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Service Members Home Ownership Tax Act Of 2009 - Motion To Proceed - Continued

Floor Speech

Location: Washington, DC


Mr. COBURN. Mr. President, first, I would like to say thank you for presiding. You drew the unlucky number tonight and I appreciate it.

We are embarking on a process that is going to start tomorrow night and people are going to cast a vote on a bill they have not read, and saying we ought to go on with it.

For just a little history, 97.8 percent of the time in the Senate that a cloture motion passed to proceed to the bill, the bill becomes law. That is an interesting statistic, especially when we are going to hear those who say they just want to have the debate. The fact is, that is not what is going to happen.

As one of the two practicing physicians in the Senate, I thought I would spend a little bit of time tonight talking about what I see is wrong with our health care system as well as talk about what I see as good about our health care system and then talk about the approach this bill takes. My staff has been through the vast majority of this bill. I personally have not, but I will. I will talk about how it affects us.

What is the real problem in health care today? What is it that keeps people from getting care? The No. 1 problem that keeps people from getting care is cost. It costs too much. Fully either one-fourth or one-third of every dollar we spend on health care does not help anybody get well and does not prevent anybody from getting sick.

There is an interesting study out by the Thomson Reuters report that says that $600 billion to $850 billion is wasted annually in all American health care.

When you break it down, it is broken down like this: 40 percent is health care waste, unwarranted treatment, overuse of antibiotics, use of diagnostic lab tests to protect against malpractice exposure. That accounts for $250 to $350 billion in annual health care spending. It is attributed to extra tests and procedures generated mainly from defensive medicine or Medicare's fee-for-service system.

The second biggest factor out of this $800 billion we are wasting is health care fraud. It is 19 percent of health care waste--at least $125 billion to $175 billion a year, and most of that is in government-run health care programs. Not the private--the private sector has less than 1 percent of fraud. They also have a denial rate that is one-half to a one-third of Medicare's rate in terms of denial of payment claims.

The third most important thing in terms of waste is administrative inefficiency. The large redundant volume of paperwork in the U.S. health care system accounts for $100 billion to $150 billion in spending annually.

The fourth most important area, 12 percent of health care waste is health provider errors, errors we make caused by me as the doctor, or a hospital, that causes us to spend money we should not have to spend.

Six percent of the health care waste is preventable conditions, such as somebody with diabetes getting their blood sugar out of control and ending up in the hospital; whereas if they had good care, coordinated care, it wouldn't have happened.

Of course, No. 6 is 6 percent of health care waste, and that is lack of coordinated care, where we do not coordinate the care, where doctors don't talk to one another, doctors don't talk to the hospital, doctors don't get all the information, so consequently we waste money.

So the first problem that plagues us is that cost is too high. We fully know that $1 out of every $3 we spend on health care is not helping health care. That is our pot of gold. That is where we lower the cost. Just think what health care would cost if it costs one-third less today or if it costs the same for the next 5 years. That means we could cover everybody who is not covered for free and have about $400 billion left over if we just went after where the pot of gold is.

The second problem with our health care system is we have disconnected the purchase of health care from the payment of health care, so that when I go to make a purchase I no longer use the discrimination that I use in everything else that I purchase, such as seeing if it is of value to me. I don't ask what it costs, I don't ask if it is the best way to get this, if it is the most economical way to get there. I don't question to make sure--are you sure I have to have this done? I don't necessarily get a second opinion. I don't ask, if it has to be done, where is the best place as far as efficiency and dollars to get it done.

The reason we don't ask those questions is because most of the time the money isn't coming out of our pocket because we have this perceived false belief that our insurance company or the government is paying for it. If our insurance company is paying for it, we are paying for it because for every 3.5 percent cost our company is paying for insurance, 2 percent of that would have been our wages. And for every $1 that we spend on Medicare, our grandchildren and our children are paying into that fund to pay for our Medicare. In fact, it does cost us, but we have disconnected that cost.

