Michael Burgess

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to congratulate Dale Fisseler on obtaining the position of City Manager for the City of Fort Worth. Mr. Fisseler was recently promoted from his previous position with the City of Fort Worth as Assistant City Manager and will now be taking over the reins as City Manager of the fifth largest city in Texas. Mr. Fisseler has been working for the City of Fort Worth since 1990, where he started as a Water Superintendent. In 1999, he was named Director of the City of Fort Worth's Water Department, which provides water to almost 1 million people throughout Fort Worth and Tarrant County. Many local officials agree that Mr. Fisseler is most deserving of this position. Fort Worth Mayor Mike Moncrief supported this notion by stating that ``obviously Mr. Fisseler is familiar with our city's history, challenges and opportunities. We are very pleased that the best person for the job was already a member of our Fort Worth family.'' It with great honor that I congratulate Dale Fisseler on this deserving opportunity and wish him the best in his future endeavors. The North Texas region is truly fortunate to have the type of dedicated public servant that Dale Fisseler personifies, and I wish him every success during his tenure as the City Manager of Fort Worth.

Mr. BURGESS

Mr. BURGESS. I thank the gentleman for yielding, and I thank both the chairman and the ranking member for bringing this bill to the floor. Madam Speaker, as pointed out, this has been one of the most popular pieces of legislation that we could pass certainly during my short tenure in Congress. And, Madam Speaker, I would only point out that with a 10 percent approval rating, it is incumbent upon us to continue to pass legislation that is indeed popular. I am an original cosponsor of the Do-Not-Call Registry Fee Extension Act, and as has been pointed out, this bill will extend the Federal Trade Commission's authority to collect fees and to administer and force the do-not-call registry. This registry is popular. This registry's effect has been profound. Since the creation of this registry, as we heard testimony in our committee as we worked on the bill earlier this year, over 145 million telephone numbers have been registered. And as we heard from Ranking Member Stearns a little while ago, that number is now up to 150 million telephone numbers. As the Director of the Federal Trade Commission, Linda Parnes, eloquently stated in her testimony before the Energy and Commerce Committee last October, the do-not-call registry ``helps to restore the sanctity of the American dinner hour.'' While I firmly believe in a free market and I believe that businesses should be able to and should be responsible for formulating their own business plans and business practices, I also believe that Americans have a right to privacy. People should be able to have the option of whether or not they want to receive telephone calls from telemarketers in the privacy of their homes. Thanks to the do-not-call registry, Americans can sign up and they are afforded this decision and this discretion. To keep the registry working in the future, it is imperative that we act swiftly and pass this important legislation to further extend the protection of privacy for all Americans. As Commissioner Parnes pointed out, let's help restore the sanctity of the American dinner hour once and for all.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I come to the floor tonight to talk about health care, which we sometimes do in this hour. It's an important subject, and we are going to hear a lot about this over the coming year. We have got a Presidential election that is now in full throttle across the country. We just had Super Tuesday, and by a strange turn of events the nominations are not settled and my home State of Texas now next month will, in fact, play a big role in helping select the nominees of the two parties. During this coming month, I expect we will hear a great deal about the plans and visions and the aspirations of the different candidates for health care. But let's not forget, when we talk about health care, that it is on the floor of this House where about 50 cents out of every health care dollar that is spent in the United States of America today, it is on the floor of this House where that spending originates. I can't help but observe the last speaker who was addressing the House on the subject of the budget was critical of the President's budget, which is his prerogative and his right, but I would remind the previous speaker that it is his party that is in charge, as it was last year, and while it is the President's obligation to present a budget to the Congress every year, it is then the Congress' obligation to work on that budget and pass a budget, which will be voted on later in the year, that either accepts or rejects those proposals put forth by the President. Indeed, last year, that is exactly what happened. So the budget that went forward last year was not the President's budget, I would point out to the gentleman from New York, but the budget last year was the budget passed by the majority on the House of Representatives floor last year, and the same thing will be true this year. They are in charge. It is their right and prerogative under the rules of the House that they will have absolute authority to create the budget and, as a consequence, those things that are felt to be important are going to be those things that are championed by their side. Those things that are felt to be less important will be those things that are left of the budget. That responsibility lies in the House of Representatives. Under the rules of the House, that responsibility lies with the majority party. Currently, the majority party is the party of the gentleman who just spoke. So while I appreciate his passion, I appreciate his fervor in talking about the President's budget, I think he would be better served to actually spend some time talking to his leadership about the priorities as they come forward over this next year, because there are some significant problems that faced this House last year that were simply kicked down the road at the end of the year. In fact, we saw a repeat of that last week. We were obliged to reauthorize the Foreign Intelligence Surveillance Act so that we have the tools necessary, our intelligence community has the tools necessary to prevent terrorist attacks on our homeland security and to help protect our soldiers who are serving in Iraq and Afghanistan. We couldn't do it, so we kicked the can down the road a couple of weeks right at the end of the year, December. We were supposed to do something about Medicare because physicians across the country were facing a 10.1 percent reduction in their reimbursement, a 10.1 percent pay cut if Congress didn't act. Well, we did act. We prevented that, but we prevented it for 6 months. Six months. What an insult. What an insult to the physicians of this country who are taking care of our Medicare patients, the patients we have asked them to care for. We couldn't even do our work to give them the certainty of what they would be reimbursed for the next year? No, it's 6 months is all you get, Doc, and then we're going to come back and visit it again. And, oh, by the way, we'll be in the middle of that Presidential campaign by then, so don't expect us to devote much more attention to it in June than we were able to muster in December. But I digress. My purpose in being here tonight is to speak a little bit about what is going on in the practice of medicine, and, in spite of the fact that I may sound a little bit despondent, I will tell you that I am so optimistic about the world ahead, what the future holds for the young people today who are contemplating a career in health care. When I was a young medical student in the mid 1970s in Houston, Texas, I could never have imagined that the day would come in my lifetime when a person could, of their own volition, go to the Internet and, with a couple of mouse clicks, find a place that would analyze their DNA and for less than $1,000 provide them vital insights into their genomic makeup so that they might be forewarned about some diseases, so that they might be forewarned about some conditions and use those tools to help manage their health well into the future. Now, we hardly know what the results of this type of investigation are going to be. It has only been in the last couple of months, in fact, I think it was Thanksgiving that I read the New York Times article that talked about one of these labs that would provide this service. But who would have thought when I was in medical school in the mid-1970s that this day would have dawned where that information is available not just to the physician, it's available to the patient, to anyone who wishes to go on the Internet and seek out that information, seek out that lab and have that type of analysis done. Think back on 20 or 30 years ago, a patient went to the doctor, the doctor gave a diagnosis, recommended a treatment plan to the patient, who pretty much had to accept what was given or go get a second opinion. Then, of course, in the late 1990s, and I know this very well because I was practicing actively at that time, render a diagnosis, write out a treatment plan, the patient would go to the Internet and check it out and then they come back and say, Doctor, this is what you're supposed to be doing. I went to the Internet and read about this. Now in the 21st century a patient will be coming to their physician and providing genomic information and saying, Doctor, here's what I'm at risk for developing. How are you going to help me keep that from occurring? You know, Dr. Elias Zerhouni, the head of the National Institutes of Health, talks about a world where medicine becomes a great deal more personalized. It's no longer one size fits all, it's no longer just one antidepressant is out there for everyone. It's a much more personalized endeavor. Because of the ability to know this information about the human genome, it's going to be a great deal more predictive. As a consequence, because of that predictive value, preventive medicine is going to take on new meaning, a meaning that, again, I would have never thought possible early in my training. Finally, medicine is, of necessity, going to become more participatory. A patient will no longer be just a passive passenger along for the ride on their medical journey. No, they will have to be an active participant in managing their health care from times of health and times of disease. Medicine is right on the verge of a truly transformational time. You add what we know, what we are beginning to understand and learn about the human genome and look how fast information comes at us nowadays. It is, again, just hard to think that back in the mid-1970s when I was in medical school, Internet, never heard of an e-mail, what's that? And now these are things that we take for granted. To our children, these modalities are simply second nature. They cannot imagine existing for even a day in a world where a cell phone and e-mail are not readily at their fingertips. The speed at which information comes to us is truly phenomenal and, as a consequence, in professions such as the health care professions, a dramatic effect is going to be felt because of the ability to sort through large amounts of information over a short period of time and to extract data from those large amounts of information. On the floor of this House, in September of this year, we reauthorized legislation pertaining to the Food and Drug Administration. It was truly landmark legislation. I don't know if my friends on either side of the aisle really recognized how significant that legislation was, because, for the first time, for the first time the Food and Drug Administration is provided with the tools for collecting that type of information and proactively researching that database. The day may well dawn when a problem like Vioxx is discovered early, early in its release into general use and the types of difficulties that were encountered with that medication several years ago will, in fact, be a thing of the past. The red flags will be up. The warnings will be there. They will come immediately to someone's attention because of the type of database management that will be available. Truly, we will have a system that is totally interactive. The resultant effect on public health will be profound, because it's not just the side effects and the untoward effects that we are talking about, what if there was an unexpected beneficial effect where, perhaps, more people ought to be offered the benefits of this therapy or this medication. Certainly, the story that we have learned with the type of medicine, the class of medicine called statins that lower cholesterol, that story has evolved significantly over the last several years. In the early 1990s, a LDL cholesterol of less than 130, you're in good shape. Then a couple of years later, it was less than 100, and now it's well under 100. The numbers to shoot for have gone down because the experience with that medicine, the information and data that has been gathered has pointed the way for physicians to understand that a subsequent lowering of that value will, indeed, protect a person's health in ways that they wouldn't have imagined when those medicines were first released. Medicine is in a transformational time. Congress is going to have a lot to do with how medicine is practiced and paid for and regulated, not just in the next couple of years, but in the next 20 years, 30 years, 40 years, 50 years. The decisions that we make on the floor of this House today are going to extend far into the future, probably far beyond the lifetimes of many of us who serve in this House today. But Congress really is not in the business of being transformational. Congress is transactional. We heard that just a few moments ago with the discussions on the budget. What does Congress do? We take money from this group and we give it to this group, and it defines who we are morally if we listen to the rhetoric of the last speaker. But that's what Congress does. We transact, we take money from this group, and we give it to this group. If you will watch the discussion that unfolds on the budget over the next several weeks, that will become intuitively obvious to the most casual of observers. However, in a body that is so focused on the transactional, is it possible to keep an eye on the transformational and be certain that we don't derail the transformation that is likely to be occurring in medicine today? That's one of the tasks, that's one of the challenges, that's one of the obligations that we have serving in this body. Now, I would submit if Congress wants to participate in the transformation, if they want to participate in improving health care, they are, in fact, capable of doing so. In fact, Congress could be a partner in the transformation if we can step back from the transactional long enough to focus on the transformational. This is not just theoretical. I had an opportunity to speak to Dr. Michael DeBakey, pioneer in heart surgery, a gentleman of great renown. We honored him on the floor of this House with a Congressional Gold Medal earlier this year. I had an opportunity to sit down with Dr. DeBakey. He talked about some of the changes that he has seen in his lifetime. He related how when he was a young man and graduated from medical school and then did his residency at Tulane Charity Hospital in New Orleans, he wanted to go into research. But he knew that in order to have the credentials to go into research he would have to go to Europe in order to obtain those credentials. This was back in the 1930s. Well, nowadays, someone who graduates from medical school and finishes their training and wants to devote a lifetime to research gets those credentials in the United States of America. In fact, other physicians travel to this country, to our hospitals, to our Texas Medical Center in Houston, to our Southwestern Medical Center in Dallas, to our M.D. Anderson Hospital in Houston. They travel to our country to get those credentials because that's where the best science is being done. Dr. DeBakey reflected what caused the change between the time he graduated in the mid-1930s and what we see now at the end of the 20th century and the beginning of the 21st century. He maintained the cause of that change was the focus and attention, and, yes, the funding that Congress provided to medical research right after the Second World War. Indeed, the funding and the vision of the entire National Institutes of Health was a product of that type of visionary thinking. So as Dr. DeBakey presented that thought to me, it was with the underscored emphasis that Congress can do this because Congress has done this before. So if we stay focused on helping and protecting and promoting that transformation in medicine, then it is possible for Congress to be, again, a participant in that transformation and not an enemy of that transformation. Now, I am fortunate, because I did spend a number of years practicing medicine, working one time in a multispecialty practice, part of my time in a solo practice, part of my time in a single specialty practice, having practiced medicine in several different modalities during my lifetime, it gives me the ability to see things from the provider's side and now to see things from the policy side. It is so important that we spend the effort understanding those things that will work and understanding those things that will not work. I alluded earlier when I first started speaking about the problems that we face because we couldn't do our work in December and we postponed any real reform on the reductions in physicians' payments that we see year after year. You have seen me put up the posters that detail how hospitals, drug companies, HMOs are paid on a cost-of-living adjusted basis year over year, but physician reimbursement is paid on a crazy formula that reduces and ratchets down reimbursements year over year. That just simply won't work. When I talk about Congress being a transactional body and that transactional activity being the enemy of the transformational, that is precisely the type of transactional activity to which I am referring. Think of it. We always talked about the laws of supply and demand. What are we doing to the supply side of that equation if we are actually telling our doctors we don't value what you do, and we don't care about the fact that you take care of our sickest patients, our Medicare patients? That is just not important to us in Congress, and then we underline that by postponing dealing with it for 6 months. Again, an assaulting concept to the doctor who is toiling day after day to take care of the patients that we have asked them to take care of for us. Another aspect of that activity, as the year wound down last year, was the attempt to attach a rather inflexible program of e-prescribing to whatever fix we managed to achieve for the Medicare payment. Now, e- prescribing is not inherently a bad concept. Madam Speaker, you think about it, I am left-handed so my handwriting has never been good. And then I went to medical school and had to take notes fast, and my handwriting got worse. And then I got old, and my handwriting got even worse. And so it is very difficult to read those handwritten prescriptions that we scribble out quickly at the end of a patient visit. What a benefit it would be to the patient, to the pharmacist, and to the physician to have a method whereby that prescription was shot to the pharmacist via e-mail at the time of the patient encounter. It would save waiting time, no problems with legibility, and there could be computer algorithms that were developed that would prevent a patient receiving a medicine to which they were allergic or which would counteract or interfere with another medicine they were taking. So a good concept. And then like so many things, Congress deals with it in a way that makes it untenable. The e-prescribing bill introduced by a Senator on the other side of the Capitol, said, Doctor, if you do this, we will provide you a carrot and a stick. The carrot is a 1 percent increase in your reimbursement for taking care of that patient and providing an electronically written prescription at the end of that patient visit. Just 1 percent. Now I am going to make some numbers up because it makes the math work. In fact, the numbers are probably much lower than what I am going to make up. But assume a physician working in an average practice in a city like mine sees a Medicare patient, return visit, moderate complexity. Assume they are paid $50 for that visit. That is actually pretty generous if you look at most of the Medicare fee schedule reimbursement rates. But because it makes the math easy, let's say $50. So if that doctor participates in an e-prescribing regimen, what does that mean? It means they get an extra 1 percent. That is 50 cents for those of you slow at math. So that visit is going to take about 15 minutes if you do it correctly. Again, remember it is a moderately complex Medicare patient, a senior citizen. So you get an extra 50 cents if you, instead of writing that prescription by hand, you put it into a laptop or BlackBerry and send it off to the pharmacist electronically. You can see four of those patients in an hour. If you are really pushing yourself and you have everything firing on all eight cylinders in the office and the front desk and nurses are moving along, you