Michael Burgess

Mr. BURGESS

Mr. BURGESS. Mr. Speaker, I reserve the balance of my time.

Mr. BURGESS. Mr. Speaker, I yield 3 minutes to the gentleman from Georgia (Mr. Deal), the ranking member on the Health Subcommittee.

Mr. BURGESS. Mr. Speaker, I yield myself such time as I may consume. Before he leaves, I want to thank Chairman Dingell for his willingness to work with the minority side on this. We had a lot of give-and-take, both at the staff level and certainly at the subcommittee level and the full committee level, and for that I am grateful. I think this is a good piece of legislation, and I think it was improved by the work of the staff, both on the majority and the minority side, and I think it was improved by the committee process as we worked this bill through committee. I am pleased to support H.R. 2900, and this bill, of course, will improve the drug and medical device safety approval by the FDA. Over the past several weeks, members of the Energy and Commerce Committee, both Republican and Democrat, have come together to hammer out a bill that will ensure that the American people can rely on the decisions made by the Food and Drug Administration, that their drugs are safe, and that regulatory requirements don't overly infringe on innovation or sound clinical practice of medicine. H.R. 2900 will achieve several goals, such as providing additional resources to the Food and Drug Administration to improve premarket drug and device approval, create new postmarket surveillance authorities, enhance clinical trial transparency and data mining, and ensure the adequacy of pediatric studies for drugs and devices. I would like to thank, again, Chairman Dingell and Chairman Pallone for working with our Republican staff to improve this legislation before we convened the markup, and of course during the process of the markup, again, both at the subcommittee and at the full committee level. I'm pleased that we were able to modify the Direct to Consumer Advertising provision to protect this bill from a constitutional challenge, Mr. Speaker, and in a manner relying on the existing Food and Drug Administration regulatory standards. In regard to pediatric exclusivity, the committee was able to find a workable standard as opposed to the original proposal that would have required the Food and Drug Administration accountants to post a lot of overtime in their jobs. I'm also pleased with regard to one of my concerns about how the new postmarket surveillance regime would impact the independent practice of medicine. I'm pleased that Mr. Waxman, Mr. Pallone and Dingell and their staffs worked with me to improve the language relating to the restrictions on distribution and use pursuant to elements of a drug's risk evaluation and mitigation strategy. Certainly, Mr. Speaker, it was not the intent, or I did not feel it was the intent of our legislation to be circumventing clinical judgment of trained and experienced practitioners. The original language threatened clinical decision making that is both lawful and based on scientific evidence and sound medical opinion, but I'm pleased that it has been tempered by the concerns that I raised to the above-mentioned gentlemen. One issue that I hope we will continue to work on as this bill moves toward conference committee relates to the provision on conflicts of interest. The Food and Drug Administration advisory panel serves a vital science function when it comes to the approval of drugs and devices. I believe that we should strive to weed out any conflicts of interest for those that serve on these panels. But in reality, Mr. Speaker, that is easier said than done. The standard established in this bill, limiting panels to one waiver for a conflict of interest, could severely impair the Food and Drug Administration's advisory panel process, especially for panels convened to review drugs or devices targeted at very small patient populations, such as those with very rare diseases. For drugs or devices that would fall into these categories, it can be extremely difficult to find sound scientific experts. This irrational standard will only make it harder to perform that function. Moving forward, I hope we can find and strike the acceptable balance. It has already been shown that our collaboration on this endeavor has produced better legislation. I hope we continue that as the process moves forward. Mr. Speaker, I reserve the balance of my time.

Mr. BURGESS. Mr. Speaker, I am expecting additional speakers, but at present, I will reserve the balance of my time.

Mr. BURGESS. Mr. Speaker, I yield myself such time as I may consume. Number one, my understanding is as we took this bill through the subcommittee and committee that we accepted legislative language on an amendment that would provide for a reverse trigger so that if the gentleman and other appropriators want to provide more money for the evaluation of new drugs and devices, the actual contribution from the user fees will decrease. After all, it was a Democratic Congress in 1992 that began the first Prescription Drug User Fee Act, and the reason for that legislation was because it simply took too long to get drugs and devices through the regulatory maze. And as a consequence, practicing physicians such as myself were denied access to life-saving medications for their patients. So the Democrats in the early 1990s improved the process by adding the prescription drug user fees, but we would all be happy with the appropriators if they would step up to the plate and appropriate the correct amount of money. Additionally, let me just point out that consumer groups and patient groups actually are going to be involved in the negotiations for the next prescription drug user fee authorization. That is language that was brought to us, I don't remember by which side, but it was an amendment that was accepted by the full committee. So, Mr. Speaker, although there are concerns expressed by the gentleman who just spoke, the reality is many of those things were actually addressed through the committee and subcommittee process. I will speak a little further on the conflicts issue as I do my closing remarks on this bill, but Mr. Waxman so eloquently spoke about how unfortunate it was we stripped out an Institute of Medicine recommendation in his previous remarks. The reality is that the Institute of Medicine recommended that waivers be available for up to 40 percent of FDA panels. Those are the individuals who are the exerts and who understand what these compounds can and cannot do. Mr. Speaker, I recognized throughout the committee process that I had a responsibility as the only member on the committee on either side who had ever picked up a pen and written a prescription for a patient, who had ever sat down face to face with a patient and talked about benefits and potential risks from medications, and who had ever talked to a patient about the cost of their medication. I think this legislation was well crafted and well worked up between both sides as we went through the committee process. Mr. Speaker, I reserve the balance of my time.

Mr. BURGESS

Mr. BURGESS. I'm happy to yield to my friend from Pennsylvania for a few minutes and give him time to talk.