The third thing we have done is we have a Tax Code that says if you are fortunate enough to have your employer pay for your health care benefits, you get $2,700 more in tax benefit than everybody who doesn't have their employer paying for their insurance. You get about $100 in tax benefit if you don't get your insurance through your employer. So we have a 27-fold discrimination that advantages those whose employer pays for their health care versus those who have to buy it on their own or their employer doesn't offer it.

That is wrong. It is not fair. It is unequal treatment, and it creates this maldistribution. But, even having said that, the cost for an individual plan versus the plan bought through your employer, if you buy it in a nationwide marketplace, if you could, it would be 20 percent less than what you could buy it for through your employer. Those are the real statistics.

Then the fourth thing I see that is wrong, as both a patient--I ought to stop here in a minute and tell everybody, at 61, almost 62 years of age, I am a two-time cancer survivor. I have had malignant melanoma and metastatic colon cancer. I also have atrial fibrillation. I have been a patient. I have been on the other side of my stethoscope as a patient.

What I see is, we have limited the options for people in this country. If your employer buys your health insurance, you have very limited options. You get take it or leave it most of the time. Here is what we are providing: You get to take it. If you don't take it, then you have to go outside and you loose that $2,700 advantage, so it comes out of your pocket.

We don't have the freedom to choose within our employer. We also have the States. We heard the Senator from Maine talking about the greatly increased costs in Maine. There is a reason Maine has the massive inflation in their health care insurance. They created the State plan that caused it, that truly limited the competition. So they have seen the results of limited competition because of what they installed. But every State has an insurance commission that both decides who is eligible to sell in the State but also follows the mandates; here is what the minimum is that you have to buy in your State.

Then, of course, if you have Medicaid, you have limited options because 40 percent of the physicians in this country will not see you. If you have Medicare, you have limited options because now about 15 percent of physicians, fast rising to 30 or 40 percent of the physicians in this country, aren't going to see you.

Then if you have VA, you get VA and that is it. You don't get to choose your doctor or you don't even get to choose your location. Here is where you will be, no matter how many miles it is, and here is the doctor you will see. The same thing with TRICARE essentially because TRICARE has limited coverage in terms of availability of all the physicians.

The fifth thing I see that is wrong is there is an absolute lack of transparency as to what something costs and what you can expect as far as quality outcome. That makes it hard to know how to buy, where to buy, or who to buy from. Who do you trust? So if there is no transparency in either quality or price, you are going to have a tough time making a decision. All of the things I am describing describe a lack of liberty, a lack of freedom.

We have government mandates. Have you ever gone to a hospital--this is a great question. One of my constituents wrote in and told me this, and I never had thought about it. Go to a hospital in the middle of the day and try to get a parking spot. Then go to a hospital at 10 o'clock at night, and the parking lot is almost empty. What you are seeing in the difference in the parking lot is the administrative bureaucratic overhead that is required in a hospital to manage the mandates that the government has put or the insurance company has put on the hospital.

If you look at it, fully one-third of the people in every hospital in this country don't do anything to help anybody get well. They are filling out forms, they are pushing the paper, much like this study I mentioned from Thomson Reuters.

Then we have the insurance mandate. What is wrong? If, in fact, you have a preexisting illness, you don't get insured. That is wrong. We need to fix that. Or if you get sick, insurance companies have figured out a way to drop you. That can't be right. That is why you bought insurance in the first place, and that is not just in the health insurance industry. Try filing a claim for a new roof on your house and see what your insurance costs do next year or if they will insure you. We get hail all the time in Oklahoma and we get roof damage and a lot of times if you have that 2 out of 10 years, they will not even reinsure you. So you have to go find somebody else.

It is a practice of risk management that they are using that doesn't think about the potential market of who their customer is. So I agree we ought to fix those things.

Then we have the costs. Already the Senator from North Dakota tonight talked about drug prices. The one thing he didn't tell everybody is that the reason drugs are cheaper in Canada is because they threaten not to honor intellectual property of this country.