can see four patients in an hour. So four $50 visits. So that is $200 reimbursed for that hour's work. That is not the doctor's pay. Don't misunderstand me. He has to pay all of the overhead as well. Nevertheless, during that hour, that physician will generate $200 in revenue. For that, if they do e-prescribing, we will reward them and give them an additional $2 for that hour's work. That is not a great incentive, but let's think about it also from the fact that it is not just one prescription that doctor writes for that Medicare patient, no. The average Medicare patient has three or four prescriptions. So when you figure it on a per prescription basis, the actual benefit to the physician is somewhat less than 10 cents for every prescription that is handled electronically. And it is a little bit more involved to do that. A doctor who is used to writing out a prescription quickly can do so quickly. Typing it into a laptop or BlackBerry is going to take longer, maybe a minute or two minutes. But if you are seeing 30 patients a day, 2 minutes per patient, that adds up to an extra hour, and that extra hour is an hour away from hospital activities, seeing other patients, an hour away from family. It comes from somewhere, because we all know that the hours in the day is a zero sum game. If you take an extra hour, it comes from somewhere else. So we are going to compensate for that. We are going to pay a little less than 10 cents per prescription as it is written. What if you don't do it? You say it isn't worth it. You cut my reimbursement every year in Medicare, I have to take on this big expense, I have to learn a new technology, pay the expense of the software maintenance, I am not going to participate. Well, the bill that was introduced last December, after 4 years' time, would have applied the stick to encourage, again, our physician community to utilize this technology. And the stick was a 10 percent penalty. Wait a minute, a 1 percent up tick and a 10 percent penalty. That is imbalanced. Let's go back to our hypothetical return visit, moderately complex Medicare patient, a $50 reimbursement, 10 percent penalty, that is a $5 penalty for that visit. And if you are seeing four patients an hour, that is a $20 penalty for that hour's work. You see the balance. If you do it, we will pay you $2 because we think it is worth that. If you don't do it, it will cost you $20. And we wonder why our senior citizens call up to get an appointment with a physician when they get covered on Medicare and no one wants to see them? This is the way we behave. We cut their pay. We can't agree amongst ourselves to do something rational to protect physician reimbursement rates at the end of the year. And by the way, we want to add this thing on top, this secondary insult on top of the others. I urge Congress to not focus on the transactional; focus on the transformational. What do you need? If you are going to move from a system we have today, which is based on a written prescription, to a true electronic prescription environment, who do you need on your side on that? I am telling you, if you don't have the doctor on your side, it is not going to happen. Yes, you can frighten and cajole and preach all you want, but it is important for Congress to remember that this transformation will take place faster, with much more expediency, if we will take the time and trouble to instruct, educate, provide for, provide the proper support and proper compensation for our physician community if they undertake it, embracing this type of technology. One of the things we are going to hear a lot of as we go through this Presidential election year, terms like ``universal coverage,'' ``universal access,'' and they don't mean the same thing, so it is important to spend a few minutes differentiating between the two. We will hear talk about mandates and whether they are a good thing or a bad thing. We will hear ``individual mandates,'' ``State mandates,'' ``employer mandates,'' and it is important to spend a few minutes discussing the differences between those terms as well. Let's deal with the concept of universality of medical care. That is one that many people in this body and many people on the Presidential trail today say they want to see. Now, universal coverage, universal access. Universal access, everyone has insurance whether they want to do it or not. It is a little tough to do that in a free society, but yes, we can write laws that can make that happen. See the discussion on mandates in a few minutes. But universal coverage is one of the options available to us. Universal access would say that everyone has access, everyone has the ability to go out and purchase an affordable policy. And if they can't afford it, they have the ability to access a funding mechanism that will provide the type of premium support, the type of premium assistance to get them that coverage. And that debate will occur over this next year. Universal coverage, universal access. On the whole issue of mandates, and this is an important concept for people to understand, is it better to say this is law, this is something you have to have, or is it better to create the types of programs that people will actually want to have? Let's think about that for just a minute. What does the term ``individual mandates'' mean? It means a law is passed by a legislative body, in this case the Federal Government, although it has been tried at the State level. An individual mandate means that everyone has to go out and buy insurance. In my home State of Texas, we have that with our automobile policies now. Everyone has to buy an automobile policy. With an individual mandate, that is how we would achieve universal coverage. You have to buy insurance, and if you don't, there is a penalty to be paid of some sort. In the State of Massachusetts, in really what I consider a very bold attempt to provide coverage for everyone, an individual mandate was instituted. It hasn't worked out exactly as planned, and some of the difficulties encountered in Massachusetts were cited in California as a reason why that State's plan for universal coverage was recently defeated in the California State Senate. Many people looked at the option, or the requirement, I should say, of buying insurance and said, I don't know. And then remember the law of supply and demand. We increase the demand because we mandate it, you have to do it. What happens? The price goes up, and as a consequence some people looked at that and said, I really can't afford that. I will pay the fine rather than buying the insurance. Truly a perverse incentive. So some of the support for the concept being talked about in California found itself lacking when faced with that equation in another part of the country. How can you consider putting an individual mandate on when it drives costs up and people find themselves in a position that they would rather pay the fine for not having the insurance than they would to purchase the insurance itself? When we talk of mandates, and there have been several studies done on this, think back to the 1960s. The United States Congress put a mandate out there that every motorcycle rider in the country would have to wear a helmet. They reversed that mandate and put that obligation, correctly, in the court of the States to make that decision. And the reason Congress reversed that decision was the hue and cry and outcry from across the land from motorcycle riders saying that you can't make me wear a helmet in a free society, and Congress eventually backed down. And so that was kind of an unpleasant experience with mandates. Most States do have an individual mandate for automobile insurance, and they get good compliance with that. But it is interesting, one of the States with the best compliance has no individual mandate. So mandates don't always equal better compliance, and nowhere is that more evident than our current tax structure. The Internal Revenue Service, which collects our taxes, there's a mandate, an individual mandate on every person who earns above a certain income level that you will pay taxes. You will pay a percentage of that in taxes and, in fact, everyone knows, it's no secret that if you don't pay that tax the punishment is going to be sure, it's going to be swift, and it's going to be extremely unpleasant. We've got 15 percent of the country right now that lacks health insurance. Can we get improvement on that number by putting an individual mandate on? Look at the case with the Internal Revenue Service. A severe mandate, severe penalties for noncompliance, and what is our compliance rate with the Federal income tax? It's about 85 percent. In other words, 15 percent don't comply. So this requires a good deal more study and a good deal more attention than just simply making that leap of faith and saying everyone needs insurance, therefore, there will be an individual mandate that everyone will have insurance. Again, there were some problems with the cost structure when that was tried in Massachusetts to the point that the people in California, the State Senators in California, when they looked at that, said, maybe that's not the best idea for us. Well, once we determine what the overall goal is, then perhaps our path will be a little bit easier. Certainly we want to democratize our health care in a way that preserves choice, makes certain that patient focus is the central theme, and we want to continue to promote innovation, because, remember, America is the country that is known for medical and scientific innovation. Well, what about the concept of creating products that people actually want? Do we have a model? Do we have a template that we can look at to perhaps discuss that a little further? And, in fact, we do. We passed a bill on the floor of this House, late in the night of November 22, 2003, called the Medicare Modernization Act which provided for a prescription drug benefit for citizens on Medicare who had not had one previously. It was called Medicare part D. What's been the experience with Medicare part D? And I will stipulate that there were people on both sides of the aisle in this House, there were people on the right who were critical of the Medicare part D program, and there was certainly no shortage of critics on the left who were critical of the Medicare part D program. But as that program was instituted and has now been up and running for over 2 years, what lessons have we learned from Medicare part D? Well, we've learned that more than 90 percent of the persons who were eligible for that coverage have, in fact, enrolled. Wait a minute. With the IRS, with severe and certain and sure penalties, we only get 85 percent compliance. With Medicare part D, by creating programs that had value to patients we've got 90 percent compliance, and 80 percent are happy with the program. If we go back to our friends at the IRS and say, what's the percentage of people that are happy with the way our tax system is administered, I don't think the number is 80 percent. Consider that when we passed that bill on the floor of this House in the early morning hours of November 22, or actually I guess it started on the night of November 22. It was in the early morning of November 23 that the bill actually passed. Consider at that time we were told by the best actuaries at the Office of Management and Budget and the Center for Medicare and Medicaid Services that it was going to cost about $37 a month for that coverage. What has the experience been? The average plan costs less than $24 a month now, over 2 years into the program. So this is a Federal program that relies on some competitive forces and relies on some participation of the private sector, and, in fact, has reined in some of the increase in spending that was feared to accompany this program by restoring the savings and incentives and leveraging competition and getting the buy-in from the patients themselves. What would be the more favorable trajectory? Force people into a program, difficult to do in a free society, and your compliance rate may not be exactly what you want it. Or would it be better to create a program of value that also relied a little bit on some competitive forces to keep that cost down. Now, one of the great debates that was had on the floor of this House a year ago when the current majority party took over was the whole concept of reforming the part D benefit. And we don't hear much about that anymore. They weren't successful. One of the big proponents, or one of the big themes that was proposed was to cause or ask or demand that the Secretary of Health and Human Services negotiate drug prices with drug companies. I will just tell you from a lifetime in health care that HHS or CMS, they don't negotiate prices, they set prices. That's what they do. And many of us on my side of the aisle felt that that would be counterintuitive to the way this program was working, and in fact, it was working. And, you know, Madam Speaker, and this is only partly in jest, but if we wanted to create a program where the head of a Cabinet agency, an agency secretary was to negotiate, maybe we ought to look to the Department of Education and ask the Secretary of Education to negotiate prices with college deans for the cost of higher education. That might be a better trajectory. I'm waiting to see that legislation come forward from the majority. But, nevertheless, part D was left untouched last January. I'm grateful that it was, and I think again the numbers speak for themselves. This is a template. This is a model, this is a program that we perhaps should seek to duplicate because it created a condition of value, that consumers, that patients, that individuals wanted, and the compliance rates are high. The satisfaction rates are high. And, most importantly, seniors now are getting the medicines they need to keep them out of the hospitals and out of the doctors offices, and the overall cost for delivering Medicare, while it is still extremely high and still likely unsustainable over time, it has at least moderated or ameliorated over the last couple of years. In fact, the trustees' report from June of last year that came out said the bad news is Medicare is still going to be broke. The good news is it's going to go broke a year later than what we told you before. So seeing the beginnings of that cost savings and how that can change the practice of medicine and the delivery of health care in this country, that's a powerful anecdote for people to consider. One of the things that we talked about is the speed at which information will come to us in the future. And there's no question that it's increasing every day. Most of us wear a Blackberry on our belt that has more computing power than the big computers on Apollo 13. It's astounding what's happened with computer power over the last two or three decades. And we hear a lot about the improvements of health information technology, the improvements in the platforms and what that improvement can mean to patient care, what it can mean to the practice of medicine, what it can mean to bringing down the cost of medicine. And, indeed, these are powerful influences. Madam Speaker, I will tell you I haven't always been a big proponent of things like electronic health records. But as my experience on the ground in Louisiana in 2005 and early 2006 taught, getting to visit the medical records room at Charity Hospital shortly after it had been dewatered, I didn't know that dewatered was a verb, but, nevertheless, that's what the Corps of Engineers told us they did, and indeed, these flooded basements were now available for people to go into, the scene in the medical records room, the medical records that were damaged by the high water, damaged by the chemicals that circulated in that water, the black mold that was going on these paper records made it abundantly clear that these were records that could never provide useful information to a physician or a patient again. And how much more powerful would it have been to have that information available electronically, available to be transmitted from New Orleans to Dallas or Houston or wherever the person had had to travel to after that terrible storm and in the ensuing aftermath. It changed my thinking on electronic health records and electronic medical records. But I will also tell you, I'm concerned about the Federal Government's ability to create the structure that people feel is necessary for that day to dawn where electronic health records are, indeed, the standard. And I say that because when I came here 5 years ago, the discussion was, the Federal Government is going to create those platforms. It is going to create the software. It is going to create the type of information technology that private industry will then follow the leadership of the Federal Government. And, Madam Speaker, it's 5 years later and we still don't have it. I did have the opportunity to speak to a CEO of one of the larger insurance companies in this country a few months ago. In fact, he talked at a symposium that was put on by Health Affairs downtown the first of November. He talked about within his company he has 45,000 employees, and fully 15 percent were employed in the development of software. Fifteen percent were employed in the development of that information technology architecture that we all talk about here on the floor of this House. In fact, he said if his software development portion was a stand-alone company, it would be one of the largest software development companies in the United States of America. And yet it is a single branch of a single private insurance company. And more to the point, they had developed algorithms, mostly from financial data, but they had tens of thousands of conditions, medical conditions that they had studied, again using purely financially data, and they had found some things that actually seemed clinically very relevant and certainly important for a company that might be interested in holding down the costs of administering health care. They found that if they paid for A and B, C was very likely to follow, and guess what? They were very likely to have to pay for D, and D cost a lot of money. The example given to me was of treating an individual with a heart attack. If that individual with a heart attack, if they did not anticipate an episode of depression following that individual's illness, it would very likely interfere with their rehabilitative efforts after they got out of the hospital, and so their likelihood of a long term return to health and productivity was curtailed. And again, they found this by analyzing financial data, that if they put someone in the hospital for a heart attack, successfully treated them, discharged them, but did not anticipate depression, they were very likely at some point to pay for a hospitalization for depression, pay for treatment of another heart attack because they didn't comply with the regimen after they got out of the hospital. Very powerful information. And as someone who spent 25 years in clinical medicine, I will tell you, that's just exactly the type of information that would be extremely valuable to the clinician. Well, what's the problem? The Federal Government said 5 years ago that it was going to develop the platforms that private industry would then take up and follow, and we haven't done it. And yet here's an individual from the private sector excitedly telling me about what his company is doing and the benefits that they've found. And you have to ask yourself, would it not perhaps be better for the Federal Government to allow that to happen, allow a company to develop that type of software, to develop those types of programs, to perhaps bring the clinicians now and begin to populate some of those fields with clinical data so that they could get even better and more accurate information. And I asked that individual, well, what would it take? What would you need to see from us to allow this to work better for you? And, no great surprise, he talked about the things that we talk about on the floor of this House all the time. He said, it wouldn't hurt to have some regulatory reform. It wouldn't hurt to have some reform in what are known as the Stark laws that prevent hospitals and physicians from doing too much together for fear of some type of unjust enrichment. We would need some modifications to some of the privacy laws. And at the end of the day, too, we're going to need some safe harbors with liability. But if you provided us that, we could really take this to the next level. And we won't. And yet they're ready to make the investment and they're already making the investment, even without any Congressional activity, because they find it delivers value to their patients, to their physicians and, yes, to their bottom line because they're a profit-oriented company. What is the difficulty with this body recognizing that that type of activity is going on all around us, and maybe we don't need to reinvent the wheel here on the floor of this House. Maybe we just need to wake up and look around at what is happening literally just across the street. Now, some of the other things I want to talk about this evening before I run out of time, I have already alluded to the problem with supply and demand in our physician workforce. Just a little over 2 years ago when he was finishing up his term as Chairman of the Federal Reserve Bank, Alan Greenspan came and talked to a group of us one morning and the inevitable question about Medicare came up: How are we going to pay for it in the future? What is it going to cost? And