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Health Care And Education Reconciliation Act Of 2010

Floor Speech

Location: Washington, DC


Mr. COBURN. I thank the Senator for his question. If you look at Thomson Reuters and several others who have studied the health care field, the estimate for defensive medicine costs is $250 billion a year. It is not just that we order tests that protect us from frivolous lawsuits, but those tests have consequences. Some of those tests actually hurt patients or expose them to radiation or, in fact, limit our ability to do what is best for the patient because we are more interested in protecting ourselves.

Mr. McCAIN. May I ask the opinion of the Senator from Oklahoma as to why he thinks there is no address of medical malpractice reform whatsoever in this legislation that has the slightest impact on reducing health care costs?

Mr. COBURN. I think there are two reasons. One is because there is large support of those who wrote this legislation by those who benefit from suing doctors. That is pretty straightforward. And the doctor's only defense is to order tests which they need but which the patient doesn't necessarily need. The second is because they couldn't get--or wouldn't put it in the bill because they knew it would pass and the American people would agree with it. You know, it is beyond me.

But let me go to the point of this current amendment. I have delivered somewhere over 4,000 babies, and 2,000 of those were Medicaid babies. Over half the babies I have delivered in my life I have cared for through Medicaid. The State of Oklahoma just cut, in February or March, Medicaid reimbursements 3 percent. They are going to cut it another 8 percent. Forty percent of the primary care doctors don't see Medicaid patients because the price that is paid for the coverage doesn't cover the cost, let alone any margin. It doesn't cover the cost of nurses, the rent, the malpractice, and everything else.

The second point is, of the specialists who are available, 65 percent of the specialists in this country won't see Medicaid patients. So when I am taking care of Medicaid patients, I have trouble finding somebody better than me in a specialized area to care for my patients.

What is the other thing we know about Medicaid? Even if you normalize for social factors, their outcomes are worse. The cost in terms of the number of procedures, the failure of therapeutics--all are worse.

So why is this a good idea? It is not just a political stunt. If Members of Congress are enrolled in Medicaid, the first thing that is going to happen is Medicaid and reimbursements are going to go up so that the availability of the finest and the best and the brightest in this country is available to Members of Congress. So it is not just a stunt to say we put our membership in Medicaid; it is a very important ulterior motive to improve Medicaid.

Think about it. If you are one of the 16 million people who are going to get health care under Medicaid, supposedly, in this bill--and I doubt that seriously, simply because we are going to see a marked decrease of 50 or 60 percent of doctors who won't see them--think about what is going to happen: You are not going to be able to find a doctor. You may have coverage, but you won't be able to get anybody to care for you. Is that coverage? Is that care? Is that prevention? Is that management of chronic disease? No. None of that will happen.

So the whole idea of placing us in a leadership position into Medicaid is so that we will lead and fix it and make it what it should be. There is only one health care system worse in America than Medicaid, and that is the Indian Health Service. That is the only one that is worse. Everything else outside of those two programs is better. So why would we consign 16 million Americans to a health care program that is failing today? So the way to fix that is to put us into it. And I guarantee you, the self-interests of the Members of Congress will fix Medicaid and make it what it should be.

With that, I yield back to the original author of the amendment.


Mr. COBURN. This is a constructive amendment that saves millions and millions of dollars in Medicaid. The fraud in Medicaid prescriptions is out of this world. It can be fixed. This amendment will prohibit prescriptions for recreational drugs for rapists and child molesters. Nobody can disagree with that. It is not in the bill. It is the current state. But if this bill goes through without this amendment, your tax dollars are going to be paying for Viagra for child molesters. That is what is going to happen. There is an Executive order that this will override. The bill overrides the Executive order. So there is no prohibition in the bill for this at this time.

A Government Accountability Office audit of Medicaid found 65,000 instances of improper prescriptions costing $65 million over the last 2 years, including thousands of prescriptions written for dead patients by people prescribing and posing as doctors. The audit focused on 10 types of frequently abused prescription drugs in just 5 States, which means this audit, which is just over 5 States, multiply by at least 10, and you get $650 million worth of fraud in prescriptions in Medicaid alone.

We are not going to address that.

Sixty-five doctors or pharmacists were banned from Medicaid for writing or filling prescriptions or illegally selling drugs--but just in those five States.

About 1,800 prescriptions were written for dead patients and 1,200 prescriptions were ``written'' by dead doctors--just in those five States.

This amendment would direct the Centers for Medicare and Medicaid Services to enact the GAO recommendations to prevent and eliminate these fraudulent prescriptions. Specifically, it would direct CMS to establish a fraud prevention system for the Medicaid Program and issue guidance for States to prevent the processing of claims of all prescribing providers and dispensing pharmacies debarred from Federal contracts or excluded from the Medicare and Medicaid programs; ensure that drug utilization review and restricted recipient program requirements adequately identify and prevent doctor ``shopping'' and other abuses of controlled substances; develop a claims processing system to identify both duplicate enrollments and deaths of Medicaid beneficiaries and prevent the approval of fraudulent claims.