Mr. BURGESS. Mr. Speaker, this evening, I wanted to come to the floor of the House to talk once again a little bit about health care. Health care in this country is going to be something that is on the front pages during the next 18 months until the next Presidential election, I suspect, and something we're going to devote a great deal of time and energy to on the floor of this House, perhaps even this month. As we debate the future of medical care in this country over the next 18 months and through the Presidential election that will follow in 2008 and the Congress that convenes in 2009, we've got to decide on the avenues through which our health care system will be based. And essentially, Mr. Speaker, right now we have a system that is based part on the government, part on the public sector, and partly on the private sector. The issue before us is, do we expand the public sector? Do we expand the government's involvement in health care? Do we expand the government's involvement in the delivery of health services, as popularly referred to as universal health care, and back in the 1990s, it was termed ``Hillary care,'' or do we encourage and continue the private sector involvement in the delivery of health care? The two options bring about a significant number of questions and a significant number of concerns addressed on both sides of the aisle. But I'm hopeful that as we continue to study this problem and debate this problem in this body, we will shed some light on the direction that we should be taking. And Mr. Speaker, I don't think there is any question that the United States has developed one of the best health care systems in the world. Access can be an issue, but the quality of health care practiced in this country is second to none. You have people coming from all over the world. When I was a medical student at the Texas Medical Center down in Houston, Texas, you would have people coming from all over the word to avail themselves of the medical care that was available at Texas Medical Center. And close to my district in north Texas, you have Southwestern Medical School in Dallas, a number of Nobel Laureates on the clinical faculty there. Unbelievable sources of talent and knowledge that are available to training the young physicians of tomorrow. So these are the types of things we've got to be certain that we preserve, protect and defend as we do things that will perhaps alter the way medicine is practiced in this country. Now, there are a lot of people who take issue with the fact that I maintain that the United States has the best health care system in the world. Plenty of people here in this body would say that's an overstatement. They would say, you've got a large number of uninsured people in this country, or prescription drugs cost way too much. The issues are there, but you know what, Mr. Speaker? The old saying is that numbers don't lie, but if you torture them long enough, they'll admit to almost anything. We've got to dispense with a lot of the platitudes and the soundbites and try to get to really what is causing the problems that we have here, and how can we best go about correcting those problems? Well, how about applying some American ingenuity to getting those problems solved. So, tonight, in talking about the different principles that guide the debate about public versus private in the delivery of health care services, it's important to concentrate a little bit on the background on how we got to the system that we have today. The idea that we have a problem to solve is not new. Secretary Leavitt, I certainly agree with him when he made the remarks in a speech not too long ago that tackling the division between the two philosophies, public versus private, recently the Secretary said in a speech and in an op-ed piece, he posed the question, should the government own the system, or should the government be responsible for some organization in the system and leave the proprietary standpoint to someone else? Mr. Speaker, during World War II, this country was faced with some significant problems, and one of the problems was the specter of inflation. So Franklin Roosevelt said, look, we're going to have wage and price controls in this country so that inflation doesn't get out of control. Employees found themselves highly sought after because a lot of the workforce was overseas fighting the war. Employers wanted to keep their employees happy. They wanted to keep them employed. They wanted to keep them loyal to their respective companies, but they were unable to raise wages because there was a Presidential decree that we were under wage and price controls. So the Supreme Court rendered a decision that benefits, things we talk about now as a benefits package, health care, retirement, these things could be available and would not violate the spirit of President Roosevelt's wage and price controls. Thus, the era of health insurance benefits or employer-derived health insurance was born. And Mr. Speaker, it worked tremendously well, so well that it persisted well after the end of the Second World War. Now, a lot of people will look at Western Europe and say, they've got a government-run system. Why don't we do what Europe did? How did Europe develop a system, a single-payer, government-run system? Even though some of the countries in Western Europe were victorious at the end of the Second World War, the war was fought in their back yard; their economies were devastated. It was important for their governments to stand up a medical care system quickly to avert a humanitarian crisis. That is what led to the institution of single-payer systems that you see in many countries in Europe today. But America, by contrast, came through the war with a benefits package, if you will, that was available to employees. Employees like it. Employers liked it because the employees were happy. The employees stayed, to some degree, healthier and were able to work more effectively and less time off for sick leave. So the American system persisted and did very well for a number of years. Now, fast forward some 20 years from the end of the war to the middle of the administration of Lyndon Johnson, fellow Texan, fellow House Member, albeit on the other side of the aisle, but during the tenure of President Johnson, he signed both the Medicare and the Medicaid programs into law. This was a large government program and represented a fundamental shift. It was the first time that the government got involved in a big way in running the practice of medicine. But it was created to focus on the elderly, to focus on their hospital care and their doctor care, and certainly make sure that persons who were then to be covered by Medicare weren't left in poverty in old age because of mounting medical bills. But then fast forward another 40 years to the 108th Congress, and we had the Medicare system that was big and expensive and was very, very slow at change. It was like trying to turn a battleship. In 2003, in this House of Representatives, the President came to us, in the very first State of the Union message that I attended as a Member of Congress in my first term, and the President said he was going to, or this Congress was going to bring a Medicare prescription drug benefit to Medicare, that people had waited too long for this; it was too important to wait for another President or another Congress. And indeed, Congress set about the work of providing what we now know as the Part D benefit. And within the year, we voted on that package, and within the next year, it was, indeed, starting to be run. But the government system needed to address some of the inefficiencies that were built into the system. Now, the Medicare prescription drug plan has given seniors access to medications that, quite frankly, they just didn't have available before. And when you look at how medicine has changed from 1965 to 2005, when the Medicare drug plan took effect, the changes that had been brought about by the advances in medical research, my dad was a doctor as well, and I used to tease him that, back in 1965, doctors only had two pharmaceutical choices, penicillin and cortisone, and they were regarded as interchangeable. My dad didn't think that was very funny. But the fact is, you come to 2005, look at the lives that have been saved by the introduction of a medicine like statin, medicines that are used for reduction of cholesterol. Dr. Elias Zerhouni of the National Institutes of Health estimates that 800,000 premature deaths have been prevented between 1965 and 2005 with the introduction of medicines to manage cholesterol and lipid levels in patient's blood. That's a tremendous change. In 1965, some people simply had the heart attack and died. In 2005, 2007, that no longer happens. But they are required, in order to maintain that state of health, to be maintained on a medication. Well, if the medicine is too expensive for the patient to buy, they don't take it, and they suffer the health consequences. And as a consequence, the system becomes more expensive because people end up utilizing the system more frequently and the outcomes for disease management become much worse. The Medicare Prescription Drug Program has been successful. There have been a certain number of people who have been critical, but it has been a great benefit for seniors. And the fact that it is up and running now well into its second year, there is a great deal of satisfaction, and the penetrance into the number of people who have had prescription drug benefits who are covered by Medicare is now at an all-time high. Now, in this country, as I mentioned earlier, the government pays for about half of our health care expenditures. We have a GDP of roughly $11 trillion in this country. The U.S. Department of Health and Human Services states that Medicare and Medicaid services alone, in fact when we vote on our Labor-HHS appropriations bill this year, it will be significantly north of $600 billion. So that is about a half of what we spend in health care. The way the other half is broken down, primarily the weight is borne by commercial insurance, by private insurance. There is a significant number of dollars that are contributed as charity care or uncompensated care. Certainly there are some individuals who do still simply just pay for their medical care out of pocket, but about half are from the Government source and half from private sources or the goodwill of America's physicians. The numbers are going to increase because the overall dollar expenditure in health care is going to increase. The baby boomers are aging. There are more and more advances discovered with every passing month. The Federal Government is going to continue to funnel taxpayer dollars into Medicare. We have to ask ourselves, are we getting value for the dollar? Are we doing the best that we possibly can do with that money? Is the government doing an excellent job of managing our health care dollars? Do we think that the government is better suited to be the arbiter of a person's health care needs, or are those decisions better left up to an individual and their family? And who, at the fundamental end of it all, who is better able, who is going to be able to handle the growing health care needs in this country? I would argue that if you have a public only, a government-run system, a universal, single-payer system, that in America it is going to be a significant problem. In fact, it will have the perverse incentive of hampering our innovation and perhaps even hampering the delivery of the most modern health care services available. As an example, I would suggest that we have a model that we can examine, and that is our neighbor to the north in Canada. Canada has a completely government-run system. The Supreme Court in Canada in 2005, however, said that the waiting times in Canada were unconscionable and access to a waiting list did not equate to the same thing as access to care. Now, in Canada they actually have a safety valve, because if somebody needs a medical procedure or needs a medical test done, they actually do have an area where there is a surplus of medical care available, and that would be on their southern border, the United States of America. So if somebody has the ability to pay and wants to come from Canada and cross the border to Henry Ford Hospital in Detroit, they are very capable of doing that. I am certain that the good folks at Henry Ford Hospital welcome their neighbors from Toronto all the time to sell essentially excess capacity that they have, whether it be an MRI or a CT scan or even a mammogram, heart surgery, or an artificial hip. The things that are on the waiting list in Canada that might take months or even years can be accessed relatively quickly simply by crossing the border. The waiting list is significantly long for some procedures. If we look across the ocean to the country of Great Britain, the National Health Service, of course, has long been established in Britain. The citizens of that country regard their health system with a good deal of affection. But there is, in fact, a two-tier system in England. If someone is on a list for a hip replacement and has the money to pay for it, they can go outside the system to a private orthopedic physician and have that surgery performed. Obviously, someone who doesn't have the means to provide that for themselves will simply have to stay on the waiting list. You get into a little trouble with the fact that when it takes so long, if someone is of a certain age, another year or two wait is a significant percentage of their remaining expected life years. In many ways that is not fair either. A sad reality that exists, but it is true. So, in both instances, you can see that where the single-payer, government-run system has been oversubscribed, where they have a private system, either here in the United States for the country of Canada or a two-tiered system in the country of Great Britain, they have a private system to act as a backstop. So, the question that I would ask is, if the private sector is more nimble and more able to provide care on a timely