the Chairman was concerned as well, but he did say, When the time comes, I think Congress will make the hard decisions that Congress is required to make so that the program will continue. He stopped, and then he went on to say, What concerns me more is will there be anyone there to deliver the care when you need it? And we've already talked about some of the problems that are inherent in the formula by which Medicare reimburses physicians. And one of the things I don't think I can stress enough on the floor of this House, because I don't think Members understand this, they think, well, that's just Medicare; that's just a part of the practice of medicine. That's not the whole story. Well, it is about half the story. Actually, the Federal Government does pay for about half of the health care expenditure in this country, if you go back to the first moments of this discussion. But the other thing is that the rates by which Medicare reimburses for health care informed the rates that are set by the private insurance companies in this country. So indirectly, we have a system of Federal price controls on medicine in this country today. And that's why, when we ratchet down the reimbursement rate for physicians on Medicare, and everyone in the body is quick to say, Oh, well, doctors make plenty of money. There's no need to worry about that. Remember, also, we are affecting not just Medicare, over which we have jurisdiction, but we are also affecting those reimbursements in the private sector as well because there is not a level playing field between provider and third-party payer. That's one of the problems inherent in our system now. People that go to the physician don't actually pay the physician; they pay the insurance companies. Same with the employers. They don't actually pay the physician; they pay the insurance company. So that interposition of a third-party intermediary has created a good deal of the tensions and a good deal of the problems that we see today. But we must not forget, that is a system that is there, that is a system that is in place, and when we make a decision about Medicare reimbursement rates, the ripple effect throughout the health care world in the reimbursement is significant, it's profound, and it is immediate. One of the things that I feel very strongly about is that we do need to help people know what they're buying and what they're getting in health care. And one of the bills that I introduced early in the first session, the last year of this Congress, was H.R. 1666, which does deal with health care transparency. It sets a floor of a level of transparency that should be available in every State. Many States have already undertaken this work. My home State of Texas has, and, in fact, patients can go to the Internet to a Web site. It's texaspricepoint.org, abbreviation txpricepoint.org, and they can get information about the hospitals in their county. Most of it is pricing information. Other information, other useful clinical information such as length of stay is also available. At some point I expect there will also be the transparency about things like complication rates and infection rates, but it's still a work in progress. Other States have done similar activities. The State of Florida with its RxCompare. People can compare prices for different prescriptions, which has been useful for the people of Florida. What the intent of H.R. 1666 was to not provide a Federal standard but at least to provide a level of transparency below which States should not go. And I would like to see this House of Representatives at some time take on this problem, because I think it is one that is extremely important. And it does lead in to the other issue of how States and hospitals report complications, such as infections. And, again, I do think there is a role for Congress, I do think there is a role for the Federal Government, not so much in writing that legislation State-by-State, but providing the framework by which the reporting can occur to allow a Federal agency such as the Centers for Disease Control the ability then to aggregate that data and provide useful information back in real-time to the States and to the hospitals and to the physicians about infection rates in their particular areas. Most epidemiologists will tell you the chance to measure is the chance to cure, or the chance to prevent, in the case of infections. And the metrics, just the activity of undergoing the metrics in those conditions, will oftentimes lead to improvements that were unanticipated at the beginning of that program of metrics. Other legislation that's out there that deals with our physician workforce, H.R. 2583, H.R. 2584, both bills designed to affect individuals earlier in their career, in the health care workforce even prior to the entrance into medical school, the ability to provide a little bit more flexibility and a little bit more balance in the health profession scholarship, a little bit more flexibility in loan forgiveness and tax incentives for individuals who are going to medical school and will agree to practice in medically underserved areas in high-need specialties, and that is essentially primary care, also fields like OB/GYN and general surgery, to provide a little bit more flexibility to help incent people who are willing to make those types of decisions. And there is significant lifestyle decisions that they are making to undertake those type of careers. And then there's another program to increase the number of primary care residencies that are available, again, in high-need areas, medically underserved areas for specialties that are in high demand, and, again, we are principally talking about the primary care specialties. The barriers for entry for a medium-sized to moderate-sized hospital to start up a residency program are essentially costs. And some of those start-up costs in this legislation can be provided for in a loan. And there will be a loan that is paid back so that money will recycle, and the overall return to the taxpayer is increased that way. It will allow those hospitals the ability to set up a residency program where none has existed in the past. And I can think of many, many hospitals in my home State of Texas that could benefit from that type of activity. And one of the things when people study how physician manpower is distributed, you can say a lot of things about doctors, but sometimes we are not very imaginative and we don't tend to go very far from where we trained, and there are some valid reasons for that. You get comfortable with referral patterns. People know you from your training program, so they're apt to refer to you. There's a degree of comfort there. And myself, for example, I went into practice less than 25 miles from where I did my training. A lot of doctors do follow that same sort of trajectory. So if we can move the training programs into the areas that need the physicians, it may then follow that those physicians who train in those programs will end up staying in those medically underserved areas. It's difficult for me to come to the floor of the House and talk about things related to health care and at least not mention some of the problems that we face with our medical justice system in this country. And I know there are lots of people out there with a lot of different ideas, caps on noneconomic damages, medical courts, early offer arbitration. The time has come for us to have a serious discussion to put some of the partisan differences aside, to put some of the special interests aside and have a rational discussion about how we can meaningfully impact that problem in this country. My home State of Texas passed rather significant legislation 4 years ago dealing with the issue of caps on noneconomic damages. It was patterned after an earlier California law, the Medical Injury Reform Act of 1975. It was passed out in California, which put a $250,000 cap on noneconomic damages. The Texas legislation was a little bit different. Instead of a single cap, there were three different caps, each capped at $250,000, but the aggregate was $750,000 compensation available for noneconomic damages. It has worked very well in my home State of Texas. The year that I left practice to come to Congress, we were in crisis. We had gone from 17 medical liability insurers down to two. You certainly don't get much in the way of competition when you only have two insurers, and as a consequence, the price for those premiums was ever escalating. Now we have had many insurers come back to the State. They've come back to the State without an increase in premiums. And, in fact, Texas Medical Liability Trust, my last insurer of record, has returned, the last time I checked, 22 percent reductions and dividends back to their physicians that they cover. And that's significant because, remember, these premiums were going up by 10, 15, 20 or 25 percent year over year, and then on the past 4 years, they've not only stabilized, but they've come down 22 percent. Small and medium-sized hospitals that self-insure for medical liability have had to put less in reserve against a bad judgment, and as a consequence, there has been more money to spend on just exactly the kinds of things you want your community hospital to be spending its money on; things like nurses' salaries, capital improvement, investing in their capital infrastructure. So it is a good news story from the State of Texas in terms of what we've been able to do with liability in my home State, and I'm not going to say that's the only answer, but I think it is a very good answer. I introduced legislation, H.R. 3509, to essentially provide the Texas legislation on a national scale. In fact, we had a lot of talk about the budget earlier tonight. Last year, I offered that bill to the Budget Committee because the Congressional Budget Office scored it as nearly a $4 billion savings over 5 years. I realize that's not much when you are talking about a $3 trillion budget, but that's $4 billion. That's a significant savings, and I was willing to donate that to the Congress. Take up that concept, write it into law in your budget resolution, and let's get something done to stabilize medical liability prices in this country, not so much for my home State of Texas, as we've already done it. But what about Pennsylvania? What about New Jersey? What about Maryland? What about New York? Maybe those areas could benefit from some of that same type of thinking as well. Well, suffice it to say that that concept was not accepted, but I will extend the offer to members of the Budget Committee on both sides of the aisle that $4 billion in savings is still available to you. H.R. 3509 is the bill, and I will be happy to relinquish all ownership rights and donate that to the greater good of the United States Congress and the people of the United States. One last piece of legislation that I want to mention, and it was introduced right at the end of the year, H.R. 4190. We talk on the floor of this House a lot about the problem of the uninsured. In fact, I've spent some time talking about it this evening. H.R. 4190 isn't a new insurance program. It isn't a new expansion of Medicare or Medicaid or SCHIP. What H.R. 4190 does is take the concept of being uninsured and extend that privilege to everyone who serves in the United States Congress. H.R. 4190 would remove us, as Members of Congress, from the Federal Employee Health Benefits plan, provide us a voucher, if you will, to go out and purchase insurance on the open market. And I can't help but think, if we were put in the position of many Americans who are faced with those decisions about having to buy health care coverage on their own out in the open market, perhaps we would get a little more creative about the unequal treatment from the Tax Code for employer-derived insurance versus an individually owned policy. Perhaps we would get a little bit more creative about providing a little more flexibility in a health savings account. Perhaps we would get a little bit more flexible even if we are of the mindset that said, Well, we are going to extend our single-payer health care to more and more people. Well, what if Members of Congress had the same problem finding a doctor that your senior citizens at home tonight are having when they call up the doctor they've seen all of their lives and are told, Sorry, we can't take any more Medicare patients? Well, H.R. 4190 is an intriguing concept. I haven't had much interest as far as cosponsorship is concerned, but it's still out there. It's still available, and I welcome Members from both sides of the aisle to think about that, to look at that, and see if we couldn't forge a common bond and a good-faith effort to really do something for the people who lack insurance coverage in this country or the people who are fearful that they will lose their insurance company if their job changes or their financial situation changes. There's a lot of things out there on the horizon, Madam Speaker. There is a lot of good that this Congress can do. I think it is important for me to make the point one last time that medicine is evolving in a big way. It's going to change significantly in our lifetime. Congress can participate in that evolution, and actually participate and be a force for good if we're only willing to pick up and take on the work that the American people have sent us here to do. Thank you, Madam Speaker, for your indulgence.

Mr. BURGESS

Mr. BURGESS. I'll be happy to yield.

Mr. BURGESS. Mr. Speaker, I thank the gentlelady from Tennessee for yielding to me. It is kind of ironic. We were here on the floor of this House last night. The House was full, Members on both sides. We heard the President deliver his final State of the Union address, and of course, as is typical for a State of the Union address, he touched on subjects near and far, went through the domestic agenda, went through the foreign agenda. When he got to talking about the conditions on the ground in Iraq, I don't know about the gentlelady from Tennessee, but I was just absolutely struck by the scene in this House when he commended the troops for the activities and the success that they had achieved on the ground. One-half of the House stood up and applauded; the other half sat on their hands. And Mr. Speaker, I don't know if there's been another time in American history when America goes to war, sends their sons and daughters to war, America is winning the war, and it's become something we don't want to talk about. There's other things that command our attention now, and we'll go on to other things. The gentlelady was right, it was a year ago that we stood on the floor of this House and debated for hour after hour after hour on the efficacy of sending additional troops to Iraq. We were told by the majority leader over in the Senate, the Democratic majority leader, that the war was lost; there was no need to send additional men because we had already made the decision in the Senate, or the other body in the Capitol of the United States, that the war was over and the war was indeed lost. The gentlelady's right, you can pick data points to prove whatever you want to prove in Iraq. They're all over the map, but if you look at trend lines over time, you begin to see a story taking shape, and that is the story that began to take shape in April of last year, perhaps a little reinforced in June of last year, July of last year. My most recent trip to Iraq, my sixth trip, I wasn't sure what I was going to find because when you picked up the papers, the data points were scattered all over the place, but little by little, the story came out. And about a week after I was there in July, the New York Times finally broke the story, hey, there's a war we just might win going on in the country of Iraq, written by two individuals who, quite frankly, aren't always on the side of the President of the United States, so it seems, in their writings in the New York Times. The New York Times itself is not always on the same page as the President in a lot of foreign policy issues, but there it was in black and white for all to see. Now, I went to Iraq in July of 2007. I very much wanted to go because I knew that the surge had started. I knew that General Petraeus had committed to come back and present data to Congress in September of 2007 to talk about the success, or lack thereof, of the additional reinforcements that were sent into the country of Iraq. And I knew that this House, I knew myself as a Member of this House, was going to have to come to some decisions or some conclusions, if it's working it or it's not working; if it's not working, we will have to rethink the strategy. So it was an important trip for me to take because I knew on every other trip that I had taken to Iraq what I saw on the ground bore no resemblance to what I was seeing on my television screens on CNN and CBS and the evening news and the morning shows. You have to go and look at it for yourselves to be able to understand what is happening. You know it's not an easy job. It was a brief war, but it's been a long hard slog to get to where we are today, and history will have to decide whether the investment in time, the investment in lives, the investment in families who are deprived of their loved ones during these long deployments, history will decide the accuracy of the words that we speak tonight. But I will tell you from the strength of that last trip in July and what I have seen reported since that time, I have to believe that this country going forward is going to be in far better shape in 10 years', 20 years', 30 years' time because we have an Iraq that has an opportunity now to be a stable partner in a quest for peace in the Middle East, as opposed to a haven and an outpost for continued terrorism in that part of the world. In July of 2006, I took a trip to Iraq. Peter Chiarelli on that trip said, you know, it's funny, I don't know want to make of it, but in a part of the country of Iraq that is very, very dangerous, al Anbar province, a city called Ramadi, we don't know what to make of it but some insurgents that were in the hospital yesterday turned over all of their arms to our soldiers, and we'll just have to wait and see what develops. In fact, he asked me not to talk about it when I got back in July of 2006 because, again, he was not sure what that meant. July of 2007, fast forward to that time. We got off the C-130 in Baghdad International Airport, get on the helicopters and are immediately taken to Ramadi. Ramadi, that was too dangerous a place to travel to a year before, was our first stop. We met General Gaston of the 2nd Marine Expeditionary Force there on the ground in Ramadi. Ramadi is a city about the size of Ft. Worth. Ft. Worth, Texas, is the largest city in my district back home. It was the provincial capital of the resurgent caliphate as established by al Qaeda in western Iraq. The reality, though, was that things had changed enormously over that past year and in ways that, quite honestly, had not been reported in the press back here at home. Again, I didn't know what I was going to find when I went there, but I have to tell you the job that was done by the Marines in the 2nd Marine Expeditionary Force, the job that was done by the troops on the ground on these long deployments that they were undertaking, the job was truly phenomenal. A year before I would not have been able to travel to the city of Ramadi. Now, not only could I travel to the city of Ramadi, after the briefing, after the endless Power Point that the military always gives you when you go over there, we got in vehicles and drove to downtown Ramadi. I've got to tell you, I was a little concerned; General Gaston, are you sure that it's okay for us to go to downtown Ramadi? Last year, General Chiarelli said it's kind of dangerous out there. He said, ``Let's go.'' We drove downtown. It was a Saturday morning, early on a Saturday morning. We drove to the market. It looked like a market any other place in the Middle East. There was a lot of activity. In fact, there were the typical sights and sounds of a city that has, perhaps, seen better days. They were working on some sewer pipes. There was, in fact, a little bit of construction going on. But this photograph was taken last July 17th in the city of Ramadi. This shows the shops. I don't know where all this stuff came from. If this was an American market, I would assume all this stuff came from China. I'm not sure where it was made. But all of these wares were for sale, and there was shop after shop after shop lined up and down either side of the street. You can see the faces of the young men there; a little bit of curiosity, all of these Americans showing up and walking through their streets. I'm sure for them it was a sight that they had not seen too often. But again, you see on the faces of these young men, these are not faces that are suspicious, these are not faces that are fearful, these are faces that are smiling. They were, in fact, glad to see us. And I found out a few minutes later why they were glad to see us; they were hoping that we had a pen or a quarter. They had apparently been well coached by our marines. Their school was going to start in a few weeks, and because they would be attending their classes, they were anxious to know if we had a writing instrument that we might part with that they could have.

Mr. BURGESS. Well, I'll be honest, I don't remember the number of shops. There were many. Perhaps on the side street that we were on, at least a dozen on one side, and then a similar number on the other side.

