go to the doctor or the hospital, but not much assistance to stay at the highest level of personal health.

To me, the most fundamental reform that we need to achieve in Medicare is to make it truly a health program with its orientation being long and quality life. (Applause.)

GOV. VILSACK: Senator, you mentioned you've had a number of job opportunities to see how many Americans work. My job today is as moderator and to keep this on time, and the timekeeper has told me that our time has expired already. I want to thank you for being part of this conference. And again, ladies and gentlemen, please join me in thanking Senator Graham. (Applause.)

SEN. GRAHAM: Thank you. Thank you very much.