basis, why in the world would we do anything that would interfere with that system? It is a complex relationship. How Congress does its job and how we react to the situation can, in fact, have a significant impact on making sure that we have the best health care possible. Certainly I think it is incumbent upon Congress to promote policies that keep the private sector involved in the delivery of health care in this country. Now, you almost can't talk about health care in this country without talking about the problem of the uninsured. Regardless of the number you use, whether it is 42, 45 or 46 million, it does become a question of access for people without insurance. But I would also point out that health care is rendered all the time in this country to people who don't have insurance or don't have the means to pay for it. It is not always rendered in the time frame that would be most propitious for the best health outcome, and certainly it is not always administered in the time frame where it is the least expensive type of care, but access to care in this country is, in fact, something that is generally available. But it can become very expensive and the time involved can be significant. Now, we have a program in this country. It is about to turn 10 years old. In fact, it is a program that we have to reauthorize this year or it will expire at the end of September. This is a program that provides health insurance for children whose parents earn too much money for them to qualify for Medicaid and not enough money to purchase health insurance. So we have the SCHIP program that operates as a joint Federal-State partnership. It does provide some flexibility to States to determine the standards for providing health care funding for those children, again, who are not eligible for Medicaid and whose parents have not been able to get private insurance. The program has been very well thought of. It has been very successful across the board. This year, in fact, before September 30, we have to reauthorize the State Children's Health Insurance Program. There is going to be a lot of debate. I suspect there will be a lot of debate this month. Certainly, in my Committee on Energy and Commerce and the Committee on Ways and Means, there will be a lot of debate on the best way to go forward with that. One of the things I have had a problem with since coming to Congress and examining the SCHIP system is the fact that it is a program that was designed to cover children, but, in fact, we have some States that cover adults. Pregnant women, okay, it is reasonable to have them covered under the SCHIP system. But nonpregnant adults, it strains credulity to have a system that is there to provide health care for children, and in four States in this country we actually have more adults covered under the SCHIP program than we do children. Certainly, where you have a State where all of the uninsured children have been covered by the SCHIP program, it may be appropriate to cover some adults. But until that trigger point is met, until that condition is met, to me it makes less sense to cover adults, when there are children who would benefit from having the coverage from the State Children's Health Insurance Program, to have them remain uncovered while we cover a population where the money was never intended to be used for that purpose. A bill that I introduced, H.R. 1013, would make certain that SCHIP funds are spent exclusively on children and pregnant women and not on any other group. I hope to be able to have that concept considered when we go through the reauthorization of the SCHIP program. Last year in Congress we also debated and got through the committee process the reauthorization for Federally Qualified Health Centers. We did not finish the work on that legislation, so we are likely to have to take that up again this year. But about someone who is not a child, not a pregnant woman, who doesn't have access to health insurance, there are many places in the country where Federally Qualified Health Centers exist that give the patients access to health care without insurance; gives them a medical home, gives them continuity of care, a place they can go and see the same health care providers, whether it be a physician or nurse practioner, can see that person over and over again; provides primary health, oral and mental health and substance abuse services to persons at all stages in the life cycle. Federally Qualified Health Centers take care of 15 million people in this country every year, typically someone who does not have insurance and so would be counted as one of the uninsured, but the reality is that they do have access to the continuity of care, just as someone who has insurance. Both the SCHIP program and the Federal Qualified Health Centers are designed to help the poorest, youngest and neediest in our communities. But what about for individuals who can afford to pay some for their health services but just choose not to? We need to get past that point, and certainly there are two things that would improve the access to health insurance for people who do have the ability to pay something for their health care, health savings accounts and health association plans. Health savings accounts are a tax-advantaged medical savings account available to taxpayers who are enrolled in a high-deductible health plan, a health insurance plan with lower premiums and a higher deductible than a traditional health plan. In the old days we used to refer to this as a catastrophic health plan. Now, about 1996 or 1997, long before I ever thought about running for Congress, I was a physician in practice back in Texas. The Kennedy- Kassebaum bill was passed by the House and Senate and signed into law. It had in it what was called a demonstration project that would allow 750,000 people in the United States to sign up for at that time what were called medical savings accounts. I subscribed to one of those. I purchased one of those for my family. The primary reason I did it was not even so much cost considerations but because it kept me in control of making health-care decisions. Those were the days when HMOs and 1-800 numbers were the order of the day, and I wanted to be certain that the health care decisions made in my family were made by my family and not by a bureaucrat or an insurance executive at the end of a 1-800 number. The medical savings account proved to have a lot of restrictions on them. For that reason, a lot of people shied away from them. So I don't know that they ever got to their full enrollment of 750,000, but to me it was another very viable form of insurance. Again, the premiums were lower because the deductible was higher, and you were able to put money into an account like an IRA, called a medical IRA, that would grow tax-free. The interest in it would grow tax-free year over year. This money could be used only for legitimate medical expenses, but if you found yourself in a situation where you needed to pay for medical care, yes, you had a high deductible, but now you have saved some money that can offset the high deductible. When the Medicare Modernization Act passed in 2003, we also did away with a lot of the regulations and restrictions on medical savings accounts, and the follow-on for that are what are called health savings accounts or HSAs. For an HSA, the funds contributed to the account are not subject to the income tax and can only be used to pay for medical expenses. But one of the best parts about having an HSA is that all deposits stay the property of the policyholder. They don't go to the insurance company. They don't go to the government. They stay under the control and ownership of the person who has put those funds, regardless of the source of the deposit. So even if an employer makes a contribution to that, the funds belong to the person who owns the insurance policy. Additionally, any funds deposited that are not used that year will stay in the fund and grow year over year, different from the old use-it-or-lose-it programs that were so prevalent and popular during the 1990s. The popularity of health savings accounts has grown considerably since its inception. The latest numbers I have are, unfortunately, a couple of years old. They are from 2005. But by December of that year, 3.5 million people had insurance coverage through an HSA. Of that number, 42 percent of the individuals are families who had income levels below $50,000 a year and were purchasing an HSA type of insurance. Additionally, about another 40 percent were individuals who previously had not been insured. So this allowed a way for people who were previously uninsured to access insurance. A good number of those folks were between the ages of 50 and 60, taking away some credence to the myth that HSAs are only for the healthy and wealthy. These programs have been well-subscribed. Again, the numbers that I have are from 2005. I suspect they are much more robust at this point. Well, when you consider a young person just getting out of college, roundabout age 25, if they don't want to go to work for a major corporation and therefore have employer-derived insurance, what are their options? I will tell you, 10 years ago, you didn't have many options. In fact, I tried to purchase a health insurance policy for an adult child just in that situation. You almost couldn't get an insurance policy for a single individual, regardless of the price you were willing to pay. Fast forward to 2005 or 2007. You can go on the Internet, type ``health savings account'' into the search engine of your choice, and very quickly you will be given a plethora of choices from a variety of different health plans. In my home State of Texas, a male age 25 looking for health insurance can find a high-deductible PPO plan from a reputable insurance provider for between $60 and $70 a month. So that is eminently affordable. Sure, there is a high deductible involved with that. That means every fall, if you go get a flu shot, you are probably going to pay for that flu shot out-of-pocket, or if you have money in your health savings account, you can make a draw on that. So that type of expense is not going to be covered, but if that individual is in an accident and ends up spending 3 or 4 hours in the emergency room and a day in the intensive care unit, they will be covered because those expenses will rapidly exceed their deductible. That individual will be covered with health insurance. That is a concept that we need to make people aware of, that there are options. Even though you may work for a company that doesn't provide insurance or you are self-employed and are a small group and otherwise would not have access to employer-derived health insurance, the concept of a health savings account is available and marketed over the Internet, and there is a lot of competition for those products. As a consequence of that competition, the price on those has come down in the years since they were introduced. Mr. Speaker, another concept that we have debated in this House at least every year I have been here is the concept of association health plans. Association health plans allow small employers to band together to get the purchasing power of a larger corporation when they go out and price insurance on the open market. To date, we have passed that legislation four times that I can recall in the House of Representatives. It never passed in the Senate. I would like to see us take up and at least discuss that as a possibility this year. I don't know in fact if that will happen. But association health plans may not bring down the number of uninsured directly, but it certainly would help bend the growth curve that is going upward of the number of people not covered by insurance because it allows for small employers to get access to much more economic leverage in the market for buying insurance policies and allows them to be able to offer that insurance policy to their employees in the small group market. It means that a group of perhaps Chambers of Commerce or a group of realtors could band together and offer health insurance to their employees where otherwise it might not have been available. All of these things are important. Another factor to consider, and we have to be careful here, about a year and a half ago, Alan Greenspan was talking to us just before he left his position at the Federal Reserve. Someone brought up the topic of Medicare, and where is the funding going to come from? Mr. Greenspan said he was confident at some point in the future Congress will come to grips with this problem and will solve this problem. But he went on to say what concerns me more is, will there be anyone there to provide the service when you require it? Those words really struck me. What he is talking about, are there going to be doctors there in the future? Are there going to be nurses in the future to provide for us when we are the ones who are relying on Medicare for our health services? Back in my home State of Texas, the Texas Medical Association puts out a journal called Texas Medicine, and last March they had a special issue called, ``Running Out of Doctors.'' Our country faces a potential crisis with a health care provider shortage or a physician shortage in the future. So when we work on health care issues in this body and on both sides of the aisle, this is going to be important; when we work on health care issues in Congress, we have to be is certain that we retain the doctors of today, that we encourage the doctors who are in training today, and that we encourage those young people who might consider a career in health care, that we encourage them to pursue that dream and realize that dream. Certainly the doctors of today, those at the peak of their clinical abilities, it is incumbent upon us to make certain that they remain in practice and they continue to provide services, services to our Medicare patients and services to patients who typically have one, two, three or more medical problems. Some of the most complex medical issues that can face a practitioner today will occur in the Medicare population. Well, what