Mr. BURGESS. And of course I do need to make the point that this was an area that just a few months before had seen some of the most intense fighting. And many of the buildings at the front of the street, well, let's just put it this way, a JDAM doesn't do anything for your drive- up appeal. And there were several buildings that obviously had suffered the scars of war. But as you went a little further down the street, you began to come upon scenes such as this. And I would simply point out that at the very edge of the photograph here, and I had forgotten this, we see a brightly colored garment set that looks like it would be appropriate for a woman to wear. I saw more women on this trip to Iraq than I can recall seeing at any other trip where I had been through the country. And it was, to me, reassuring that the female members of Iraqi society felt comfortable enough to travel out to the shops on a Saturday morning and be with their husbands and their children, as you so eloquently point out, as commerce was breaking out all over on the streets of Ramadi. Again, I just want to show another picture of some children. These guys were pretty curious as to what was going on with all of these strange folks that had shown up and were walking through town. Again, you can see in the background some additional brightly colored wares for sale. This fellow turned out to be fairly inquisitive. And he had a keen interest, again, in writing instruments that I want to assume that's because his school was starting up in a few weeks' time. What has been described as ``The Anbar Awakening,'' we heard the President reference it last night, began in the city of Ramadi where the Sunnis began to recognize, you know, these guys from al Qaeda; they're actually not our friends. They refer to the Americans as occupiers, but maybe it's the al Qaeda guys that are actually the occupiers. And we do believe that at some point the Americans want to go home, but we can't say the same for our friends in al Qaeda. And the Sunni sheiks, the tribal leaders in the towns, rapidly turned it. And to hear it be described by our marines and our soldiers there, it literally turned on a few weeks' time, some rather intense fighting as the surge began to mount its full reinforcement, and then suddenly things changed dramatically for the better. And for me, on this trip, the one thing that I saw that was different from any other trip that I had taken over there on the ground, now, we can criticize the Baghdad government, and both sides of the aisle I know will do that with regularity, I may do so before this night is over, but the local political shift that's taking place on the ground in Iraq, the county commissioners, the city councilmen, the mayors that are doing the kinds of work that you want your local government to do, you know, quite honestly, I go home every weekend and the people are happy to see me. But if there's a problem at home, most of the time they're not going to call their Congressman; they'll call their mayor, they'll call their county commissioner, or they'll call their county administrator or their county judge because those are the folks that are closest to the people, and it's up to them to deliver for their constituents, the same conditions we have here in our districts back home. The local political shift really is what, to me, is the fundamental building block of the return of civil society, a civil society that had been so badly damaged under the years of Saddam, a civil society that has been so badly damaged by the war and then the insurgency that followed is now beginning to take hold. And it is very effective. Now, the question remains, will the central government in Baghdad respond to the needs of those local officials with enough dispatch that they are, in fact, bolstered and supported by the central government in Baghdad? It is sometimes startling to me to think that a government so young can already have such an entrenched bureaucracy that is slow to act. But nevertheless, we hear some stories coming out that there is more and more of this type of activity occurring. But again, the stability at the local level was something that I don't think I can tell you that I had witnessed on any of the five previous trips through that country. All of those trips more dealt with the security that our forces were establishing. Now we see the security that is actually being established by the Iraqis themselves. They had a job fair, I understand, in this part of town about a week before and hired everything that showed up. And there were a lot of people that came. The jobs were fairly labor intensive. Again, there had been a lot of bombing in the city. There was a lot of concrete littering the street that had to be picked up. The reinforcing steel that was embedded in the concrete had to be broken out or dissected out. There were several groups of men that were straightening out this rebar to use as reconstruction projects. But again, the work was going on. And the mood, this was July in western Iraq, it's 10 o'clock in the morning and probably already 125 degrees, but the mood of the people was truly something that I will always remember because they were doing for themselves the types of things that free people want to do for themselves. And it was a wonderful feeling. And you know the soldiers could feel it, too, when they walk through these towns. The ability to give to these young men a life ahead of them that they wouldn't have had, they would have been conscripted into Saddam's army and fought a war at someplace or other; they now have a life ahead of them that really, quite honestly, their parents dared not hope for them and now it is brought to them courtesy of the United States Marines, United States Army. I yield back to the gentlelady from Tennessee, and I want to thank her for allowing me to participate in the discussion this evening.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today in recognition of Fort Worth City Manager Charles Boswell. After 30 years with the City of Fort Worth, and just over three years as the City Manager, Mr. Boswell has announced that he will retire in January of 2008. Mr. Boswell began his career with the City of Fort Worth in 1977 as a Budget Analyst and over the years climbed the ladder to become the city's 21st City Manager in 2004. Under his leadership, Fort Worth citizens approved six bond packages which resulted in more than $766 million in new streets, parks, libraries, fire stations and other major improvements. These feats repeatedly helped Fort Worth earn honors as one of the best places in the nation to live and work. Mr. Boswell is credited with introducing innovative financial management strategies that have resulted in a financially solid municipal organization and have been key in reducing the amount of city tax dollars needed for debt service. At the same time, Mr. Boswell built the city's reserve funds to their highest levels to cover emergency needs as they arise. I have been privileged to have had a city manager in my district who understands what it means for a city to be healthy as a whole. Mr. Boswell's focus and efforts to include ``The Other Fort Worth'', an area east of I-35 that had been forgotten for decades by some, has planted a seed for revitalization that will benefit Fort Worth and Tarrant County residents for years to come. Although his tenure as City Manager is officially ending, I know Mr. Boswell will continue to serve Fort Worth as a dedicated citizen and advocate. I join his colleagues, friends and family members in wishing him all the best as he looks forward to spending more time with his family. Again, Madam Speaker, I am proud to recognize Charles Boswell for his tireless duties as a dedicated serviceman to the City of Fort Worth, Texas. It is an honor to recognize such a hard-working and devoted citizen. It is the servant leadership of Mr. Boswell, and those like him, which truly makes our nation great.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today in recognition of Fort Worth Assistant City Manager Libby Watson and her years of dedication and service to the City of Fort Worth, Texas. Ms. Watson has been with the City of Fort Worth for almost 20 years, since 1989, and has recently decided to retire. Ms. Watson began her career with the City of San Diego in their Financial Management Department in 1974, and was later appointed the Financial Management Director of the City in June of 1982. In 1986 she moved to Austin, Texas, where she became Assistant City Manager. Then, in 1989, she moved back to her hometown of Fort Worth to become the Assistant City Manager. Outside of her job, Watson is very active in her community. She participates in various activities such assisting with Girl Scouts, and she is the Treasurer for the Circle T Council Board of Directors. Under Ms. Watson's leadership, Fort Worth has become a model city for the surrounding area. I know that the decision for retirement was not an easy one for her to make. I join the City of Fort Worth and all those who are fortunate enough to know Ms. Watson in wishing her all the best as she looks forward to spending more time with her family. The City of Fort Worth will truly miss her experience and leadership. It is with great honor that I recognize Libby Watson for her years of hard work and selfless dedication given to the citizens of Fort Worth, Texas. I am proud to represent her in Washington, and her service will set a standard of devotion and true leadership, one that will never be forgotten.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I thank the gentleman from Texas for yielding. You've got to wonder why we're here today. It almost seems like another episode of that Bill Murray movie ``Groundhog Day'' where people went through the same thing over and over again. When this last session of Congress ended in the middle of the night the end of December, I think we all had seasonal affective disorders. We went home, but there was a new year and a new day was dawning and a genuine sense of bipartisanship that we were going to work together to have things done. So what's the first thing we consider? A consideration of the veto override of the SCHIP bill which we voted on again and again and again. Is this the spirit of bipartisanship that we can expect out of the Democratic leadership, as we try to craft legislation to help stave off what seems to be a serious downturn in the economy? Once again, here we are on the floor of the House being forced by the Democratic leadership to cast a vote that will serve the sole purpose of helping one side of the aisle score political points against the President. Do we need to reauthorize this program? No. We already did that. The CBO said we did it, and we funded it through March of 2009. Then why are we here? The only reason I can think of is the fact that next week we are going to hear from the President on the State of the Union Address, and after that, the Democrats have decided that maybe a little more political theater is in order to influence the press coverage of the President's address. So that's why we're here, not to do the people's work, to influence the press after the President's State of the Union Address. This bill was a flawed bill when it came to our committee. My chairman referenced the 43 Republicans, but no Republican helped craft this legislation. We were not allowed to work on this bill in subcommittee. Our committee process was a sham. This bill was written in the dark of night in the Speaker's office, and no Republican participated. I dare say that no one on your side really understood what was in that bill, and we get it back again and again and again, and at the same time the American people are wondering when we are going to do the work that they sent us here to do. Madam Speaker, one of my favorite movies is a delightful comedy called Groundhog Day. In this movie, Bill Murray plays a local television weatherman who gets trapped in a strange little town while covering a news story about a locally famous groundhog. But instead of being able to return to his home and get to the other business that he needs to attend to, Bill Murray's character is forced to repeat the same day over and over and over again. No matter what he says or what he does, every day he wakes up just to relive the same day over again. And, Madam Speaker, after being involved in the SCHIP debate this Congress, I know that most of my colleagues on this side of the aisle are now able to relate to this movie in a very personal way. It doesn't matter what we seem to say or what seems to happen with this issue--for some reason the Democratic leadership will bring us down here to the floor of the House to have the same debate and to vote on the same bill time after time after time. Once again, we are being forced by the Democratic leadership of the House to cast a vote that will serve the sole purpose of helping Democrats score political points against the President. Do we need to reauthorize the SCHIP program? No, we already reauthorized through March of 2009. Do we need to increase funding for the SCHIP program? No, the non- partisan Congressional Budget Office has already said that S. 2499 that was signed into law on December 29, 2007, has already fully funded the SCHIP program through March of 2009. Then why are we here, Madam Speaker? Well, the only reason I can think of for this vote is the fact that the President is going to be delivering the State of the Union Address next Monday, and the Democrats have decided that they need a little more political theater in order to influence the press coverage of the President's address. Well, Madam Speaker, we're going to sustain the President's veto today, and we're going to do it because the President did the right thing by vetoing this poorly written expansion of Washington- controlled, bureaucrat run healthcare that leaves the poorest kids behind. And anybody who cares about needy children can vote against this bad bill proudly. I'm both proud and concerned that Republicans had no part in writing this legislation. Proud because this bill is an embarrassment. Concerned because we're all supposed to be legislating on behalf of children, and as everybody knows, no Republican member of this House was even asked for an opinion, much less invited to participate in writing the Democratic SCHIP bill. I don't even think the Democrats who wrote it understand what they've done. I challenge the supporters of this bill to look people in the eye and say that they understand all of the provisions that are actually in this bill. Because I have some questions for you about some very troubling provisions in this bill. Madam Speaker, it would be a compliment to say that the so-called process which produced this bill is an abuse of our democratic system of government. Yet, I'm sure that some will show up here with a handful of talking points from your Democratic staffers who actually constructed this legislation, and you will explain to us that it is not an abomination at all, but a wondrous triumph of bipartisanship. Give me the name of one Republican in the entire House of Representatives who directly participated in these discussions. Name just one. I know that the authors of this bill certainly did not consult with either Mr. Barton or myself; I know that they have not included any members of the Republican leadership in the House; and I'm not aware of a single Republican member of the Energy and Commerce Committee or the Ways and Means Committee being invited to participate in this process. And although we were excluded from the negotiations and the Democratic leadership has repeatedly refused to hold a legislative hearing on this bill, we have learned a few facts from the official projections produced by the Congressional Budget Office, and from what I've read, this bill isn't something that I could ever support. For example, we know that the vast majority of the people added to the SCHIP program under the Democrats' bill will either already have private health insurance or they live in families with incomes too high to be eligible for SCHIP coverage today. In fact, the Congressional Budget Office projects that H.R. 3963 will lead to over 1.2 million new enrollees being added to SCHIP as a result of an ``expansion of SCHIP and Medicaid eligibility to new populations.'' This means that these 1.2 million children live in families whose incomes are too high to qualify for the current SCHIP program. On the other hand, CBO projects that only 800,000 currently SCHIP eligible kids will be enrolled as a result of H.R. 3963. This means that 50 percent more higher-income kids will be enrolled than currently SCHIP eligible kids. And who will be paying for this expansion of SCHIP eligibility to higher-income families? Well, according to the Congressional Research Service, the vast majority of the $70 billion in additional tobacco tax revenues will come from low-income families. In fact, the Congressional Research Service said that tobacco taxes are ``the most regressive of the federal taxes.'' So, with H.R. 3963, the Democrats really are taxing the poor in order to give to the rich. In their defense, I guess it is difficult for the Democratic leadership to know exactly what is in their own bill since it has neither been subject to a single legislative hearing nor conferenced by the House and the Senate. Unfortunately, we don't know when the Democrats are going to stop playing politics with the health of low-income children and begin the process of working with Republicans in a bipartisan manner to produce a long-term reauthorization of the SCHIP program. I hope that time comes soon, and when it does, I stand ready to work with them. As it stands now, I urge all Members to reject this cynical ploy and vote no.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I come to the floor of the House this afternoon to remember one of the most dedicated public servants from the State of Texas we lost on December 30 of this year. Ric Williamson was a member of the Texas Transportation Commission and served as that body's Chair that oversees statewide activities for the Texas Department of Transportation. He was appointed to that position in March of 2001 by Governor Rick Perry and in January of 2004 became the chairman of the Texas Transportation Commission. Prior to his appointment, he served in the Texas State Legislature from 1985 to 1988. Numerous professional and legislative accomplishments are attributed to Ric Williamson, and many awards from the Texas media, including twice being recognized as one of the 10 best legislators in the Texas State Legislature in 1989 and 1991. Ric was born in Abilene, Texas, and graduated with a B.A. degree from the University of Texas in 1974. He later founded his own natural gas production company. He made his home in Weatherford, Texas, with his wife, Mary Ann. He has three beautiful daughters, Melissa, Katherine and Sara, who spoke so eloquently on behalf of their father in the memorial service that we held this past January 3. Ric has two grandchildren. Most recently, his grandson was born at the beginning of December of this past year. Chairman Williamson brought a sense of purpose, a sense of vision, and a sense of urgency that had not previously been present in the State of Texas when it came to issues regarding transportation. He established a strategic plan, he set real goals, and then he did everything within his power to meet those goals. He wanted to reduce congestion. He wanted to improve safety. He wanted to expand economic opportunity, increase the value of the assets in the Texas highway system, and clean the air. One of his greatest legacies was to empower local leaders to make local transportation decisions. The best example of this empowerment is the State Highway 121 Project in my district of the Dallas/Fort Worth area. This brought over $3 billion in highway construction funds to north Texas. At a time when the rest of Texas and, indeed, many other areas of the Nation have money only to put towards maintenance, we have money available for new construction because of Ric's vision. He wasn't always easy to live with, he wasn't always easy to work with, but you always knew where you stood with Ric Williamson; you were never left guessing. He was more than just a leader for Texas; he helped make Texas a leader for the Nation. The United States Department of Transportation now looks toward Texas as a model for other States to use to employ some of those innovative solutions to their challenging problems. And that was, in whole part, due to Ric's unique vision for the State of Texas. Shortly after Ric Williamson's death, the Federal Highway Administrator Richard Capka said, ``He helped pave the way for some of the Nation's most innovative transportation projects, and he is largely responsible for bringing highway financing for Texas and the rest of the Nation into the 21st century.'' He got Texans thinking. He got other Americans thinking on a broad and deep level about issues regarding transportation in a way that probably had never been done before. During the memorial service for Ric Williamson, and many people got up and spoke on his behalf, it was frequently brought out how Ric Williamson regarded politics as a full contact sport. He would go at it with everything he had. And again, you always knew where you stood with Ric Williamson and he wasn't always easy to live with. But Ric Williamson believed that these discussions should take place within the light of day, not behind closed doors, not in some smoke-filled room. So, it's to his credit that he pushed these ideas in the State of Texas, but it was never done in secret; it was never done behind some veil. Everyone always knew where Ric Williamson was and what he was doing. He will always be remembered by his friends and associates as a true champion for all things Texan. He was unafraid to challenge the status quo. He was highly regarded for bringing innovative ideas to provide safe, economic, and reliable transportation to improve the quality of daily lives of all Texans. On a strictly personal level, Ric remained a patient mentor to me, a steadfast friend, and I will greatly miss him.