For years, the Federal Government had required States to provide prescriptions for Viagra and other impotence drugs to Medicaid patients, including to convicted sex offenders, child molesters, and rapists. States had provided the coverage based on a 1998 letter from the Clinton administration. As a result of that, an Executive order was issued in 2005, which this bill, if unamended, will reverse. Mr. President, 800 convicted sex offenders in 14 States received Medicaid-funded prescription drugs for erectile dysfunction. That is according to a 2005 survey.

The predators' victims have been as young as 2 years old. So we have convicted sex offenders, rapists, and child molesters who were taking Federal tax dollars and buying a drug so they can act again.

In Florida, 218 cases; New York, 198 cases; Texas, 191 cases, and it goes down the list.

This amendment would prohibit the new health care exchanges from providing coverage of ED drugs to convicted child molesters and convicted rapists. It is pretty simple.

The claims that are made on this bill are outlandish. As somebody who has practiced medicine for 27 years, 50 percent of my patients were Medicaid patients. What you are going to do if you do not fix some of the things in this bill is destroy the best doctor-patient relationships in the world. That is what you are going to do.

You are going to put 16 million people into a failing Medicaid system that the States cannot afford. Almost every State is cutting Medicaid reimbursement. At this time, only 40 percent of the doctors in the specialties will see Medicaid patients. It is going to go to 20 percent. So we are going to put 16 million people in a system, and then they are not going to be able to find a doctor. Because of the costs, in my own State, we are going to have an 11-percent net reduction in Medicaid reimbursements, which is only 75 percent of Medicare.

What do you think is going to happen in all the States in the country when the Medicaid reimbursement goes down and we add 16 million new people to Medicaid? You are going to call it care. You are going to rub your shoulder, rub that medal on your shoulder, and say: Oh, we fixed health care. You are going to promise them they are going to have care, but they are not going to have care. They are going to have a card, but they will have no care. We are going to have Indian Health Service-type care in Medicaid because nobody is going to be there to care for them.

The claims under this bill keep me sleepless at night--not because of Washington but because of those 10,000 Medicaid patients I have taken care of through my career for whom I know you are going to destroy what care is left for them. You can claim otherwise, but the facts are going to prove you wrong. We are seeing it in every State in the country right now--the cuts to Medicaid reimbursements.

So at least you ought to help save $650 million a year by getting rid of fraudulent prescriptions, eliminating prescriptions for convicted child molesters for erectile dysfunction, and recreational uses with drugs such as Viagra. The American people do not want to pay for that.

To vote against this amendment, to not fix something that is very obvious, is criminal--it is not just not right, it is an active aid to help those who would hurt our children.

I yield to the minority whip.


Mr. COBURN. Mr. President, what needs to be fixed in this bill is a whole lot more than that, but this is a great attempt to try to solve a problem.

Let me describe a scenario, what is getting ready to happen. Every State is cutting Medicaid reimbursement. We are going to add 16 million people to Medicaid. We cannot get them all seen now. Then we have a doctor cut that is coming to 21 percent for people who are under Medicare. What is going to happen? What do you think the average physician in this country is going to do? I can tell you that they are going to do three things: Fewer will see Medicaid patients so there will be fewer doctors taking Medicaid at the time we increase the enrollment by 50 percent. That is No. 1.

No. 2, fewer doctors are going to take Medicare as we have this ballooning increase of baby boomers going into Medicare.

No. 3--and this is probably more important than anything--we are going to see a large percentage of doctors, with this bill passed with no continuity as to how they are ever going to get funded under Medicare, quit. They are going to quit. They can take their training, their effort, their education and knowledge and apply it in some other field of endeavor and not have to live with the hassle of a 21-percent cut hanging over their head.

Even if we fix it for 3 years, 3 years from now the same problem is going to come up, except it is going to be worse. So there is no fix in it. There is an unrecognized $300 billion to get doctors even, let alone take away the cut--no increase--with this amendment. My hope would be we would fix this situation for 3 years.

Mr. GREGG. Mr. President, I ask unanimous consent that we be able to participate in a colloquy on our side of the aisle.

The PRESIDING OFFICER. Without objection, it is so ordered.

Mr. GREGG. Mr. President, I wish to ask the Senator from Oklahoma, who is obviously a physician and has an indepth knowledge of this issue, I heard the other side of the aisle say: There are no cuts to the benefits of people on Medicare. If you reduce doctor payments under Medicare 21 percent, don't you think that is going to affect what they receive? Technically, there will be no cut because they will still have the right to see a doctor. Is it not going to be hard to see a doctor because doctors will stop seeing them?