steps do we need to take to make certain that we have doctors in practice, that we have people there able to deliver those services that Alan Greenspan was talking about a year and a half ago? Well, Mr. Speaker, you almost can't have this discussion without talking a little bit about medical liability. Now, in the 4 years prior to this Congress, every year, again, we passed some type of medical liability reform bill in the House of Representatives. It never got enough votes in the Senate to cut off debate and come to a vote. I feel certain it would have passed had it come to an up-or-down vote, but they were never to muster the 60 votes. We need commonsense medical liability reform to protect patients, to protect patients' access to physicians, to stop the continuous escalation of costs associated with medical liability in this country. And in turn, this makes health care more affordable and more accessible for more Americans because we keep the services available in the communities as they are needed, when they are needed. Mr. Speaker, I believe we need a national solution. Our State-to- State responses to this problem, some areas, like my State of Texas, have gone a long ways towards solving the problem, but there are many areas in the country where the problem persists, and it does remain a national problem. We have an example, I think a good example, in my home State of Texas of exactly the type of legislation that we should be considering in the House of Representatives. Texas, in 2003, brought together the major stakeholders in the discussion, included the doctors, patients, hospitals, nursing homes, and crafted legislation that was modeled after the Medical Injury Compensation Reform Act of 1975 that was passed in California in 1975. There were some differences with the California law, but basically it is a cap on noneconomic damages. In Texas, we had a significant problem as far as medical liability was concerned. We had medical liability insurers that were leaving the State. They were simply not going to write any more policies. They closed up shop and left town because they couldn't see a future in providing medical liability coverage in Texas. We went from 17 insurers down to two at the end of 2002, the year I first ran for Congress. The rates were increasing year over year. Running my own practice in 2002, my rates were increasing by 30 to 50 percent a year. In 2003, the State legislature passed medical liability reform, again based on the California law of 1975. The California law in 1975 was also a cap on noneconomic damages. They had a single cap of $250,000 on all noneconomic damages. In Texas, the cap was trifurcated. There was a $250,000 cap on noneconomic damages as it pertains to a physician, a $250,000 cap on noneconomic damages as it pertains to the hospital and a $250,000 cap on noneconomic damages as it pertains to a nursing home or a second hospital; so an aggregate cap of $750,000 on noneconomic damages. How has the Texas plan fared? Remember, we had gone from 17 insurers down to two because of the medical liability crisis in the State. Now we are back up to 14 or 15 carriers. And most importantly, those carriers have returned to the State without a premium increase. In 2006, 3 years after the passage of the medical liability reform, an insurance company called Medical Protective, I had a policy with them for years and years, Medical Protective company cut their rates 10 percent, which was the fourth reduction since April of 2005. Texas Medical Liability Trust, my last insurer of record when I left practice in Texas, has had an aggregate cut of 22 percent since the law was passed. Advocate MD, another insurance company, has filed a 19.9 percent rate decrease. Another company called Doctor's Company has announced a 13 percent rate cut. These are real numbers, and they affect real people in real practice situations in Texas. It is a significant reversal. The year when I first came to Congress, we lost one-half of the neurosurgeons in the metroplex because of the medical liability expense problem. The doctor looked at the renewal bill and said, I cannot work enough to pay for this and pay for my practice and support my family, so I will go elsewhere. The net effect is it put the whole trauma system in north Texas at risk because one neurosurgeon was going to have to do the work of two, and you cannot physically work 24 hours a day, 7 days a week, delivering that type of care. So the whole trauma system was put at risk before this law went into effect in Texas. A young perinatologist whom I met during my first year in office, had gone on and gotten specialized training to care for those high-risk pregnancies, well, you can imagine what his medical liability premiums were. Mine were high as an obstetrician. His were even higher as a perinatologist who specialized only in high-risk cases. And, in fact, at a lecture in Texas, he came to me and said, you know, I am going to have to leave the practice of medicine altogether because I simply cannot get insurance. Well, how are we furthering the cause of patient care if we take a young person who is very dedicated to taking care of the highest-risk pregnancies in the metroplex and we say, sorry, you can't practice because we can't get you insurance anywhere. Happily, in Texas, that situation reversed, and that doctor, I know, is in practice. The problem with the neurosurgeon, because of the straightening out of the insurance in Texas, has been reversed. Our trauma system is protected, as is the young man who is practicing high-risk obstetrics and saving babies even as we speak. One of the unintended beneficiaries of the legislation was the benefit for community, small, mid-sized community not-for-profit hospitals who were self insured as far as medical liability was concerned. They had to put so much money in escrow to cover potential bad outcomes that that money was just tied up, and it was not available to them. Now they have been able to back some of that money out of escrow because of putting stability into the system with the cap on noneconomic damages, and now they are able to use that money for capital expansion, nurses' salaries, exactly what you want your small community not-for-profit hospitals to be engaged in. They can, once again, participate in those activities because of the benefits from the medical liability plan that was passed in Texas. So, Mr. Speaker, I took the language of the Texas medical liability plan, worked with legislative counsel and made it so it would conform with all of our constructs here in the House of Representatives. And although I didn't introduce that legislation, I offered it to the ranking member on our Budget Committee last spring when we offered our Republican budget here on the floor of the House. Mr. Ryan, the ranking member, had that scored by the Congressional Budget Office, and the Texas plan as applied by the House of Representatives legislative counsel and applied to the entire 50 States would yield a savings of $3.8 billion scored over a 5-year time span. That is not a mammoth amount of money when we talk about the types of dollars we talk about in our Federal budget, some $2.999 trillion, but $3.8 billion over 5 years is not insignificant. And it is basically money that we left on the table because we did not include the language of that medical liability reform in the budget that was passed this year. Now, when I say the problem, although the problem in Texas is measurably better than it was when I took office here, consider a 1996 study done at Stanford University that revealed within the Medicare system alone the cost of defensive medicine, that is medicine that you practice so that you tone the chart and you look good if something goes wrong and the case is brought to trial; if you have practiced satisfactory defensive medicine, you will be able to defend yourself in the case of a medical liability suit. A couple of doctors and economists at Stanford got together and said, what does this cost Medicare? What does it cost for doctors to practice this type of defensive medicine? And it cost about $28 billion a year back in 1996. I would submit that the number is probably higher today if they were to revise and redo that study. So that is a significant amount of money, and the Medicare system is the one that pays for that. Remember, Medicare runs about $300 billion a year. That's almost 10 percent of its budget that is being spent on defensive medicine because of the broken medical liability system we have here in this country. We can scarcely afford to continue on that trajectory that we're on with the medical liability system in this country. Another consideration, Mr. Speaker, I talked a little bit about young people who are perhaps considering a career in medicine or nursing, and the current medical liability system is a deterrent for going into the practice of health care because they look at the burden that's placed on young doctors and nurses for the payment for medical liability insurance, and we keep people out of the system and it's something we have to consider because, again, remember, we're talking about physician workforce issues and how we keep the doctors of today in practice, but how do we encourage that young person who's in middle school or high school today who's thinking about a career in one of the health professions, and we want them to be able to pursue that dream. But currently, they get to the end of college and they look at the expense for getting medical training, they look at the money they will have to put up front to purchase their medical liability policy when they get out, and they say maybe it's not worth it. And the problem, Mr. Speaker, with that is these are our children's doctors and our children's children's doctors who perhaps are not going to go into the healing professions because of problems within the medical liability system. I could talk about that a great deal longer, but let me get to three specific pieces of legislation that really get to the core of dealing with the physician workforce issues and I think the problems that we're going to face in the future if we don't get our arms around this problem. A recent piece of legislation that I introduced is H.R. 2584, the so- called Physician Workforce and Graduate Medical Education Enhancement Act of 2007. Part of this legislation is to ensure this workforce in the future by helping young doctors with the availability of residency programs. One thing about physicians is we tend to have a lot of inertia. We tend to go into practice where we did our residency. We tend to not go too far from home when it comes to setting up a medical practice. So with that in mind, and in fact, that was one of the main thrusts of the article that was included in Texas Medicine, is to develop more residency programs in the communities where the medical need is greatest and develop those residency programs with the type of physician that's needed in those medical communities: primary care to be certain; obstetrics to be certain; general surgery; again, the types of physicians that we want to be on the front lines practicing in our medium-sized communities. We need to get young doctors in training in locations where they're actually needed. This bill, the physician workforce bill, would develop a program that would permit hospitals that do not traditionally operate a residency training program the opportunity to start a residency training program and build a physician workforce of the future and build it from the ground up, start at home, start right where it's going to be needed. On average, it costs $100,000 a year to train a resident, and that cost for a smaller hospital obviously can be prohibitive. Because of the cost consideration, my bill would create a loan fund available to hospitals to create residency training programs where none has operated in the past. The program would require full accreditation and be generally focused in rural suburban inner community hospitals and focus on those specialties that are in the greatest need, and that will, of necessity, be some of the primary care specialties that I just mentioned. Well, what about those people who may not yet be in medical school but may be contemplating a career in health care? Locating young doctors where they're needed is just part of solving the impending physician shortage crisis that I think will affect the entire health care system nationally. Another aspect that must be considered is training doctors for high-need specialties. The second bill, H.R. 2583, the High Need Physician Specialty Workforce Incentive Act of 2007, will establish a mix of scholarship, loan repayment funds and tax incentives to entice more students to medical school and create incentives for those students and newly minted doctors to stay in those communities. This program will have an established repayment program for students who agree to go into family practice, internal medicine, emergency medicine, general surgery or OB/GYN and practice in a designated underserved area. It will be a 5-year authorization at $5 million per year. It will provide additional educational scholarships in exchange for a commitment, a commitment to serve in a public or private non- profit health facility determined where there's a critical shortage of primary care physicians. Well, in addressing the physician workforce crisis, looking a little bit at residency programs, looking a little bit at medical students and, of course, medical liability but the placement of doctors in locations of greatest need and the financial concerns of encouraging doctors to remain in high-need specialties, the next bill, H.R. 2585, will address perhaps what is the largest group of doctors in this country, what I like to call the mature physician, and certainly the largest and still growing group of patients, our baby boomers, those who are just on Medicare and those soon to be on Medicare. Now, before I get too far into this, I'm joined by my friend from Pennsylvania. Did you wish to weigh in on this subject this evening?