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to congratulate Liberty Christian School in Argyle, Texas for winning the TAPP Division II State Championship in football. This season's title was the program's third state title in six tries, and capped a season in which the Warriors went 12-2 and were the No. 1 ranked team in the Dallas Morning News' Large Private School poll the entire season. Liberty Christian's season was certainly a magical one. After beginning the season 1-2, the Warriors won 11 games in a row. They held opponents to two touchdowns or less in nine of those games while scoring 40 or more points in eight games during that stretch. The Athletic Director of Liberty Christian, Coach Darren Chrane, attributed the success of this season's team after their rough start to the resolve of their senior class. ``They decided that they weren't going to be denied a win and went out there and dominated against a good football team.'' Coach Chrane stated. This year's team was eighth out of all private schools in offense with an average of 384 yards per game. Defensively, the Warriors were 11th overall with 246 yards against per game. These student athletes exemplify the type of leadership and work ethic we all strive to possess. I extend my sincerest congratulations to the Liberty Christian football team, Athletic Director Darren Chrane, Head Coach Mark Bowles and the entire coaching staff, and all of those involved in the successful 2007 season. I wish them the best of luck in their future endeavors. It is my honor to represent a group that exhibits such talent, hard work, and dedication.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to congratulate the City of Lewisville's Independent School District. The Lewisville Independent School District has received an AA+ bond rating for 2007. District officials apply for the ratings each year, which are granted by Standard and Poor's Corporation of New York. Lewisville is the only district in Texas, and one of three districts in the Nation, to receive such a rating this year. The Lewisville Independent School District has demonstrated a strong aptitude for increasing fund balances while responding to modifications in State funding policies. The AA+ rating is an improvement from the district's AA rating in 2006. The Lewisville Independent School District has managed to increase its bond rating from AA- to AA+ in two years, despite statewide school finance issues. State funding policies have been changed multiple times throughout the last decade, and Lewisville has positively modified its spending practices each time in response. I extend my sincerest congratulations to the City of Lewisville and the Lewisville Independent School District. It is my hope that they will continue to be as fiscally responsible and resourceful as they have proven themselves to be in the past. It is my honor to represent them in the United States Congress.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to remember Coach Neal Wilson, the longtime athletic director of Lewisville Independent School District in Lewisville, Texas and a tireless public servant. Coach Wilson began his four decade-long coaching career in 1965 with the Lewisville ISD, and was Lewisville head football coach from 1978 to the fall of 1985, when he assumed full-time athletic director duties. He retired in December 2000, but came back for brief athletic director stints at surrounding school districts for several years. Coach Wilson then came back to assume the athletic director role in the Lewisville ISD during the spring of 2004, and then again in 2007. In 2003, Coach Wilson was inducted into the Texas High School Coaches Association Hall of Honor, and in 2005, Flower Mound High School in Flower Mound, Texas, renamed its football stadium the Neal E. Wilson/ Jaguar Stadium. Coach Wilson was known as a strong advocate of all sports and took great pride in making sure he not only gave equally to all sports, but also increased his knowledge about every sport with each passing day. His motto, according to Lewisville assistant athletic director Rody Durham, was that you have to give the kids a chance to win. Coach Wilson expected himself and every coach to do their part to put their teams in the best position possible and lead by example. ``When we have needed him, he's always been there for us,'' Coach Durham said. My thoughts go out to his wife Donna and two sons, Darrell and Lance, as well as a long-list of family and friends. Coach Wilson will be greatly missed by the many that are fortunate enough to speak of the impact he had on their lives.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to remember The Honorable Ric Williamson, former Chairman of the Texas Transportation Commission and a dear friend of mine. Ric began his 23-year tenure in faithful public service to the state of Texas in 1984, when he was elected as a State Representative. In 2001, he was appointed by Texas Governor Rick Perry to serve on the Texas Transportation Commission, and was named chairman in 2004. Ric served on several boards, including the Southern Regional Education Board, Legislative Budget Board, Department of Information Resources Board, Uniform Statewide Accounting System Committee, and the Southern Legislative Conference, to name a few. As Chairman of the Texas Transportation Commission, Ric's visions always aimed at improving the state of transportation and the quality of infrastructure in Texas. Many times his initiatives were deemed controversial or difficult, but his resolve and determination persevered and many of his harshest critics have come to respect and support his innovative transportation concepts. Ric will always be remembered by his friends and associates as a true champion for all things Texan. Unafraid to challenge the status quo, he was a highly regarded leader bringing innovative ideas to provide safe, economic and reliable transportation to improve the daily lives of Texans. On a personal level Ric remained a patient mentor and a steadfast friend. My thoughts and prayers are with his wife Mary Ann and his family. Ric will be greatly missed.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I come to the House floor tonight to talk, like I often do, a little bit about health care. And this is the first day that the Congress is back in session after the December recess. And legitimately, someone might ask is it maybe a little early to begin this type of discussion. But the reality is, since we didn't finish our work in the last year, it is entirely appropriate for us to begin this year talking about some of those same things that were left undone at the end of 2007. Specifically, the reauthorization of the State Children's Health Insurance Program. An 18-month extension was passed at the end of the last Congress. I was grateful for that. I voted in favor of that. But the reality is this Congress should do its work and reauthorize this program for the full 10 years as it was intended when the reauthorization was up last September. We had a lot of opportunities to do this in my committee, the Committee on Energy and Commerce, but we failed to have a markup in subcommittee. We had a markup in full committee that was little more than a charade. We brought a very bad bill to the House floor in August. It was passed, but was not taken up by the Senate because the bill was so flawed. Then we had the Senate bill come to the House floor and it was a new bill, not a conference committee report. We had ample opportunity to debate that and take it back to committee and have a subcommittee hearing and subcommittee markup, a full committee hearing and a full committee markup, but we chose not to do that. We brought that same bill to the floor and voted on it. The House passed because they have a majority on the other side, and the President vetoed it and the veto was sustained. The same bill was brought up a second time in early October. The same result. The bill was passed, and the bill was vetoed and the veto was sustained. In the interim, many of us worked to try to overcome some of the obstacles to passage for this bill because we felt this was the correct thing to do. But the reality was that politics trumped policy. And at the end of the day, the best we could muster, at the end of December, at the very last minute, was to pass an 18-month extension. Madam Speaker, perhaps I should be grateful for that, because with an 18-month extension we will be past the next Presidential election before we are forced to look at this bill again. But I hope this Congress does not take that tactic. I hope this Congress takes seriously its obligation to study this problem and find out where the difficulties occurred last time and see if we can't come to the floor with a bill that could be broadly supported by both sides of the aisle. I think that is a possibility. But the reality, again last fall, some people thought the politics were more important than the policy. And the end result, well, we saw what the end result was. The same thing happened with our Medicare proposals. We have every year this mad scramble at the end of the year. If Congress doesn't do something because of the odd formulas by which we pay physicians in this country, physicians that we have asked to take care of our Medicare patients, but we have a very odd formula by which we reimburse those physicians. And as a consequence, every year at the last minute we are left scrambling, seeing if we can't do something. It is called the physician fix. It is almost like something that will happen on the winter solstice every single year, because if we don't do something by January 1, massive pay cuts are administered to the physician corps in this country. Again, the very physicians whom we have asked to take care of some of our sickest and most complex patients, and these physicians this past year faced a 10 percent pay cut. Now, at the last minute, we did do something to forestall the pay cut. We passed a rather modest bill to give a one-half percent positive update to physicians who take care of Medicare patients. But we only did it for 6 months' time, which means we literally kicked the can down the field. And the reality is we will have to face this again in June. And guess what? The deeper we go into this year, the more politics will take over, because it is a Presidential election year, and it is a Presidential election year the likes of which this country has not seen since 1952, or perhaps even 1928, when both sides are running for essentially what is an open seat in the United States Presidency. Well, I did come to the floor tonight because I wanted to have a candid conversation about health care. I think many in this Congress know I had a life before Congress. I was actually a practicing physician for 25 years back in my home State of Texas. So I feel I can approach this problem from both the provider level, on the basis of that 25 years in practice, as well now as the policymaking level, the legislative level, because obviously we do deal with a lot of health care here on the floor of the House of Representatives. I want to talk in some greater detail about the issues pertaining to Medicare, and I will get to that, but let me step back and talk about where the status of health care is in this country, because when you watch the Presidential debate, it seems everyone is talking about health care. Perhaps that is a good thing. In reality, the conflict in Iraq is not as divisive as it was a year ago. And as a consequence, you hear less talk about this country's involvement in Iraq. And as a consequence, you hear more talk about domestic issues. Health care and the economy have replaced some of the rhetoric that we heard during the 2006 fall election and some of the rhetoric that we heard on the floor of the House a scant year ago regarding this country's foreign policy. In reality, that is a good thing. It is a strange phenomenon when this country is prevailing in a conflict that we stop talking about it. I can't think of any other time in American history when that was the mindset. Nevertheless, that is what is occurring now. Again, as a consequence, we are talking a good deal more about health care. When you hear the talk about health care out on the campaign trail, you recognize there are some fairly different ideas that are out there and being talked about. And it is not that one person has any quarter on the best ideas, but it certainly lays the issue at the feet of the American people that there are very different ways of dealing with this problem, very different ways of setting the goal, very different ideas about what the goal should be, and obviously very, very different ideas about how to accomplish that. In fact, there is a lot of discussion about should we talk in terms of reform of our system of health care or is, in fact, the situation beyond the reform and we need to talk about actually transforming our method of health care in this country. And we will hear that debate play out. We will hear talk about things like mandates and universal coverage. Those are debates we should have at the national level, and those are debates where there should be broad participation. Madam Speaker, we lost a very good friend in Texas at the end of December. Ric Williamson was the chairman of our Texas Department of Transportation. He died rather suddenly at the end of year, an individual who was younger than I am; so needless to say, it was unexpected. During the memorial service that was held for Mr. Williamson later that week, a lot of discussion of how he had been a State legislator before he took the position with the Texas Department of Transportation, and many of his friends and former colleagues got up to talk about Ric Williamson's life. And almost to a person they talked about how Ric Williamson regarded politics as a full contact sport. That is you went at it with everything you had, but you do it openly. You do it in the committee room. You do it in the light of day. You don't do it behind closed doors in some secret conference in the middle of the night and cut a deal one side with the other. That is what this debate should be. It may be hard. We may come at each other again with full body contact in this debate, but it should be done on the floor of the House. It should be done on the floor of the committee rooms and not in a back room where a deal is cut at the last minute. Many options face us in this country. And again, we will hear a great deal of debate about things like universal coverage and mandates. We will hear a great deal about things like do we in fact craft policies that people actually want, or do we decide what policies people want and then administer them accordingly. But, Madam Speaker, freedom is the foundation of life. In my home State of Texas, that is very much the case. We thrive on unlimited options. Two years ago when we had the great Medicare part D debates, I remember at first there was a lot of criticism that no one will sign up to deliver these plans. There will be no plans. There will be a default government plan. So guess what happened? In my home State of Texas, we had 45, 46, 47 companies sign up to provide these drug plans. And then we were told there were too many choices. The reality is Americans thrive on choices. And choices are what this debate, in my opinion, a lot of what this debate should be about. It is what has made this country great. And, in fairness, it is what has made, at least from a scientific basis, the health care in this country the envy of the world. Well, again, the same kinds of options are going to be out there facing Americans during the debates, and I urge them to pay attention at every level. I know I must direct my remarks to the Chair, Madam Speaker, but if I could speak directly to the American people, I would encourage them to pay a great deal of attention to what is talked about, who is offering what, are they believable, and, in the end, do we think anything will really change no matter how many times they mention the word. When it comes to innovation, the United States of America is undisputably the world's leader. In the last 25 years, 17 of the past 25 Nobel Prizes in medicine have been awarded to American scientists working in labs. That is a phenomenal record. Four out of the six most important discoveries of the last 25 years have occurred in this country, things like advanced scanning techniques, things like statin drugs to lower cholesterol, things like coronary artery stints and bypasses, things that have extended life to citizens who 30 years ago, quite frankly, there might not have been any help, there might not have been any hope. Now, innovations can improve health and life expectancy. It certainly does not mean that can't improve on a good thing, that we step back and rest on the accomplishments that are already there. But it certainly means in the environment that we provide in this country, quite honestly an environment that tolerates uncertainty from time to time, an environment that rewards risk-taking from time to time, that environment is a good thing for the furtherance of the science of medicine and ultimately a good thing for health care in this country. Madam Speaker, one of the lead articles in this week's New England Journal of Medicine, and I apologize, I have forgotten the author's name. I just read it briefly on my way up here this morning, but it talked about how doctors now need to be prepared for a patient coming into their office and saying, I just had extensive genetic testing done on my own at a low cost, and now I have some information about my own human genome, and I would like you to help me interpret that. Indeed, that day has arrived. And doctors in this country do need to be aware of these changes and do need to be prepared to answer their patients' questions and provide insight and