There is a real good way to make sure drug prices go down. Both the Bush administration failed on this and the Clinton administration failed on this--and this administration. If Canada wants to tell our drug companies what price they will pay, then we will tell them what we will pay for their lumber, and we will tell them what we will pay for anything else they want to import to our country. But we put all the focus on the drug companies instead.

So I am going to get to my point. The other thing that is wrong is, on average it costs $1 billion per new drug just to go through the FDA process in this country because we have such a litigious society, that it costs two to three times more to approve a drug in this country than it does anywhere else in the world.

We have drugs that are fantastic drugs that are made by companies in this country that are not allowed to be sold in this country that have passed all the safety and efficacy standards of the European common market, but they can't get them through our Food and Drug Administration because the Food and Drug Administration is worried about somebody criticizing them if they ever make a mistake. They met the standards, did it right, recalled it, now they are afraid to approve anything because they are afraid somebody will be critical of them.

Another thing that is wrong is we have the lack of any real market forces. Insurance companies really don't have to compete.

They really don't have to compete. The government sets the price for everything, essentially, because Medicare says what they will pay and everything else is priced off that.

Here is another thing that is wrong with our health care system. We are starting to experience it. There is a maldistribution of physicians both in terms of geographic location and physician specialty. One in 50 graduates of med schools last year went into primary care. Everybody else went into specialty and subspecialty residencies. Why did that happen? The reason it happened is because the earning power of somebody who has 7 years of medical training is one-third of somebody who has 8 or 8 1/2 or 9. How did that happen? Because Medicare set the payment rates. Medicare set the payment rates, so they created a maldistribution in terms of the payment for physicians.

Another thing I noticed as a practicing physician and as a patient is that our whole system right now has its emphasis on sick care, not on preventing disease, not on prevention, not on the maintenance of chronic disease. We wait until people get sick and treat them. That is expensive. The reason it is that way is because Medicare won't pay for prevention. They refuse to pay for prevention. If you sit down with a patient in your office, a Medicare patient, and spend the time to go through the risk factors and the lifestyle changes and their medicines, the things they need to do, you will not be compensated enough to pay the electricity bill for that office visit. So what has happened is we have incentivized people not to spend time with the patient. We have incentivized them to see more patients for shorter periods of time and not listen to the patient and not spend the time on prevention because our dollars have been incentivized against it.

Then, finally, government systems are designed to be defrauded. If you think about it, it is easy to make $500,000 a month off Medicare; it is hard to get caught. All you have to do is know a whole lot about medicine, have a little bit of guts, and set up a vacant office somewhere and put one computer in it and run everything over the line, and you can rip off Medicare like crazy. We know the drug dealers in Florida are starting to shift away from drugs and into Medicare fraud because it is easier to do. They can make more money. It is harder to get caught, and when you do, the penalties are much less. It is designed to be defrauded, but we haven't changed that.

I have talked about the problems. Let me talk about what is great about American health care.

I want to make the point in a minute that the worst thing we can do in trying to fix what is wrong is destroy what is right. We have the greatest acute care anyplace in the world. If you get sick, there is no better place in the world to get sick than in the United States. I don't care where you are. The statistics bear that out. There is no question. If you get cancer in this country, you have a 50-percent greater likelihood of being alive 5 years from now than anywhere else in the world. It really doesn't matter what type cancer. There are some differences on some, but overall you are 50 percent more likely to be alive.

The third thing that is great about our country is, innovation in health care is two-thirds of the world. Actually, last year it was 74 percent of all innovation in health care came out of this economy. We have invested in the research. We have the scientists. We have the researchers who have pulled together technology, thought, experience, and research, and come up with great innovations that make big differences in life expectancy and quality.