Mr. BURGESS. I thank the gentleman for his input. Certainly, the ability to recruit doctors to Texas from Pennsylvania has been greatly enhanced by the passage of the Texas medical liability bill, but you point up a very real problem that the physicians in Pennsylvania face. And, again, it points up the need for a national solution to wait and have the process work its way through every State legislature, State by State. It costs an enormous amount of money, costs an enormous amount of time, and just the effort, the efficiency of those doctors affected is going to be diminished. So I really appreciate the gentleman taking the time to come down here and add his thoughts about what is happening in his home State of Pennsylvania. Mr. Speaker, let me go on and talk just a little bit about H.R. 2585. That will address some of the problems that are faced by the physicians who are in practice now, the physicians who are the primary source of care for our Medicare patients. As baby boomers retire, the demand for services is going to go nowhere but up, and if the physician workforce trends of today continue, we may not be talking about a Medicare funding problem. We may be talking about why there is no one there to take care of our seniors. Year after year, there's a reduction in the reimbursement payments from the Center of Medicare and Medicaid Services to physicians for the services they provide for Medicare patients. It's not a question of doctors just simply wanting to make more money. It's about a stabilized repayment for services that have already been rendered, and it isn't just affecting doctors. The problem also affects patients. It becomes a real crisis of access. Not a week goes by that I don't get a letter from a physician from somewhere in the country or a fax that says, you know what, I've just had it up to here, and I'm going to stop seeing Medicare patients. I'm going to retire early. I'm no longer going to accept new Medicare patients in my practice, or I'm going to restrict those procedures that I offer to Medicare patients. And, unfortunately, I know this is happening because I saw it in the hospital environment before I left practice 5 years ago to come to Congress, and I hear it in virtually every town hall that I have in my district. Someone will raise their hand and say how come on Medicare, you turn 65 and you've got to change doctors. And the answer is, because their doctor found it no longer economically viability to continue to see Medicare patients because they weren't able to pay for the cost of delivering the care. They weren't able to cover the cost of delivering the care. Now, Medicare payments to physicians are modified annually under a formula that is known as the ``sustainable growth rate.'' Because of flaws in the process and flaws built into the formula, the SGR-mandated physician fee cuts in recent years have only been moderately averted at the last minute; and if long-term congressional action is not implemented, the SGR will continue to mandate physician cuts. Now, unlike hospital reimbursement rates which closely follow the consumer price index that measures the cost of providing care, physician reimbursements do not. I have a graph here, again from the Texas Medical Association, that shows based on various calendar years what the cuts in the SGR formula have amounted to as far as physician reimbursement versus what the cost-of-living adjustment has been for Medicare Advantage, the Medicare HMOs, for hospitals, for nursing homes, for pharmaceuticals now would be the same type of formula. Only physicians are asked to live under this formula. In fact, ordinarily Medicare payments do not cover or only cover about 65 percent of the actual cost of providing the patient services. Can you imagine going to any industry or company and ask them to continue in business when you're only paying them 65 percent of what it costs them to stay in business? The SGR links physician payments updates to the gross domestic product and the reality is that has no relationship to the cost of providing patient services. But simply the repeal of the SGR has been difficult because it costs a lot of money; but perhaps if we do it over time, perhaps we can bring that down to a level that's manageable. Paying physicians fairly will extend the career of practicing physicians who would otherwise opt out of the Medicare program, seek early retirement or severely restrict those procedures that they offer to their Medicare patients. It also has the effect of ensuring an adequate network of doctors available to older Americans as this country makes a transition to the physician workforce of the future. In the new physician payment stabilization bill, the SGR formula would be repealed in the year 2010, 2 years from now, but would also provide incentive payments based on quality reporting and technology improvements. These incentive payments would be installed to protect the practicing physician against that 5 percent cut that is estimated to occur in 2008 and 2009. Note that this would be voluntary. No one would be required to participate in either program that dealt with quality improvement or technology improvement, but it would be available to doctors or practices who wanted to offset the proposed cuts that would occur in physician reimbursement until the 2 years time the physician repayment formally can be repealed. Now I know that a lot of the doctors don't like the concept of postponing the SGR by 2 years. In fact, in the bill 2585, by resetting the baseline of the SGR formula, a technique that we used in this Congress back in 2003, by resetting the baseline, the amount of cuts contemplated for 2008 and 2009 are actually modified significantly, and, in fact, there may not be a cut at all in 2008 or 2009. This could translate into an actual positive update for physicians in those 2 years. But the critical thing, in my mind, is that we have to be, regardless of what we decide to do over the next 2 years, we have got to be working on a long-term solution to get out from under the tyranny of the SGR formula. Now, why do it this way? Why not just bite the bullet and get the SGR out of the way and get it repealed once and for all? The problem is, it costs a tremendous amount of money to do that. The problem we have in Congress is, if we are required to submit all legislation that we propose to the Congressional Budget Office to find out how much something costs, we are going to be spending the taxpayers' money, we have got to know how much we are going to spend, over what time will we spend it. Because of the constraints in the Congressional Budget Office, we are not allowed to do what's called dynamic scoring. We can't look ahead and say, you know, if we do this, we are going to save money. The Congressional Budget Office doesn't work that way. That's why postponing the renewal of the SGR by 2 years, take that savings that is going to occur over those 2 years, sequester it and aggregate that savings and put it towards paying for the repeal of the SGR and replacing it with a cost of living index, the Medicare, economic index that would be fundamentally much fairer. One of the main thrusts of the bill is to require the Centers for Medicaid and Medicare Services to do just exactly that and to look at the 10 diagnostic codes for which most of the monetary expenditures are rendered. You know the old bank robber, Willie Sutton, when he was asked why he would rob the bank, he said, that's where the money is. Let's go to where the money is. Let's go to those top 10 procedures and diagnoses that spend the greatest amount of Medicare and look for where the greatest amount of savings can be found within that. The same considerations actually apply to the Medicaid program as well, so it will be useful to go through this process in identifying those top 10 conditions and trying to modify things so that the delivery of care for those top 10 conditions actually ends up costing us less. With the time that remains, I know I have talked about a lot of stuff tonight, a lot of it is technically very complex. I will admit it, a lot of it is actually very boring to listen to. But it is an incredibly important subject, and it is an incredibly important story that we have to tell here in Congress. It's a story of how the most advanced, most innovative and most appreciated health care system in the world actually needs a little help itself. The end of the story should read, ``happily ever after,'' but how are we going to get to that conclusion? In fact, the last chapter may well read, ``private industry leads to a healthy ending.'' At the beginning of this hour, we talked about the debate that will forever change the face of health care in this country. Again, I think it's important to understand, that we understand here in Congress, that we understand what's working in our system and what is not. We can't delay making the changes and bringing health care into the 21st century. I believe the only way we can make this work is if we allow the private sector to be involved, to stay involved and, in fact, lay the foundation for the improvements that we all want. The pillars of this system are that we are going to have, be rooted in, the bedrock of a thriving private sector, not the tenuous ground of a public system that has proven costly and inefficient in other countries. I believe we need to devote our working Congress to building a stronger system and involving the private sector within that system. History has proven this to be a tried and true method. We can bring down the number of insured. We can increase patient access. We can stabilize the physician workforce, and we can modernize through technology, and we can bring transparency into the system. Each of these goals is within our grasp if we only have the foresight and the determination, the political courage to achieve each goal. Again, I referenced when I was a medical student in Houston, people would come from around the world to come to the Texas Medical Center for their care. There is a reason that people come from around the world to the United States for their health care and for their treatment. We are the best, but we must make adjustments to remain at the top of the game.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, it is my greatest pleasure to announce that Paula Blincoe Collins of Denton has been selected by the Denton Public Art Committee to create its first commissioned piece of public art which is to be displayed in the lobby of the Denton Civic Center. The piece is a mural that portrays Quakertown, an African-American settlement that stood where the Denton Civic Center is before it was relocated to Southeast Denton in the 1920s. The artist Paula Collins is well known for her skills in brick sculpture. Among her many creations are two previously completed projects for City facilities, the ``Woman of Justice'' installed in 1994 and two entrance monuments erected in Denton at the Pecan Creek Waste Management facility in 2000. For this project, which is expected to be completed in spring 2008, Ms. Collins will consult with the descendants of the original Quakertown residents. Together they will select a wide assortment of images that represent life in that community and which will be depicted on the brick mural. The nine-member Public Art Committee was appointed by the City Council in 2006 to promote the cultural environment, tourism, enhance community aesthetics, improve the quality of life by allowing people to experience art in public places, showcase cultural diversity, and create a distinctive city identity. It serves as an advisory committee to the Parks, Recreation, and Beautification Board, which are also council appointed. The director of the Greater Denton Arts Council serves as an ex-officio member and the director of the Denton Parks and Recreation Department is staff liaison to the committee. Its funding comes from the hotel tax funds allocated annually for public events and projects that make Denton an attractive tourist venue. I am honored to serve such a talented individual like Paula Collins, and I know that her art will beauty our great city.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today in recognition of the life of Constance Goines. Mrs. Constance Goines, age 60, passed away Tuesday, June 19, 2007. Mrs. Goines was the beloved principal of Van Zandt Guinn Elementary School, located in the 26th Congressional District of Texas. Her work was dedicated to creating a safe and welcoming atmosphere for students who came from struggling families but had a desire to learn in their hearts. Under her fine leadership, the campus developed a reputation for helping students perform at high academic levels despite their social challenges. Her commitment to education, to students and to the entire community were evident throughout her life. It is my hope that she will be remembered for her compassion and that others will follow her lead. Mrs. Constance Goines is survived by her husband of 33 years, Conley R. Goines of Fort Worth; a daughter, Kelly D. Mirtia of Fort Worth; and a brother, Larry G. English of Chicago. It was an honor to represent Mrs. Constance Goines in Washington.