direction where insight and direction occur, and be able to provide the type of environment that will allow continued learning about this new science that has just arrived on our doorstep. Two companies now offer genetic testing, genomic testing, more appropriately, simply taking a swab of the inside of a cheek and sending it off to a company and waiting a few weeks and they come back and tell you all kinds of things about what your genomic makeup is. Madam Speaker, when I think back to when I first entered the doors of Parkland Hospital in July of 1977, I would have never believed, never believed that this type of technology would be available in my lifetime, let alone that this type of technology would be available for a reasonable cost, and such a reasonable cost that people just simply elect to have it done to find out a little bit more about themselves and perhaps underscore some risk factors that they already knew were there and perhaps alleviate some concern about risk factors that may not carry the weight that the patient thought they did. It's a phenomenal time that we've entered into, truly a transformational time in medicine. And it has happened before. During the last century, I can think of three times when the scientific advances were so rapid and so solid, and at the same time, there was so much social change brought by bodies that legislate, bodies that govern, that the practice of medicine was forever changed. Look what happened back around 1910. We were coming from a time where blistering, burning and bleeding were thought to be the peer-reviewed, the evidence-based proper treatments to administer to patients who were in distress. And very abruptly, the world changed. And the world changed because we found out more about the practice of anesthesiology. The world changed because we found out a little bit about blood- banking. The world changed because we found out a great deal more about the science and manufacture of vaccines. And then at the same time when all of that science was consolidating in the practice of medicine, we had the Flexner Commission and subsequently the Flexner Report commissioned by the United States Congress. And those activities now administered more at the State level; but suddenly we had that consolidation of medical school curricula across the country. Medical schools used to be able to teach all manner of things. Suddenly, they were conscripted or somewhat conscribed in what they could teach, but they began to teach evidence-based scientific fact in the medical schools. And it was just at the right time, because the scientific body of information was changing very rapidly. And if we fast forward to the middle of the 1940s, a country at war, 10 or 12 years before, Sir Alexander Fleming had found an unusual curiosity in his laboratory petri dish: a penicillin mold could inhibit the growth of bacteria. Well, that was an astounding discovery, but it was really little more than a laboratory curiosity until an American company came up with a method of producing large quantities of this substance that inhibited bacterial growth, and thus began the modern pharmaceutical industry in this country. But it was a good thing, because we were a country at war. And, indeed, that infection-fighting antibiotic went from a laboratory curiosity that was intensely labor intensive to produce and intensely expensive to administer, and it went to something that was available to the average person in this country. And, indeed, antibiotics were available to treat our soldiers who were injured during the landing at Normandy, and I dare say many life and limb were spared because of the availability and the inexpensive availability of that antibiotic. Another rather astounding scientific accomplishment that occurred at the same time, cortisone had been discovered several years before but cortisone was not commercially available. The way they got cortisone back then was to extract it from the adrenal gland of an ox. Well, if the ox was not anxious to give up their adrenal gland, you can imagine that was a pretty labor-intensive process. But an individual that we honored on the floor of this House during the last Congress, Dr. Percy Julian, a Ph.D. biochemist, came up with a way of producing cortisone from a plant precursor, from a soybean precursor. Again, same situation: suddenly you had a medicine that was profoundly useful, but only in limited application because it was so expensive and so hard to obtain in the amounts necessary to treat a patient, and now suddenly it was readily available and it was available at a very low cost because it now could be mass produced. Well, these two striking phenomena occurred in the 1940s. And what else happened in the 1940s? Again, we're a country at war. The President wanted to prevent an inflationary spiral, or an inflationary cycle; so he enacted wage and price controls. Employers wanted to keep their employees working. They didn't want someone else stealing their employees away, because employees were at a premium. The vast majority of Americans were off involved in fighting the war. So employers came up with the idea of maybe let's offer some fringe benefits, health insurance, retirement benefits. And wait a minute. Don't think we can do that because of the wage and price controls. But a court case ensued, as so oftentimes happened, and the Supreme Court ruled that indeed these benefits could be offered, and not only were they not in violation of the wage and price control statutes, but they also could be administered as pre-tax expenses. So suddenly we had the vast social change of employer-derived health insurance arriving rather suddenly in the 1940s; and at the same time you, doctors, for the first time in the history of medicine had a cheap, inexpensive way of combating infection and treating people with other inflammatory conditions with cortisone. Again, fast forward to the 1960s. Big changes were on the horizon. In fact, in 1945, President Roosevelt died of malignant hypertension, died of a stroke. In the mid-1960s we were beginning to develop medicines that treated accelerated hypertension, or malignant hypertension. We were developing medicines that could treat psychoses. We were developing the first medicines that were now known as antidepressants; a lot of changes on the horizon. And what else changed in the mid-1960s? For the first time, the Federal Government got involved in a big way, in a big way, in paying for health care with the passage of Medicare in 1965 and, subsequently, Medicaid thereafter. And now we're at a time in our country's history, where almost 50 cents out of every health care dollar that's spent originates right here on the floor of the House of Representatives, because of the vast expansions of the expenditures in Medicare, Medicaid, VA system, Federal prison system, Indian Health Service, a lot of different ways where the Federal Government has a participatory role in health care, one that quite frankly was never envisioned 40 years ago. So the world indeed has changed because of some of the social changes that was brought about by changes in this Congress. Well, I submit, Madam Speaker, that the world of medicine is on the brink of another such transformational change. I've already alluded to the changes that are going to happen in the realm of genomic medicine, a lot of advances in the types of scanning that are available, the types of imaging that are available. Medical care in this country is going to become a great deal more personalized with the development of genomic medicine. It is of necessity going to be more participatory, but at the same time more preventive. And these are good things. These are reasons to make one excited about a career in health care and in some ways I'm envious of the young people today who look up from their desk in high school or college and say, I want to do that; I want a career in health care. I know it takes a long time. I know the government's interfering at a lot of different levels, but I want a career in health care because it's so exciting. And there's still that basic altruistic feeling inside of a lot of us in health care that we want to do that because it's the right thing to do. Well, we are on the cusp of a true transformational time in health care in this country. Now, can Congress properly interact with that transformation as it occurs? It's very difficult, and our history is not great in that regard because Congress is inherently a transactional body. We take money from here and we move it over here. We create winners and losers in this system. And all too often the transactional can be the enemy of the transformational. And it is our job, our job, every one of us who sits here in a seat in this House of Representatives, to ensure that our transactional bias does not interfere with the transformation as it's occurring under our very feet. Congress can't legislation the transformations going on in health care. It's happening anyway. It's happening whether we want it to or not. But Congress can certainly interfere with that transformation if we don't set the proper regulatory tone, if we don't provide the proper liability environment, if we don't provide the proper incentives. Congress can actually be the enemy of transformation. And, Madam Speaker, there are several more things that I want to cover this evening. But I see I'm joined by one of my colleagues, one of my colleagues in the House of medicine as well as one of my colleagues in the House of Representatives. And I would like to yield to the gentleman from Georgia such time as he may consume to likely address the issue of medical liability, because that is a big aspect of when we talk about health care reform in this country. It's a big part of the equation. So I'll yield to my friend from Georgia.

Mr. BURGESS. I appreciate my friend coming to the floor tonight. In fact, let's stay on the concept of electronic health records, electronic medical records for just a moment. I have a confession to make to my friend from Georgia. I haven't always been a big proponent of electronic medical records. There has been some debate from time to time in our literature as to whether the savings is actually as great as what is anticipated. I've used the two separate prescribing platforms in my private practice back in Lewisville, Texas, with sort of marginal success, but became a believer in the availability of an electronic medical record sometime after Labor Day in 2005. And the reason I became a believer was because after Hurricane Katrina ravaged the Louisiana and Mississippi gulf coasts, I had an opportunity on several occasions to travel to the city of New Orleans. In January of 2006, in fact, we had a field hearing in New Orleans. As part of that field hearing, we visited Charity Hospital, Charity Hospital one of the venerable old hospitals in this country, one of the hospitals that is responsible for training some of our medical pioneers. In fact, through good fortune, I had a chance to sit down with Dr. DeBakey late last fall, and he talked a little bit about his time of training in the city of New Orleans. Charity Hospital, again, one of the venerable old institutions, now likely lost to us forever. And down in the basement of Charity Hospital was a room that had been underwater for weeks. In fact, there was still water on the floor. This photograph doesn't really do that justice. There was still water on the floor after the city had been dewatered. I didn't know ``dewatered'' was a verb. But after the Corps of Engineers had dewatered the city and they were able to go back down to the records room of Charity Hospital, this is what they encountered. These are records that had been submerged for weeks in brackish water, water contaminated with goodness knows what, and what we see here is now smoke or soot damage on these medical records. This is, in fact, black mold that is growing on the medical records. And the reality is you could not send anyone in there to retrieve this information because it would simply be too hazardous, but also, the records themselves had been submerged for weeks at a time in seawater, brackish water, and the ink itself, many of these records were written in ballpoint pen by people over decades. And that ink washed off the pages so those that aren't ruined by the black mold are rendered illegible. Doctors' handwriting is hard to read anyway, but you submerge it for several weeks in brackish waters, and it truly becomes something you cannot read.

Mr. BURGESS. I thank the gentleman for his participation this evening. I actually thank you for bringing up the issue about Congressional Budget Office scoring. We're about to the time in this Congress where you hear us talk a lot about the budget, and we will be developing the parameters of the congressional budget shortly after the President gives his State of the Union message here in a few weeks. The President delivers his budget, and then we come up with a congressional version of the budget. The last year when we were working on the budget, I brought essentially what was the Texas medical liability reform model to the Budget Committee, had it scored by the Congressional Budget Office, and it scored in a savings just under $4 billion over the 5-year budgetary window, not an enormous amount of money; but for a body that spends $3 trillion a year, it was savings worth looking at. And the Texas legislation, as the gentleman from Georgia pointed out, the law passed in California back in 1975 seems like forever ago. The Medical Injury Compensation Reform Act of 1975 passed in the State of California, signed by the Governor, who at the time was Jerry Brown. This same concept in Texas was developed. And the Medical Injury Compensation Reform Act of 1975 in California capped noneconomic damages at $250,000. The Texas bill was a little more flexible than that: it allowed for a trifurcated cap of $250,000 on the physician and $250,000 on the hospital, and $250,000 on a second hospital or nursing home if one was involved. But that trifurcated cap allowed for a little more flexibility in trying to establish just compensation for a patient who, indeed, had been injured; but it also acknowledged the reality of our system in that you cannot have an open-ended amount of compensation for noneconomic damages because it throws so much indecision into the system that people can't make rational decisions. So by trifurcating the cap, and interestingly enough, in the State of Texas punitive damages were still allowed to stand, we also had periodic payments for large settlements, and we also had a Good Samaritan rule. This bill passed in 2003. It was upheld under a constitutional amendment election in September of 2003 and has now been the law of the land since that time. And we have seen phenomenal success in Texas, not only with holding down the cost of medical liability premiums, which were going up year after year after year, but we also saw medical liability insurers leaving the State in vast numbers. In fact, we've gone from 17 down to two. And you just don't get very good competition between insurance companies when you only have two of them. So we now have brought more insurers back into the State. They've come back into the State without an increase in premiums. In fact, Texas Medical Liability Trust, my last insurer of record, has reduced premiums by 22 percent over the last 4 years compared to double-digit increases for each of the last 5 years prior to 2003. So it really is a phenomenal success story. Smaller, mid-sized not- for-profit community hospitals have had to put less money into their contingency funds to cover possible liability pay-outs, and as a consequence they've been able to return more money to capital investment, hiring nurses, just the kinds of things you want your smaller community not-for-profit hospital to be able to do when released from some of the constraints of the liability system. I'm not saying that this is perfect; I'm not saying that this is what we should all aspire to. Certainly there are reasons to consider concepts like medical courts. Certainly there are reasons to consider concepts like early offer. But the fact of the matter is we can do a lot better than what we're doing today because the system that we have today only compensates a small number of the patients who are actually injured. And, moreover, the time it takes for a patient to recover money under the current system is far too long. And if you will, the administrative costs, that is, costs of the medical experts and the legal system and the lawyers' costs, consume about 55 to 58 percent of every dollar that's awarded in a settlement. Well, we wouldn't tolerate a health insurance company that had an administrative cost of 58 percent. We'd call them profiteers and we'd bring them up before hearings, but yet we tolerate it in our medical justice system every day of the week. And it's not right. I want to so much thank my friend from Georgia for joining me here tonight. This is an issue that we will get to talk about a lot over this next year. Obviously, we have got a 6-month window of opportunity on getting the physician payment formula right. I believe that means taking a short-term, mid-term, and long-term approach to the problem, which I have tried to do in the past. And we will be working with other people here in the House of Representatives, I hope on both sides of the aisle, to try to craft a solution to this problem, which has vexed this Congress for a number of years. But suffice it to say, we will be able to be back here on several more occasions talking about this and other issues as they relate to health care in this country.

Mr. BURGESS. I thank the gentleman for yielding. And here's the deal with this formula: what it results in is a vastly different universe for physicians who are providing care to our Medicare patients when you compare them with hospitals, nursing homes, HMOs, drug companies. Each one of those entities receives a positive update every year based on, guess what? It's kind of like a cost-of- living adjustment; it's called a market basket update. The physicians formula, though, unless Congress intervenes, which it did on every one of these years, unless Congress intervenes, this adjustment factor is going to go down, and it's projected to go down year over year for the next 10 years' time to the tune of approximately 35 to 37 percent, clearly an untenable factor. You know, if a doctor goes into his banker's office and says, here is my business plan, Mr. Banker, and I want you to help me get my business established, I've got this business plan where I'm going to earn about 10 percent less each year over the next 10 years' time, do you think you will be able to fund me some money? No, sir, I don't think that would happen. In no business would we ask someone to stay in business where the cost of reimbursement is going to go down year over year. And we all know, is it going to cost any less for energy to heat and cool that physician's office over those years? No. The answer is, of course not. Is it going to cost any less to have the employees in the office? Is it going to cost any less for the liability insurance? And the answer is ``no'' to all of those questions. Mr. Speaker, I know we're running a little short on time, but I wanted to give the gentleman from Georgia a chance just to talk a little bit about what is happening in the arena of liability reform in the House of Representatives, because I know that is an issue that's been important to both of us. We have done some things in Texas over the last 4 years' time which I think, from my perspective, have been very positive. There are other concepts out there that are talked about, concepts such as medical courts, concept such as earlier offer. We had a bill similar to the Texas bill that came through the House of Representatives, as the gentleman pointed out, for the 108th and 109th Congress; but I would like to yield to the gentleman just for a moment to talk a little bit about liability reform.