The other thing is we have a very skilled workforce. We have some shortages. Our nursing shortage has been created by the government because we created a health care system that has both hospice care and home health care, but we made the only way that can effectively work is through registered nurses. So we sucked all the registered nurses out of the hospitals because of time constraints and lack of holiday work and lack of shift work. The best nurses want to go where they don't have any of those things. We created a shortage when we could have created a different class of somebody doing home health care rather than an RN. But that is what we have done. We have created this sucking sound, as Ross Perot used to say, and sucked the nurses out of the hospitals. Now we have this critical shortage of nurses in our country because of what the government did.

The other thing besides the skilled workforce, the nurse practitioners, the PAs, nurses, physical therapists, pharmacists, radiologists, doctors, surgical nurses--they are great in this country.

Then we have great medicines. If you think about it, the combination of medicines that saved my life with metastatic colon cancer were all developed here. Six months of chemotherapy, of being sick every day, has been worth every morning I see the Sun. It is this research, the investment in NIH, the quality of research, the committed doctors who will do the research, committed doctors who will take care of you when you are sick and you don't feel like communicating with anybody, but yet they are patient with you--they love you, they nurture you. We have a great system here.

If you have a cardiovascular event, this is the best place in the world to have one. If you have a heart attack, a stroke, if you get cancer, if you have an acute fracture of a limb or joint degeneration, this is the best place in the world to have it.

So I have outlined the problems, which are big, and the things that are good. What do we do with that? Our goal ought to be to not destroy all these good things while we fix the things that are not good.

How did we get in trouble? How did we get to where we have the highest percentage of our GDP, this thing that really limits people in care, cost--how
did we get where we are? Why is it? Part of it has been innovation. About 30 percent of the cost increase we see in our country is because of innovation. It takes money to get innovation. When innovation comes out, we have to pay for the research that was not paid for upfront. About 30 percent of the health care inflation we see is from new products, new innovation, new ideas, new treatments, new strategies or procedures. But the rest of it goes back to this Thomson Reuters, where we have this inefficient delivery system of health care.

A question I asked my staff--and we did the research--what was health care inflation before 1970? Do you realize that most of the time it was less than the regular increase in inflation? What was the difference? What happened? What happened is the government got involved in health care. We created demand that was price-controlled demand, and all of a sudden the bubble started squeezing up.

The other point I wish to make is that most people don't realize that 61 percent of the health care in this country today is run through the government. If we have a problem with health care, we have to look at not where the 39 percent of it is but where the 61 percent is. Let me explain what that is. That is Medicare, TRICARE, VA, Medicaid, Indian Health Service, SCHIP, DOD, and FEHPB. That accounts for 61 percent of the people in this country who have health care. They are getting it through the government now. Our answer is more government? Our answer to the solution is more government?

What should our goals be? Our goals should include access for everybody; affordable prices; liberty to choose what is best for you and yours, not limited by your State, not limited by the Federal Government, it should be your choice; freedom to choose your caregiver. You don't get that in Medicaid. You don't get that at the VA. You don't get that at Indian Health Service. You limitedly get it through Medicaid. Another goal is security in your health care, knowing that no matter what happens, you will have health care. Those are things I think the Presiding Officer would agree with.

I am joined on the floor by the other physician in the Senate, Senator Barrasso from Wyoming. I welcome him.

I wanted to spend 1 additional second outlining a few things.

Here is the bill we have on the floor, the Reid substitute. I will not talk about the parliamentary shenanigans that have gone along with what we are doing. The fact is, we are going to have a debate on health care. It couldn't have been said any better than by Senator Snowe. Every major piece of legislation that has affected most people in this country has occurred on a bipartisan basis. If this gets passed, you will see a revolt in this country because it is not what the vast majority across party lines want to see. We need to meet in the middle.

Just so I can tell you what is in here or what is not in here, there is no provision in here guaranteeing that taxpayers will not finance abortion. There is no provision prohibiting the rationing of health care. You will see rationing of health care with this bill. We are seeing it now in Medicare more every day. CMS is not supposed to be doing it, but they have a reason not to do it. There is a law that says they are not supposed to do it, but it doesn't prohibit them. Now they are rationing about 17 things. They have made a decision on practicing medicine. You will see that.