Mr. BURGESS

Mr. BURGESS. Mr. Chairman, I move to strike the last word. Mr. Chairman, on Monday morning my constituents in Gainesville, Texas, woke up to a terrible sight. They woke up to discover their homes, businesses and city awash in water. Heavy rain in north Texas over the weekend and early into Monday morning overwhelmed Pecan Creek and other area streams. There have been several confirmed fatalities, 420 flooded homes, untold millions of dollars' worth of damage in the north Texas area. The first responders, the fire people, the swift water rescue teams, are still in the process of rescue recovery and evaluating the damage and helping people whose homes and businesses have been destroyed. This photograph was taken yesterday morning. It is reminiscent of photographs that were taken during the 1990s, during the 1980s, during the 1970s, during the 1960s, literally as far back as I can remember. That is why I have requested funds for a section 205 flood control project in Gainesville, Texas, and I have every year for the last 3 years. Progress has been made. Funds have been allocated to the project in fiscal year 2007, to the Corps' work plan to complete studies in engineering; but realistically, the time for study has long since passed. We need construction dollars. Funding for Pecan Creek was my number one request in the Energy and Water appropriations bill this year, last year and the year prior. I hope that the chairman and the ranking member will help by providing the funding for the construction projects that are so desperately needed by the citizens of north Texas.

Mr. BURGESS

Mr. BURGESS. Mr. Chairman, this is a very simple amendment. The Secure Flight offset amendment will reduce the Department of Homeland Security Office of Under Secretary for Management by $15 million and increase the Transportation Threat Assessment account by $15 million. The Department of Homeland Security Under Secretary for Management oversees the Audit Liaison Office at the Department of Homeland Security. This liaison office helps to oversee the Department's efforts to coordinate with the Government Accountability Office, the Office of Inspector General, and DHS component agencies. The liaison officers have not been meeting the goal for which they were first funded, that is, to keep the agencies updated and to avoid duplication, to avoid gaps and to avoid inefficiency. The liaison officers have not been successful in providing a centralized and coordinated process. Therefore, this amendment reduces funding for this office by $15 million and increases the funding for the Transportation Threat Assessment Act by $15 million. The funding would be used by the Transportation Security Administration to further the development of the passenger pre- screening program called Secure Flight. When fully implemented, Secure Flight will be able to more effectively compare passenger information to information that is contained within the Federal terrorist watch list. Secure Flight will decrease the chance for compromised watch list data by centralizing the use of comprehensive watch lists. It will further provide earlier identification of potential threats, allowing for expedited notification of law enforcement and threat management. And, finally, it will offer consistent application of an expedited and integrated redress process for passengers who have been misidentified as a threat. Secure Flight is a critical part of the TSA's overall strategy to secure the Nation's commercial air transportation system and deserves more money to be fully implemented as soon as possible. It will give cleaner and more efficient data to our air carriers. Constituents throughout our country, certainly constituents in my district, have contacted my office because they have been misidentified by the Transportation Security Administration, and they simply cannot be removed from the watch list. Increasing the Secure Flight initiative would help that process, and it is time we did increase the funding for that. Mr. Chairman, I reserve the balance of my time.