Mr. BURGESS. Let me just point out, though, one aspect of the Federal Government's involvement in electronic medical records and one of the reasons we have to be so careful. When I said earlier that the Congress, being a transactional body, can sometimes be the enemy of transformation, a year ago a lot of us heard stories about some difficulties out of Walter Reed Hospital here in the city of Washington, DC. And I traveled out to Walter Reed and visited that Building 18, and indeed, there were some significant problems. But the young man who showed me around Building 18, Master Sergeant Blades, said, You know what's really, really at the heart of a lot of this frustration is that my guys here on medical hold have to go through their medical records. They will go through this long arduous process of compiling their record, yellow highlighting the important features, all done on paper, and that will be delivered to someone's desk where it sits for 2 weeks and then gets lost, and they've got to start all over again, which increased the frustration to be sure, but also increased the time that these young men who were at Walter Reed on medical hold trying to decide whether they went back with their unit or whether they were going to be discharged and cared for in the VA system, while all of that was sorted out, the paper record did indeed seem to be an impediment to that process. But we do have an electronic medical record system at the VA, and one I've never used it myself, the Vista system, multisource software. I understand it works very well. And we also have an electronic medical record at the Department of Defense, but the problem is that the two won't talk to each other, and as a consequence, our soldiers are caught in between. And the result, at least a year ago at Walter Reed Hospital, was concerning to many of us here, and it has taken a good deal more time than I would have thought necessary to get this problem solved to bridge that gap between one set of electronic medical records and another. So we do have to be careful at the Federal level. We don't always have the best solutions. So sometimes what our approach needs to be is to provide the right regulatory environment, to provide the right liability environment, to provide the right incentives, perhaps establish some standards, as Dr. Gingrey said, and then get out of the way and let the people who know how to develop these things actually be in charge and not have Members of Congress responsible for writing software. The gentleman also brought up some very good points about the formula by which we reimburse physicians under the Medicare system. I thought the gentleman would enjoy seeing, and I know I'm not supposed to go through this because I'm accused of being too much into the process, but this is the formula by which we pay physicians, by which we reimburse physicians under Medicare. It's called the Sustainable Growth Rate Formula. It's been around for a while. It looks a little daunting, but it's, perhaps, understandable when you look at it. We have a relative value unit for work, plus a geographic modifier, another relative value unit for practice expenses and another geographic modifier, and a relative value unit for liability insurance, and a geographic multiplier. And then we see all these terms defined here. There is actually a misprint on this page, and it's the fault of the Congressional Research Service, not the person who made this poster for me. But it's almost applied at the end by CF, which is a conversion factor, referred to here as CV, the conversion factor. Well, that's an interesting thing. How do we get the conversion factor? Well, we've got to go to another formula. And here we're going to be able to calculate the conversion factor. And I won't go through all of this because I'm told I shouldn't, but at the very bottom of the page you see we need to know the UAF before we can calculate the conversion factor, the update adjustment factor. And how do we get the update adjustment factor? I'm glad you asked. The update adjustment factor is here, yet another formula. Now, I don't show these to impress people with my ability to go through the mathematical formula, but I do use this to point out that the system by which we reimburse physicians, it needs some attention.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today in recognition of Fort Worth Chief of Police Ralph Mendoza. After more than 35 years with the Fort Worth Police Department, and almost eight years as the top cop, Ralph Mendoza will retire in February 2008. During Mendoza's tenure, the city of Fort Worth saw reductions in crime and advances in technology. Serving as the first Hispanic Police Chief of Fort Worth, Mendoza is praised by other city officials, calling him an ``outstanding chief'' and applauding his efforts as Police Chief that led to a reduction in the crime rate for the city. Additionally, others go on to say that Fort Worth ``is indeed a better place'' because of Mendoza's efforts, which helped to make the city the ninth-safest in the country. Mendoza began his career with the Fort Worth Police Department in 1972 as part of the now-defunct cadet program. He graduated from the police academy in 1974 and later became the department's first Hispanic lieutenant, deputy chief and chief. He was appointed acting chief in August 1999, and was named Police Chief in January 2000. I am sure the decision to retire was not an easy one for Chief Mendoza. I join his colleagues in wishing him all the best as he looks forward to spending more time with his wife, children and grandchildren. It is with great honor that I recognize Chief Ralph Mendoza for his decades of hard work and selfless dedication given to the citizens of Fort Worth, Texas. I am proud to represent him in Washington, and his service will set a standard of devotion and true leadership, one that will never be forgotten.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to thank Mr. Monty Slough of Little Elm, Texas for his years of service in the United States Armed Forces, and for his continued service to our country by building a memorial to veterans from Denton County, Texas. After checking records at the Department of Veterans Affairs, Monty identified the names of nine fallen service members and created a personal way to memorialize their service. Without prompting or financial support, Mr. Slough began building a granite tiled memorial to Denton County soldiers, sailors, airmen, and marines who died in service in Iraq or Afghanistan. Mr. Slough has taken up the honorable but unfortunate task of paying respect to fellow veterans who pay the ultimate price while serving our country. In his own eloquent words Monty said, ``This isn't going to bring them back, but they sure as hell are not going to be forgotten.'' The mobile memorial built by veterans Monty Slough and Dee Cork is an example of why we hold our Nation's veterans in such high esteem. I believe the character displayed by Mr. Slough and Mr. Cork should be highlighted as an example of American civic duty and community support; I rise here today to show them that courtesy. It is with great honor that I recognize Mr. Monty Slough of Little Elm, Texas for his dedication to veterans and their families. I thank him for his work, I support his mission, and I am honored to represent him in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to thank Mr. Dee Cork for his years of service in the United States Armed Forces, and for his continued service to our country by building a memorial to veterans from Denton County, Texas. Working along with Mr. Monty Slough, Mr. Cork identified the names of nine fallen service members and created a personal way to memorialize their service. Without prompting or financial support, Mr. Cork began building a granite tiled memorial to Denton County soldiers, sailors, airmen and marines who died in service in Iraq or Afghanistan. Mr. Cork has taken up the honorable but unfortunate task of paying respect to fellow veterans who pay the ultimate price while serving our country. In his own eloquent words Dee said, ``It would be nice to see no one else on it, one is too many.'' The mobile memorial built by veterans Monty Slough and Dee Cork is an example of why we hold our nation's veterans in such high esteem. I believe the character displayed by Mr. Slough and Mr. Cork should be highlighted as an example of American civic duty and community support; I rise here today to show them that courtesy. It is with great honor that I recognize Mr. Dee Cork for his dedication to veterans and their families. I thank him for his work, I support his mission, and I am honored to have the opportunity to recognize him today.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to thank Mr. Dee Cork for his years of service in the United States Armed Forces, and for his continued service to our country by building a memorial to veterans from Denton County, Texas. Working along with Mr. Monty Slough, Mr. Cork identified the names of nine fallen servicemembers and created a personal way to memorialize their service. Without prompting or financial support, Mr. Cork began building a granite-tiled memorial to Denton County soldiers, sailors, airmen, and marines who died in service in Iraq or Afghanistan. Mr. Cork has taken up the honorable but unfortunate task of paying respect to fellow veterans who pay the ultimate price while serving our country. In his own eloquent words Dee said, ``It would be nice to see no one else on it, one is too many.'' The mobile memorial built by veterans Monty Slough and Dee Cork is an example of why we hold our Nation's veterans in such high esteem. I believe the character displayed by Mr. Slough and Mr. Cork should be highlighted as an example of American civic duty and community support; I rise here today to show them that courtesy. It is with great honor that I recognize Mr. Dee Cork for his dedication to veterans and their families. I thank him for his work, I support his mission, and I am honored to have the opportunity to recognize him today.

Mr. BURGESS

Mr. BURGESS. We probably won't take the entire 60 minutes because it has been a long week and it's been a long year, but I did want to come to the floor of the House this evening and talk a little bit about health care and talk a little bit about some of the things that are going on in Medicare, some of the things that are going on in Medicare as it affects our Nation's physicians workforce, and what, perhaps, I see over the horizon for the next six to 12 months. It's going to be kind of an interesting year. It's an election year in this country, and that means we never want for drama during that time. This is, of course, the special time of year at the end of the year where we all pause and kind of give a little thanks for living in the greatest country on the face of the Earth, the greatest country the world has ever known. We're blessed with many, many benefits from living in this country. Sometimes we take many of those for granted. Our health care is one of those benefits that I think we do take for granted, we overlook too often. It is appropriate to perhaps have a little checkup on that little tiny segment of the health care market that is controlled by the Federal Government. Of course, I'm being factitious because the Federal Government has under its direct control and grasp probably close to 50 cents out of every health care dollar that is spent in this country. That is, 50 cents out of every health care dollar that is spent in this country originates right here on the floor of the House of Representatives when you configure or figure the expenditures on Medicare, Medicaid, the VA system, the Indian Health Service, the Federal prison system, the federally qualified health centers around the country, 50 cents out of every dollar starts here on the floor of the House. But Medicare does have some operational problems with its physician workforce, it has some distributional problems. There are some areas that need attention in our Medicare system. And the problem, Mr. Speaker, is not just money. We've heard a lot of folks talking on my side, folks talking on the other side about the issue of money, but the issue is not just about money, although the money is extremely important. It's not just about money. It is the policies that we create here on the floor of this House and the rules that are written in the Federal agencies under our direction. It's the policies created in this House that actually lead to most of the direct problems in that part of health care that is paid for under the reach and grasp of the Federal Government. Now, Medicare was created a little over 40 years ago, the mid-1960s. And it was created to make a connection between patients and their physicians, patients and their hospitals and places where they needed to go for care, care that was becoming very expensive, and for some of our seniors was care that perhaps would be out of their reach. Now, Mr. Speaker, believe it or not, I was not in practice at the time Medicare was instituted. My dad was. And I remember very clearly when Medicare was started in this country and some of the concerns revolving around that. I don't think anyone would have really thought that we would have just done an appropriations bill where here some 43 years later after the enactment of Medicare, I don't know what the total line expenditure for Medicare was, but it is topping $300 billion for a year in Medicare. You add the expenses of Medicaid to that, and the two together with what is spent at the Federal level and what is spent at the State level when you involve Medicaid and we are well over $6 billion a year for what we pay for that. So, again, it is really not so much a question of money. It is a question of policy. But the lifeline that was created between seniors and their doctors, seniors and their hospitals, that lifeline that has been depended upon by really two generations of Americans now, almost two generations of Americans, that lifeline is frayed. Almost every day there is a little nick, a little cut. It is death by a thousand scalpels, if you will, since we are talking about health care. And it is that constant nicking, it is that constant pressure on that lifeline that is causing the lifeline to fray for many individuals. Now, Mr. Speaker, I have said on the floor of this House before and it bears repeating tonight, Alan Greenspan, the former Chairman of the Federal Reserve Board, when he left his office as chairman just a little less than 2 years ago through one of his sort of exit speeches when he came through to talk to various groups, one of the things when he came to talk to a group of us one morning back in January of 2005, I think it was, and talked about the, well, he was asked about the cost of Medicare, how in the world is Congress ever going to keep up with the ever increasing cost of Medicare; how is Congress going to deal with what is basically an unfunded obligation going into the future. And the Chairman thought about it for a moment, and as always he is very careful about what he says. He said, I think when the time comes Congress will find the courage to do what is necessary to keep the Medicare system up and running. He said, what concerns me more is will there be anyone there to deliver the services when you require them? Because, Mr. Speaker, January 1 of 2008 will be the year the first baby boomers reach the magic age of 62. They begin entering their retirement period, their retirement time; and as a consequence, we are going to see a lot of pressure put, not just on the Medicare system but on the Social Security system, on our system of long-term care, which is basically the Medicaid system under the current construction. So there is going to be a lot of pressure put on those Federal programs as more and more people of my generation reach retirement age and again to seek and ask for and collect those benefits that they believe that they have been paying into over time. But what happens if the supply-demand equation in regards to America's physician workforce, and nurses too for that matter, but what if the law of supply and demand has been drastically skewed so that there is not the supply, we are not keeping up with the supply of doctors and health professionals who are going to be required to take care of those patients as they enter their retirement years? At the risk of getting too technical, let me just share a few facts. Mr. Speaker, I am sensitive to the fact that I must only address the Chair and not address people who are here on the House floor with us, Members who might be watching from their offices. I know I am not supposed to direct my comments to people who might be watching on C- SPAN so I will confine my remarks solely to the Chair and, Mr. Speaker, this is a poster that I have used in the past, and many people have seen this poster used on the floor of this House. This is a cover from the periodical put out by the Texas Medical Association. Every year they come out with a publication called Texas Medicine. And this is from March of this past year, March of 2007. And the title article was, ``Running Out of Doctors.'' It is a concern, certainly a concern of my professional organization, the Texas Medical Association back in Texas. And it is a concern, I think, or should be a concern for many of us here in this Congress. Again, it was a concern of Mr. Greenspan's 2 years ago when he came and talked to a group of us. And, in fact, Mr. Speaker, I asked Mr. Greenspan again when he came back to visit with us just a few months ago, I said, I often quote that statement that you made to me about is there going to be anyone there to take care of the patients in the future, and do you still feel that way, Mr. Chairman? And he said, Not only do I still feel that way, I feel stronger about it today than I did a few years ago. So this is a very relevant point and something that certainly we need to keep in mind. Now, one of the things that is still up to be done, one of the things that is still on our to-do list here on the House side before we do finally draw this year to a merciful close is we do have to address, basically, what Medicare pays doctors. For whatever reason, we have to deal with that every year, and we don't always do a good job. Certainly when my side was in charge, we didn't always do a good job, and this year I think that performance is being repeated, and perhaps it is even a little bit worse this year. The fact of the matter is that if Congress doesn't do something before December 31 of every year, there is a scheduled series of payment reductions that physicians will experience as a consequence of the formula under which they are paid under Medicare. It is not a problem that is unique to this Congress. It has been going on for years. It has been going on through several administrations. It is a problem brought to us by a formula called the sustainable growth rate formula which is how physicians are paid under Medicare. Now, it is different for hospitals, it is different for HMOs, it is different for drug companies. Those expenditures are subject to essentially a cost-of-living adjustment every year. So every year there is perhaps a little bit of an uptick in what the hospitals receive, kind of a what is called a market basket update where the cost of inputs, the cost of delivering the care is figured into what Medicare reimburses a hospital. So part A of Medicare, which is the hospital payment, funded out of payroll deductions, part A of Medicare, the hospitals do receive a little bit, it is not terribly generous, but they do receive a little bit of an uptick every year. For part C of Medicare, which is the Medicare HMOs, they are perhaps even a little more generous than the hospitals. They get a little positive update so they can continue to meet the obligations that they have in taking care of our Medicare patients. We are asking the HMOs to provide that care. We are asking the hospitals; in fact, we are asking the doctors. Congress asks them to provide the care so hospitals, HMOs and now drug companies receive a little bit of an additional payment every year under the current formula structure. But for whatever reasons, physicians have been calculated differently. And the physician rate of compensation for Medicare patients is based upon something that has a little bit to do with the gross domestic product and the idea that we are only going to be able to control the expenditure on volume and intensity of Medicare services if we really ratchet down what we pay doctors year over year. But the negative consequences of that are significant, and the price that doctors pay if we do not do our work by December 31, and it looks now like we will sort of, and we will get to that in a minute, it looks like we will do that work and accomplish that task before December 31; but if we don't do that, then this year the Center for Medicaid and Medicare Services came out with a report November 1 saying doctors would receive payment reductions of a little bit over 10 percent, I think it was 10.1 or 10.3 percent, for 2008 compared to what they received in 2007. Well, stop and think about that for a minute, Mr. Speaker. These are small businesses. The physician practices that most of us were familiar with back in our communities, I was a physician in my previous life. I am very familiar with this concept. We are small businesses. And year over year, it is not costing us less to keep the lights on in that office. It is not costing us less to hire our employees to be able to provide the services that you want us to provide. It is not costing us less for liability insurance year over year. Yet Congress in its infinite wisdom says that we should be able to make do with a little bit less in compensation for the Medicare patient year over year. This year that payment reduction was 10.1 percent. Now, you might say, well, a physician's practice isn't just Medicare patients. There is commercial insurance. There is self-pay. Why are we so concerned about the Medicare aspect? What percentage of a physician's practice will be taken up by Medicare patients? And the answer is, it varies and it depends on different places in the country and what the patient mix is in various places in the country. Arguably, it might be higher in a State like Florida than it would be in a State like Wyoming. But nevertheless, the other effect of these Medicare compensation, Medicare reimbursement reductions that happen and are scheduled to happen every year for the next 15 or 20 years, the other effect is that every commercial insurance company in this country, almost, not all of them but almost, pegs their rates, pegs what they compensate, the level of what they compensate doctors to the Medicare formula. So they pay a formula such as 110 percent of Medicare usual and customary. Some will pay less than Medicare. But most pay a little bit more, not a generous amount more, but a little bit more than