There is zero number of Senators who are going to be required to enroll in the health care bill we will put everybody else on. There are nine new taxes created in this bill, nine new separate taxes. There are 13 pages in the bill's table of contents, single-spaced. This bill weighs 20.8 pounds. There are 36 pages in the CBO explanation of what they think it might or might not do. It has 70 new government programs. Think about what that means in terms of bureaucracy and then think about your choices, about who you want taking care of you and whether you and that caretaker, that physician are going to get to decide what is best for you or some of these 70 new government agencies. And 1,697 times in this legislation we allow the Secretary of Health and Human Services to create, determine, and define critical things in this bill and write the regulations--1,697 times. There are going to be 1,697 new sets of regulations in health care in this bill alone. There are 2,074 pages. There are 2.5 million people who will lose their health insurance with this bill who have it today. They are going to get moved into some government program. There are still going to be 24 million people left without health insurance, if this is fully implemented, according to CBO. This bill costs $6.8 million a word. It is $1.2 billion per page. Ten billion will be needed every year for the IRS just to follow the regulations for the tax collection in this bill. That isn't even considered in the CBO score. There is going to be $8 billion in taxes levied on uninsured individuals. There is going to be at a minimum $25 billion a year in increased mandates on States for Medicaid; there is $28 billion in new taxes on employers not providing government-approved plans; there is $100 billion of fraud annually in Medicare; there is $118 billion in cuts to Medicare Advantage; there is $465 billion in total cuts to Medicare; there is $494 billion in revenue from new taxes and fees levied on individuals, on American families, and businesses. Mr. President, $2.5 trillion is the non-Enron accounting cost for this bill.

Finally, there is $12 trillion worth of national debt today, and this bill by itself will take it to $15 trillion in 10 years. It will increase the national debt in less than 10 years by $3 trillion.

So with 61 percent of the health care in this country already supplied by the government--and either bankrupt or going bankrupt or not giving the care that is promised; look at Native American care--we are going to do more government health care.

Senator McCain had a great analogy the other day on this bill. This bill starts collecting taxes right away. The American people need to know the reason there is the delay in the onset of the benefits in this bill. It is because that is the only way they can make it score and look like it is not spending the amount of money it is spending.

But he used this analogy and I thought it was really great: This bill is like you buying a new home; you go get your mortgage, and you start paying on your mortgage, and you get ready to move in the house, and they say: Uh-oh, the deal was you can move in in 5 years, because that is when the benefits start, 5 years from now. But we want you to pay on it for 5 years before you get to move into it.

None of us would do that. Yet that is exactly what this bill does. It is not a bait and switch. It is just deceptive, and it is dishonest in its accounting. And, of course, Washington has been dishonest. We use Enron accounting. Anything that makes it look less expensive or us look better, that is how we account for it.

Finally, I would say this, and then I will yield to my colleague and fellow physician, Senator Barrasso.

Of the things that are wrong with health care in America and the things that are right--the things that are right are because we have a patient-centered system; the things that are wrong are associated with a government-centered system.

This is a government-centered health care fix, and it is not even a fix. It does not address malpractice costs. It is somewhere between $100 billion and $175 billion a year in tests we are ordering that people do not need because we refuse to address the tort system in this bill.

What we need is a patient-centered result. What we need is meeting in the middle to solve this problem for the American people.

Abraham Lincoln said: America will never be lost by being destroyed from the outside. If we falter and lose our freedoms, it will be because we have destroyed ourselves.

This bill is the path to destruction for health care in America. Eighty percent of the people in this country will get along just fine with this bill. Twenty percent are going to suffer drastically under this bill because it totally ignores the clinical practice of the art of medicine. Everything is based on a government-run, government-mandated, government-controlled fiat that takes away your liberty, takes away your choice, takes away your freedom; and now we will move physicians from having to be 100-percent advocates for the patient to an advocate for the government first and the patient second. That is the first health care outcome we could have.