Mr. BURGESS. Mr. Chairman, I would just simply say this is a good amendment. I would encourage my colleagues to vote in favor of this. As someone who travels frequently, I want this program to be upfunded and running well. Mr. Chairman, I yield back the balance of my time.

Mr. BURGESS. Mr. Chairman, I demand a recorded vote.

Mr. BURGESS. Mr. Chairman, I offer an amendment.

Mr. BURGESS

Mr. BURGESS. I have no earmark in this bill, but had I had an earmark in this bill, I would have had to submit that the middle of March, 3 months ago. As the gentleman from North Carolina so correctly points out, this is not new information. This information has been percolating somewhere within the committee for the last 3 months' time. Mr. Chairman, I will be glad to yield the remainder of my time to the gentleman from Ohio.

Mr. BURGESS. In fact, I will be happy to yield, but let me just reclaim my time for a moment.

Mr. BURGESS. No, I will not.

Mr. BURGESS. The gentleman from Texas controls the time and, no, he will not yield.

Mr. BURGESS. Mr. Chairman, I move to strike the requisite number of words. I come to the floor because of the inspiration of the ranking member of my committee, the Committee on Energy and Commerce, who came and disclosed for the body the earmarks that he had in the bill. I would like to take this opportunity to disclose the earmarks that I have in the homeland security bill as reported to me by my staff. The number is zero. But, still, the argument that goes on here today is important. We just heard a scholarly discussion about the budget that was passed by the new majority. The reality is, a lot of those fully funding issues are in what are called ``reserve funds.'' The gentleman mentioned specifically SCHIP. We have been working on that in my committee for months now. I will tell you, the funds are not there. The reserve funds are sort of like sending a get-well card to a Federal program that is going to expire on September 30 of this year because we have not yet done the work to extend it. Mr. Chairman, I also feel obligated to point out that certainly there are many times during the last 4 years that I have been here, again as just a simple country doctor who came to Congress, but there have been many times that I have been here that I have felt that our side was spending too much money. However many times I felt that way, I cannot escape the feeling that now we are fixing to spend that and a great deal more, and that does sadden me. I think, more to the point, the bill that is under discussion today is a bill that is extremely important to this country, and I think it is a shame that a new majority that campaigned on the concept of openness and being transparent about the process now has decided that there is value in opacity and intends to obscure the process as much as they possibly can. It is one thing to decide that that is the correct way to govern, but don't campaign on that issue. Don't promise what you can't deliver. If you cannot be open about your method of governing, then please don't run on that as an issue in the future. Mr. Chairman, I would now like to yield as much time as I have remaining to the gentleman from North Carolina.