Mr. COBURN. They are not going to find a doctor, and that is the whole problem. Whatever we see in the urban areas now, multiply it tenfold in the rural areas. We are going to increase eligibility for Medicaid to 133 percent of the poverty level, we are going to add 16 million people to a system that is not handling the people who are in it today, so we are going to promise them: Here is your Medicaid.

Now where is the care? It is not going to be there. There is not the available physicians in this country to care for 16 million new Medicaid patients.

If we, in fact, do not fix long term the SGR, physicians are going to do one of two things. They are either going to completely quit seeing Medicaid and Medicare patients or they are going to retire. Quite frankly, physicians my age who are still practicing are not doing it for the money; they are doing it because they love the patients. But they are going to be forced to quit because they will not even be able to pay their overhead to care for those patients.

Mr. BURR. If I may add to Dr. Coburn's comments and say, when you double the size of the Medicaid population, you are already forcing more doctors to say: I am not going to see Medicaid patients. But you are changing the payer mix. Every provider, every practice, every hospital is going to see more patients whose reimbursement is less. That is automatically going to affect Medicare right there because people are going to have to try to bring in more private pay, private insurance.

Mr. COBURN. Will the Senator yield for a second?

Mr. BURR. Absolutely.

Mr. COBURN. What it is going to do is exacerbate the cost shifting going on with Medicare and Medicaid right now, which means insurance rates for everybody else in the country are going to go up.

Mr. GREGG. I thought we were told insurance rates were not going to go up.

Mr. COBURN. All I will tell you is, the best guess of CBO--wonderful people, but they can only make decisions within the parameters they are given. There is no question private insurance, individual and family insurance, is going to go up, but everybody else's is because we are going to increase the trend of cost shifting from government programs to the private sector.

You are going to end up with three taxes. You will pay income taxes, you will pay a Medicare tax, and then you will pay a tax on your insurance--actually, you will pay four--and then you are going to pay higher health insurance premiums because the government does not cover the cost.

Mr. GREGG. I assume that is not just going to be people with incomes over $200,000.

Mr. COBURN. That is everybody in this country who has private insurance, either through their employer or the individual market.

Mr. GREGG. Isn't it equally likely that a large number of small employers will get frustrated with the rate increases they are getting in order to support people on Medicaid that they will simply drop that and push their membership, their employees over into this new exchange?

Mr. COBURN. Yes, they will pay the fee. They will pay the tax and say it is easier. Consequently, the young people in our country, because we do not have a big enough payment under the ``individual mandate,'' are going to say it is smarter for me to save my money, pay the fine, and not get insurance because when I get sick, I can get it. You are going to get what is called adverse selection, which is even going to drive the rates up further. Anybody 40 or older, watch out, your health insurance rates are getting ready to bloom.

Mr. GREGG. We have basically a multiplier effect----

Mr. COBURN. That is correct.

Mr. GREGG. In the area of costs being driven up as a result of this new policy of adding a huge number of people to an uninsured system that cannot afford it right now, Medicaid. The costs are going to multiply on people in the private sector. The effect will be higher premiums, less opportunity for your employer to give you insurance and, in the end, a higher tax rate for you, Americans who are just working Americans, not people with high incomes.

Mr. COBURN. And people who are not necessarily getting a subsidy.

Mr. GREGG. Then they do not even take care of the doctors. They cut the doctors 21 percent on top of all this.

Mr. COBURN. What happens to all this? What is the ultimate? The ultimate is failure of the insurance market.

Mr. GREGG. That is the goal, isn't it?

Mr. COBURN. That is the goal, so the government can control it all. I yield back.


Mr. COBURN. If I may, I would like to add one other thing here. Think about it. We are talking about the cuts that are set to go. But since there is no tort reform in this bill, we spend $250 billion on defensive medicine and liability costs continue to rise. You could bring them back whole, but if you give them no increase, they are still going to quit seeing Medicare patients.

One other point I would like to make is with the student loan program being totally taken over by the government, 31,800 people in this country this July will lose their jobs. So we are going to lose 31,800 jobs in the private sector, but we will add 16,500 jobs at the IRS. I don't think anybody in America would like to see that happen.


Mr. COBURN. Mr. President, this amendment saves $6.5 billion over the next 10 years for what it does on fraudulent Medicaid prescriptions--$6.5 billion--$650 million a year on fraudulent prescriptions. It also creates a prohibition so that erectile dysfunction drugs are not paid for by the American taxpayers to convicted rapists, those convicted of sexual assault, and pedophiles in this country.

You can say a lot of things about a lot of amendments. This is not a game amendment; it actually saves money. All the States are struggling with Medicaid. This is a way to spread $650 million a year to the States.

I reserve the remainder of my time.


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