Senator Barrasso.


Mr. COBURN. Mr. President, in answer to my colleague's question, there is not an incentive. This bill is full of mandates. And what it does not mandate it sets up panels to mandate. It sets up panels of bureaucrats to mandate. The real difference on this bill--and I believe we have big problems with the insurance industry, but I do not think you eliminate it. I think what you do is you clean it up and make it have to be competitive and fair and open and honest. What the bill does is it mandates.

Just this week, the Preventative Services Task Force came out with new recommendations for mammograms. If you are only thinking about cost, they are great recommendations. If you are looking at it only from cost--how do we most effectively spend the dollars--their recommendations are absolutely right. But if you are thinking about health, their recommendations are absolutely wrong.

You ask the thousands upon thousands of women last year under age 50 who had their breast cancer diagnosed early with a mammogram what they think about the Preventative Services Task Force's recommendation and listen to what they have to say. What they are going to say and what they are going to tell us is that would have made me odd woman out because I would not have had a mammogram. I am talking not high-risk patients. What they are talking about not screening--and that is what the majority of these mammograms find, with no symptoms, no increased risk--you are going to see that multiplied one-hundredfold in this system.

I know the Senator is old enough to have been trained in medicine the same way I was. There are three real tenets in medicine. The three tenets they drill into you are--the first thing is do not hurt anybody. Whatever you do, try not to hurt anybody. And in the practice of medicine and the art of medicine sometimes that happens, we do hurt people. Sometimes we hurt them on purpose to try to get them better. But the first is to do no harm.

The second is to listen to the patient. Well, the patient at this time in America is the American citizenry, where 85 percent of the people pretty well like what they have, and they want the good kept as we fix what is wrong.

Finally, the third tenet of medicine that almost every doctor is taught is,
if it has already been done and it is not working, do not do it again, and do not keep doing it.

Well, let me tell you something. Medicaid is not working. Indian health care is not working. Medicare is broke. The States are broke under the weight of Medicaid. We should give great pause as we break the three tenets of medicine in hopes of saying we reformed health care.

When President Obama spoke to us under a joint session of Congress, this is what I believe he should have said. This is an important matter for America. It is important to us economically. It affects every individual in this country. And what he should have said is: I have not been leading very well on this because we are way over here on one side on this issue, and I am going to admit I have not been leading very well. But here is what I am going to do. I am going to bring us together in the middle where we can all agree on--it is kind of like Senator Enzi's 80-percent rule. It is a great rule. Senator Enzi has joined us. He is the ranking member of the Health, Education, Labor, and Pensions Committee. I want to bring us together and find something on which 80 percent of us can agree.

Had he done that, he would have been a hero in solving the problems in which we find ourselves. Instead, we are going to try to pass something that, before we are through with it, the vast majority of Americans are not going to want. And if you do pass it, and he does sign it, they are going to revolt.

So as our friend Lamar Alexander said: What we ought to do is start over.

We ought to fix one step at a time the things we know are most important, as the author and promoter of association health plans suggests, where we increase the buying power; transparency in the insurance market; risk reevaluation so people can't cherry-pick; eliminate preexisting illnesses so they can't cancel insurance. All of those things we can do without creating all of these new programs, all these 1,697 times that the Secretary of HHS is going to write the rules and regulations.

I thank Senator Barrasso, No. 1, for his insight and experience. I would leave our colleague, the senior Senator from Wyoming, with this thought: You have two doctors down here who happen to be Senators, who have well over 50 years of practice experience. I had a business career in the health industry prior to going into medicine. We diagnosis this bill as sick. We diagnosis it as something that should be pulled from the market, just as the FDA pulled Vioxx. It will not solve the problem; it will make the patient sicker.

With that, I yield the floor.


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