Medicare. But if Medicare cuts its rates by 10.1 percent, then guess what? The commercial insurance company will be only too happy to reduce their compensation rates by 10.1 percent. And I don't think it was ever the intent of Congress to legislate an improved business plan for America's insurance companies. They are perfectly capable of doing that on their own. They are perfectly capable of going into the physician community and negotiating a lower rate if they need to do that if that is what needs to happen so they can continue to provide the care for the patients, continue to provide the coverage for the patients. They are perfectly capable of going to the physician community and saying this is what we need to do with the new rate structure; but they kind of get a little gift every Christmas from the United States Congress that says, well, we are going to reduce our Medicare rates if we don't do our work. And guess what? All of you patients who are covered under private insurance, your doctors are going to get paid a little less even though they are going to do exactly the same work on January 3 or 4 that they did on December 27 or 28. Again, Mr. Speaker, I know I need to confine my remarks to the Chair, and I will keep my remarks confined to the Chair. But it does happen that sometimes people actually do watch C-SPAN this late at night and they do see these discussions, and I have gotten some feedback, Mr. Speaker, when I have put up this poster before. I actually have three posters that delineate the actual payment formula for physicians under the Medicare system. I have only brought one tonight in the interest of time. And I bring this not to elicit sympathy but I just want people to be understanding and cognizant of just how complicated, how complicated this process is under the actual gyrations that we go through to come up with these physician formulas. Now, this is actually the first part of what really should be three slides, but I did promise some people that I wouldn't bring all three slides tonight. But the payment for physicians is figured by taking the relative value unit for work, geographical factor, a relative value unit or the cost of inputs, the practice costs which is the subscript P C in the middle parenthesis there, again, the geographic factor that is figured in, and then the relative value unit for liability insurance, and again a geographical factor figured in. Then the whole thing is multiplied by a conversion factor down here, there is a misprint, that should be C F, which is ``conversion factor,'' and the calculation of the conversion factor is every bit as complicated as this first part of the formula Again, I don't want to lose people with this discussion, but I want you to understand how difficult this is conceptually. As a consequence, Members of Congress on both sides of the aisle, when you sit down and say, I want to talk to you about how we compensate physicians under the Medicare system, literally their eyes glaze over and roll back in their head because this is simply too hard for many people to think about. Again I have spared, Mr. Speaker, the House from looking at the other two slides which also are filled with various parts of the formula. And too, let me, Mr. Speaker, this will give you some idea of how long I have been doing this particular talk, because actually this slide was current this time last year when I was doing this very same discussion. And I need to update, because now we have completed fiscal year 2007, so no longer will 2007 have an asterisk beside it. We actually have the actual figures for that, and the figures for 2008 need to be added on. This illustrates the problem we have. Now, last year right before the end of Congress, we hadn't quite figured out what we were going to do, so it was projected that doctors would have a little over a 4\1/2\ percent payment cut. It turns out that that didn't happen. We actually at the last minute came in and held doctors at what we euphemistically call a zero percent update. Well, I am here to tell you that anywhere else in Washington, if you come in saying we are going to hold you at level funding, they will say, Wait a minute, the cost of inflation, the cost of doing business has gone up so much, that is actually a cut. Well, that is exactly right, and doctors did receive essentially a cut, but we called it a zero percent update, and we did not score it as a cut, but they were scheduled to get a 4\1/2\ percent payment reduction. This year, if we don't take up the legislation that the Senate just zipped through at the last minute here at the end of the day on Tuesday, if we don't take that up and pass that before we leave town to have Christmas with our families, this negative projection will actually be twice as far, down past the end of the page, because that is a 10.1 percent reduction that doctors are facing this next year. What happens, Mr. Speaker, is every year that we come in at the last minute with that fix, that money that we come in at the last minute to provide our physicians, guess what? It gets added on to the end of that very complicated formula that I just showed you. So every year that we don't fix the fundamental problem, which is to repeal the sustainable growth rate formula, every year we don't do that, we make the problem harder to solve next year, and at some point we will simply reach the point where it is too hard to solve, it's too expensive to solve, and people will either restructure the formula because it just collapses of its own weight, or just say we are not going to even try to solve it any longer because it is just too hard. It's an odd concept because it's money that has already been spent. Going back to 2002, when there was a 4.4 percent negative update, and I was in practice then, and that did happen, but the moneys that were paid in the Medicare system in 2002 have already been paid, they have already been spent. So when they say it costs more to repeal the sustainable growth rate formula every year, it's because we are actually going to have to account for that money on our books, but the money has already been spent. There's not any magic here. We have paid the money to the physicians for that given year. We just haven't quite accounted for it on our books, and that is why there is that additive factor that goes on year after year that kind of makes it impossible to ever dig out of this hole. We certainly won't be able to if we don't ever start, and that is the direction I have tried to take in the last Congress and tried again in this Congress. I wasn't really successful in getting a lot of people to understand the significance of this. The reality is that as we continue, continue to cut at the compensation rate for physicians in the Medicare program, what happens is more and more physicians say, You know what? I just can't do it anymore. I can't keep the lights on. I can't pay the help. I can't buy my liability insurance and continue to see Medicare patients. And worse than that, there's the pernicious effect of, come on, we are right on top of the end of the year here and we are asking doctors around the country to kind of trust us on this; we are going to fix it. How do you plan in your business for expansion? How do you plan to take out loans, take capital risks? How do you plan when year over year over year in the Medicare system you have cuts stretching out ahead, and, oh, by the way, commercial insurance is going to follow suit if Congress keeps those cuts intact and keeps them in place, because we don't really have a free market for health care in this country. We have Federal price controls, and it's essentially cloaked in the Medicare program, but, nevertheless, the end result is Federal price controls on medical reimbursement rates for procedures all over the country. Now, one of the things that really disturbs me about this is it really also is a pernicious effect, a chilling effect on young people who might be thinking about a career in health care. I remember as a young man in high school and college thinking about what a great thing it would be to be a physician, to be worthy to serve the suffering, to serve my fellow man. Yeah, I expected to make some money doing it, but that wasn't the primary reason for going into the field. But, at the same time, I didn't face the kinds of student loans that the young individual today will face at the end of their 4 years of getting their BA degree, let alone the loans going through medical school, and then they have got to really defer earnings the years that they are in residency. Yes, they are paid something during residency, but nowhere near enough to pay the freight on those lines they have through undergraduate school and through medical school. Basically, we are talking about a person who may spend between 10 and 18 years after high school getting through all of their education and their training. Well, you think about that. Someone is graduating from high school and 15 years later some of his classmates have already built and sold a business and they are sort of semiretired. You give up. You postpone those active earning years by a decade, a decade and a half, and that is just one of the things that you expect when you take on a career in medicine. Well, young people are looking at that and saying, You know what? That postponement of my active earning years, and the Federal Government being so injudicious with what it is doing in the Medicare system, and that affecting other areas in the commercial aspect of medicine, maybe that is just something that I shouldn't do. Maybe I will do something else with my life, because that is a little iffy, and I don't really know if I will be able to afford the liability insurance to go into practice. So we have got to do something to help young people understand that we value, we value their service in becoming a physician or becoming a nurse, that this is something that we in Congress encourage them to do and want them to do. But right now I have got to tell you they look at it and say, I don't know if that is for me. One of the other things, and this has come up just in the last two weeks here in Congress, is we kind of worked with this concept of what are we going to do to make things right for the doctors before we get to the end of the year. Along comes this bill to require physicians to begin e-prescribing. Well, that is a good concept. Certainly, no one wants to argue with the theory. But it reminds me of an old professor I had in undergraduate school. When he was asked a question too tough for him to answer, he would look you back in the eye and say, Do you want the theory or the application? This is one of those instances where the theory is pretty good but the application, at least as has been discussed in the last two weeks, the technical term for it would be it stinks, Mr. Speaker, because we want physicians, we want them to come into the 21st century, we want them to use electronic medical records and things like e-prescribing. Any one of us can cite chapter and verse all of the good things that will come from e-prescribing; yet the number one group that we have got to get to buy into this concept, well, we don't treat them very well when we come at them with legislation, as the legislation that was brought out a couple of weeks ago over on the Senate side, but it's also been talked about over here on the House side, the so-called carrot-and-stick approach. We'll give you a little something nice now if you do it and, by golly, we are going to make you pay in a couple of years. The carrot-and-stick concept in this case really is more like, I don't know what vegetable I would associate with it, probably something more along the lines of spinach, or if we're talking about the first President Bush, perhaps broccoli. But the other end, the stick, is extremely onerous for physicians who are in practice. Let me just give you the very quick version of what this legislation, as provided to us, would entail. For doctors who participate in the Medicare system, we are so anxious for them to prescribe in the e- prescribing regimen, we are going to generously provide them an additional 1 percent, a 1 percent upgrade on what we provide in Medicare compensation. Well, Mr. Speaker, I don't remember exactly what I received for a moderately complex patient return visit. I am going to wage it was not as much as $50. But let's stipulate, because the math is easy, let's stipulate that that is a $50 reimbursement rate from the Medicare system. And a good physician who is practicing careful medicine and doing all the right things they are supposed to do as far as history taking, good careful physical exam, patient education after coming to a diagnosis and a treatment plan, you can probably see that patient in 15 minutes. So four an hour are what we are talking about, and we are talking about a physician generating, not making, but generating $200 in income for that hour they spend in their office seeing those four moderately complex return visit Medicare patients for which the Federal Government pays them the generous sum of $50. Now, if we add a 1 percent update to that, let's see, each patient, that is about 50 cents. So for that hour's work we are going to add $2 to the compensation for that physician. E-prescribing takes a little time. It takes some investment. It takes some time to learn. It is not something you can just pick up. It is quicker to scribble down a handwritten note. Now, no one may be able to read it, but nevertheless you have performed that record-keeping requirement, and it is much quicker to scribble down that handwritten note in the treatment plan and write out a prescription and rip it off and hand it to the patient. The reality is e-prescribing takes some time. It adds time to that patient encounter. It is time that realistically someone should compensate that provider for providing. That would be a fair assessment. Now, what do we do if, after three or four years' time, the doctors just haven't cottoned to this idea that we are going to pay them an extra 50 cents per patient on average to do this work for us? Well, then we come in with the stick phenomenon, and that will be a 10 percent reduction on that patient's services. So here we have gone from a $2 increase for those four patients for that hour's work, or, perhaps if the doctor hasn't done it, then that will be a $20 fine for those patients for that hour's work. Once again, our physician community is going to look at that and say, No, thank you. I don't think I will participate in that. You can keep your Medicare patients and you can keep your e-prescribing and I will go off and do something else, and the patient is the one that suffers. But it is a good concept. It is a good concept, and it is worthy of Congress spending the time, and it is worthy of Congress providing the proper compensation for physicians who are willing to invest in this technology. Right now, the bill as rolled out would provide $2,000 to buy the equipment. It probably costs $25,000 in reality. Even if you gave it to a physician's practice free, there is still going to be ongoing costs of the maintenance of the software, the ongoing costs of educating the physicians in that particular practice, and it takes longer to fill out that electronic medical record and to fill out that form for e- prescribing than what the doctors historically are used to in an old paper system. But we have decided that is not a value and we are not going to pay for that. Now, some people think that this is such a good idea because they are, in fact, going to make a significant amount of money. Certainly the people that sell the software are likely to make a significant amount of money. Certainly the pharmacy benefit managers, the big pharmaceutical mail-order houses, they are likely to reap some benefits from this. But for whatever reason, all of this good stuff that is going to come from e-prescribing, no one is really thinking that it is worthwhile to share that with the physician. But the physician is the one we want to buy into this new system. And it is a new system. It is a new way of learning and it is a new way doing things. Now, indeed, if nothing happens, younger physicians, as they go through their training, they will be exposed more and more to electronic prescribing and electronic medical records. There will come a time in probably the not-too-distant future where this evolution will just take place on its own. But the bill that was rolled out a couple of weeks ago was an effort to make it happen a little faster, to get some of those good benefits from e-prescribing, and they are significant, to get some of those good benefits out there and established early. Again, it is going to make a significant amount of money for some people who will be involved in this. But again, for whatever reason, the Federal Government does not see value in allowing the practitioner, the physician, to participate in that distribution of all of that value that we are going to derive from this system. Now, I don't mean to give the impression that I don't believe in e- prescribing and electronic medical records. Let me just go with one last poster, Mr. Speaker, and then we will wrap this up for tonight. I haven't always been a big believer in electronic medical records. Again, I have tried a couple of different systems in my time in private practice and I didn't find them all that intuitive or user friendly, but this is the day I became a believer in electronic medical records. This is the basement of Charity Hospital in New Orleans. Charity Hospital, one of the venerable teaching institutions in this country. Many of the professors I had at Parkland Hospital in the 1970s actually did their training in this very building at Charity Hospital. Charity Hospital in 2005, August of 2005, was ground zero for the strongest hurricane probably to ever hit the continental United States in anyone's memory. And the flooding that followed that hurricane obviously dealt a severe blow to infrastructure all over the City of New Orleans, and the basement of Charity Hospital was, in fact, underwater for a significant amount of time. So all of these records were submerged. This photograph was taken in probably October of 2005. So 2 months after the hurricane, a month, maybe 5 weeks after the city was dewatered, that is a verb I learned from the United States Corps of Engineers, I didn't know it was a verb before they used it, but the city was dewatered. Here the medical records sit. Now we have black mold growing on the manila folders. Probably the ink on many of these records was actually just washed off in the flooding. Who knows? It wouldn't be safe to have anyone go in there and look at those records, because look the at the mold spoors that are ready to be blown off in a big cloud waiting to be inhaled by a pair of unsuspecting lungs and cause great damage. So these medical records are in fact lost forever. And who knows what is in there, someone waiting for a kidney transplant, someone's hypertension that has been under treatment for two decades; someone's diabetes that was carefully monitored but not so much anymore. All of these records have been lost forever. Electronic medical records and medical records that are then controlled in an electronic fashion in a secure fashion up on the Internet where they can be accessed, all of these patients that had to leave the city. Many came to the Metroplex area in north Texas, and many of them were cared for by physicians at Parkland Hospital, John Peter Smith Hospital, and private physicians in the area. None of their medical records were available, and many of these patients had very complex medical conditions and were on multiple medications at the time. And if it had not been for the good graces for some of the pharmacies that actually had patient records electronically that were able to set up outside some of the triage centers to provide that data to physicians who agreed to see these patients as they came off of the transportation from New Orleans and arrived in Dallas, you can construct a pretty good medical history just going to the pharmaceutical history, and those pharmacy records were invaluable in providing good care and immediate care to those patients. But it certainly made a believer out of me in January, or when this picture was made after the flooding in New Orleans that paper records have inherently within them a fundamental flaw, and that is, in time of great natural disaster they are not going to be there to provide useful information for those patients if they are suddenly displaced, as these patients were, the medical records themselves. They could have been destroyed in a fire, they could have been damaged in an earthquake in some other parts of the country. And, unfortunately, these types of tragedies do happen, and electronic medical records does take some aspect of that tragedy away because it does provide a way for that record to be accessed in a different location, and all of that data can be pulled off the Internet and be made available to the now receiving physician who is treating that patient. Mr. Speaker, a little preventive medicine would go a long way in this entire Medicare policy debate. I just can't help but note the irony: November 1, when the Center for Medicare and Medicaid Services came out and said, Doctor, 10.1 percent cut, unless Congress does something before the end of the year. About that same time, the conference Chair on the majority side had an op-ed in The Washington Post that said, you know what, we have done such a good job with providing government health care and Medicare and we are doing a great job now with what we are doing in SCHIP. We know how that has turned out so far. We want to extend Medicare benefits to people who are down to the age of 55. We want to drag and drop this population into what is happening in the Medicare policies right now. I would just argue, before we expand the program to that degree, shouldn't we ask ourselves are we doing a good job with what we have right now. I think the mere fact that we are here at the 11th hour of this Congress and we have not dealt with the problem of physician compensation, doctors' offices across the country are looking at Congress and saying, what gives, guys? How am I going to prepare for next year? Do I hire that new doctor or not? Do I buy that piece of medical equipment or not? Do I take out a loan to improve my office or not? Because they don't have any certitude about what the activity of this body is going to be. And even at the best, the best we can do at this point is say we are going to punt for 6 months, and we will see you in June. Mr. Speaker, that is not acceptable. This Congress has an obligation to this country's physicians to behave in a responsible way. And certainly, certainly let's quell the talk of expanding the reach and grasp of the Federal Government until we take care of what we already have. Mr. Speaker, I yield back the balance of my time.