Mr. BURGESS. Reclaiming my time, the ranking member of my committee came to the floor and said he had two earmarks in the bill. So I submit to you that there are earmarks in the bill, and we should be discussing that; that should be part of the new open and transparent Congress.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to thank Mr. Tom Davenport of Lake Dallas, Texas for his 18 years of service as Superintendent of Schools for the Lake Dallas Independent School District. During his tenure, the school district has more than doubled in size and has been in a continuous building program since 1995. In his 38 years of teaching and school administration, his focus has always been on providing top-quality education for his students. In addition to his passion for education, Tom has deeply impressed me by his forward thinking in other areas. A few years ago, Tom made the decision to install geothermal heating and cooling in Lake Dallas ISD schools. He recognized that, despite higher up-front capital costs, the District would save money over time, as well as help clean the environment by using a renewable source. Tom is very active in various professional organizations on both the state and national level. He is a member of the National Association of Federally Impacted Schools, having served as President of the Federal Properties Section for two years. On the state level, he has served as treasurer for the Texas Association of Federally Impacted Schools since 1999. He is also a member of the Texas Association of School Administrators and has served as a mentor superintendent for four newly hired superintendents across the state. In the past he has served as Commissioner of Education Advisory Committee and served as Chair of the Education Service Center, Region XI TASA Study Group. He is a Senatorial District Representative for the Texas Association of Mid-Size Schools. Other professional organizations to which he belongs include, Phi Delta Kappa, Association of Supervision and Curriculum Development, Texas Association of Community Schools, and the Equity Center. Locally he is a member of the Lake Cities Chamber of Commerce and served as vice-president for six years. He was selected as the Lake Cities Chamber of Commerce Citizen of the Year in 2005. He is also a member of the Lake Cities Lions Club and is an active member of Lake Shore Baptist Church in Lake Dallas. Tom plans to reside in the Lake Cities area after retirement with his wife Carolyn. It is with great honor that I recognize Mr. Tom Davenport for years of hard work and dedication. I am pleased to join his friends, family, and colleagues in congratulating him on his retirement after years of devoted service.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I move that the House do now adjourn.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I want to also thank and commend my friends for their discussion of the suburban agenda. I am coming to the floor tonight to talk about health care, and of course they've already covered a lot of those issues in their discussion that preceded in the past hour. I want to talk about some concerns we have in the delivery of health care services throughout the country. The future of medical care in this country is going to be front and center over the next 18 months time. The elections of 2008 will be about a lot of things, but they will also be a lot about health care. Three bills that I want to focus on this evening as well, H.R. 2583, H.R. 2584 and H.R. 2585. The first, H.R. 2583 deals with residency programs. The second, H.R. 2584 deals with loan forgiveness and tax abatements for medical students and newly minted doctors. And the third, H.R. 2585, deals with physicians in the Medicare program who are adversely affected by reimbursement reductions every year under a formula known as the sustainable growth rate formula. Well, as we go through these next 18 months and deciding which avenue through which our health care system is going to go, we have two choices on the table. We've got a public sector, the government side, which already has about half of the responsibility for health care in this country. And we've got that which is comprised of the private sector, as well as that care which is just simply delivered without expectation of compensation, what used to be known as charitable care. Under the option to expand the government's role, the government's side, the government's sector involvement in the delivery of health care, typically that's known as universal health care. In the 1990s we called that ``Hillary Care.'' But could we also approach it from a standpoint of encouraging the private sector to stay involved and to improve their products and make them more flexible and user friendly in order to provide more for our health care dollar in this country. My opinion, having worked in the system for well over 25 years, is the United States does have the best health care system in the world, and it is my obligation, my charge to help it remain the best health care system in the world. Now, I know there's plenty of people in this body who would contest that statement. And there's plenty of issues around to call it into question. My predecessor in this office, former Majority Leader Dick Armey used to be fond of saying, you know, the numbers don't lie; but if you torture them long enough, they'll admit to almost anything. But let's talk about some of the different principles that are guiding the debate about public versus private and the delivery of health care services. And maybe we ought to spend a little time talking about the background. How did we get into this? How'd we get to where we are today? You almost have to go back over 60 years to go back to the time coming out of World War II when the United States, of course, was the victor; came out of the war with a flourishing economy. But during the war, President Roosevelt, in an effort to keep down trouble from inflation, put into effect rather stringent wage and price controls across the country. The employers wanted to keep employees, so a lot of employees, of course, had been drafted and were serving overseas, so those employees that were left the employers wanted to keep them working. But they were constrained. They couldn't offer raises. They couldn't offer the money that would be required; they were worried that someone across town might outbid them. Well, they went and came upon the idea of providing a health care benefit, and, in fact, the Supreme Court ruled that that was okay; that that did not violate the spirit or the intent of the law that Franklin Roosevelt had passed governing the wage and price controls. So during the war, the concept of employer-based insurance was begun. The war ended. The United States was blessed with the postwar economic boom that started, and what began as a necessity born out of a wartime economy continued. It was extremely popular. Health care insurance provided by the employer turned out to be one of the most popular employee benefits that has ever been seen in this country. And up until the early 1980s it just worked wonderfully. Contrast that, of course, with Europe. Even the parts the Europe that were victorious in the Second World War, the battles were fought in their back yard. Their economies were devastated. They needed to quickly stand up a health care system that would take care of a population that had been deprived by 5 years of war or longer. And these countries decided to promote the single payer system that you see that's so prevalent in Western Europe and in England today. But that was born of necessity also, because, again, the country's economies were devastated or, in fact, they had not been victorious in the war, they had lost the war, but they needed to quickly stand up a system that would take care of their citizens. We go from 1945 to 1965. Presidency of another Texan, Lyndon Baines Johnson. During that time, President Johnson enacted the Medicare statute, a little over 40 years ago. The Medicare and the Medicaid programs were signed into law during his administration. These were large government-run programs that were created to focus primarily on hospital and physician care for elderly and basic health care services for the people who were this poverty. Decades later, almost 40 years later, it was evident that the government-run Medicare program, extremely slow to change, very difficult to change a large government program; and anything that that caused any change within the program was going to be incredibly expensive. Already difficult to operate. But in 2003, in fact, my first year to serve in this Congress, my first State of the Union message that I heard the President deliver in this House, he talked about how the need for, or the time for a Medicare prescription drug benefit had arrived; and this was too important an issue to be left to another President or another Congress. It was work that we were going to take on that year, 2003, and get that benefit delivered to the American people. And indeed we did. We worked on that bill in various committees throughout the year 2003. Right at the end of the year we passed the bill. There was initially a prescription drug discount card that was available, but over the next 2 years the Centers for Medicaid and Medicare Services put together the plan that we now know as the Medicare Part-D plan. And in spite of all of the problems that it had getting started, arguably it is one of the better functioning government-run health care programs ever seen to date. But the government needed to catch up to a private system that was already focused on prevention, timely treatment of disease and disease management. So finally Congress put the Medicare prescription drug plan, that focused on giving seniors access go needed medications forward, and the program has been successful and provided benefits for seniors. It's come with, obviously, considerable discussion, and a big push for success, a lot of it delivered by the private sector. So here we sit at the crossroads today. Again, the government pays for half of the health care administered in the country with a current gross domestic product, the GDP of 11 to $12 trillion. The U.S. Department of Health and Human Services, through their Medicare and Medicaid services alone, pay $600 billion. Add to that the VA system, add to that the Federal prison system, the Indian Health Service, and you have about half of the health care expenditures in this country. The other half of health care is broken down with the primary weight being carried by private insurance. There is some charitable and there is some self-pay accounting for the rest. I think you'd probably include bad debt in that other 50 percent. Well, as the numbers increase, the overall cost of health care for the entire country, as that number increases the Federal Government continues to funnel the American taxpayers' dollars into these efforts, and we have to ask ourselves, what is the wisest and best use of taxpayer dollars? Is the government doing an excellent job of managing your money? It's not their money. It's your money. Do you think the government is better suited for your health care needs? Whose going to handle or who is better equipped to handle the growing health care problems crisis, if you will, in this country? The government only or the universal health care system, to me, almost is unsustainable. And it certainly is likely to hamper innovation, and hamper the delivery of some of the most modern health care services that the world has ever known. Now, two examples of that, one very close to home, that would support the notion that a private-based system is better equipped and more flexible and less expensive than a government system, look to our north. Look at Canada. Canada boasts a universal health care system. But what it fails to highlight is the tremendous wait for treatment that its patients must endure. In fact, in either 2004 or 2005, the Canadian Supreme Court ruled that access to a waiting list did not equal access to care because the waiting times were so long in that country. Their access to care is limited by the length of time that one must wait for care. Now, in Canada they actually have a pretty good safety valve, and that safety valve is called the United States of America. One of the longest borders in the world is our northern border with our northern neighbor of Canada. And, in fact, if someone has the means to pay outside the system and feels that the wait is deleterious to their health, they can leave Toronto and go to Henry Ford Hospital in Detroit and have that MRI, have that CAT scan, have the stint placed in a coronary artery if they don't feel the wait is in the best long-term interest of their health. So you can take your money, cross the southern border of the United States, and receive care almost immediately, waiting for bypass surgery where you go to the hospital that puts you on a waiting list or puts you in a hospital and put you in a cath lab and gets the problem fixed. When it comes down to your health and a serious health problem, who wants to gamble? Also, look at the National Health Service in Britain. They really have developed within their country a two-tiered system. Indeed, the wait times are a significant problem within the National Health Service. You can go outside the National Health Service, stay in the country of Britain, go outside the National Health Service and go to one of the private physicians. Physicians work in their offices at the time they are required by the government and then operate a private practice on the side. Some of the most expensive health care in the world is available right alongside the free system in the National Health Service. And the fact that it is able to run, the fact that it is able to go, certainly speaks to the fact that it is serving a need that people want filled. The other thing you have to ask yourself, if you have someone who is going to have to wait 6 or 8 months for a CAT scan or an MRI, if you have someone who is going to wait half a year or a year's time for replacement of an artificial hip and that person is nearing the age of 80, a year's wait is a significant period of time of the number of days that that person has left in their life. It is a sad reality but, nevertheless, true. Again, I come back to the notion that the private sector is more nimble and more financially responsible and it is the better way to build the future of our health system. It is a complex relationship. And how Congress should do its job to ensure that we have the best health care system possible is going to be the central part of the debate that we have over the next 18 months. In my opinion, Congress has to promote policies that keep the private sector leading the way with some interaction that leads to a well-run government system. You can hardly talk about health care in this country without coming up against the problem of the uninsured. The Census Bureau right now estimates that some 46 million people in this country are uninsured. Now, uninsured does not always mean lack of access to health care because we all have heard stories about people who use the emergency room for relatively modest problems. It is one of the more expensive ways to get care. There is also a disadvantage too in that if you wait until a modest health care problem becomes an emergency, then you are oftentimes not going to get the best health care bargain or the best bargain for your health care dollar. You are also possibly going to jeopardize the health outcome. So no one would argue that just simply relying upon our Nation's overstretched emergency rooms are a method of dealing with the problem of the uninsured. But I think it is important to point out that doctors and nurses in hospitals on the front lines every day see people and take care of their medical needs, fully recognizing that there may not be a reasonable expectation of payment for those services. And we owe those individuals a debt of gratitude for continuing to do that, sometimes in the face of some rather severe Federal regulations and an extremely hostile medical liability climate. One of the other things that we will talk about, in fact, we are required to do in this Congress is the reauthorization of what is known as SCHIP, the State Children's Health Insurance Program. This is a program that was started some 10 years ago. It had a 10-year authorization and requires that the Congress reauthorize it this year. The two gentlemen who were here before me talking about the slow pace of things in this Congress could have added the slow pace of the reauthorization of the current SCHIP language to that list of things that they were concerned about. This is legislation that, again, Congress is required to reauthorize prior to September 30 of this year when the authorization expires. There is no continuing resolution. There is no IOU or Band-Aid we can put on this program. We simply must reauthorize the program if we want it to continue. And it has been a good program, and I would argue that virtually everyone within this body wants it to continue. Not to say there are not some areas for improvement. A bill that I introduced earlier this year, H.R. 1013, the purpose of this legislation was to ensure that the SCHIP funding that Congress has made available be used to cover children and pregnant adults with this coverage. Right now we have four States that are covering more adults than they are children with their SCHIP funding. That stands the whole program on its head. It is cheaper to cover children with health insurance than it is adults. In fact, the ratio is it costs about 60 cents to provide what otherwise would cost a dollar's worth of health care insurance for adults. So we get a lot of mileage for our dollars when we put that coverage into children. If we take that coverage away from children to then cover adults who otherwise would not belong in the system but get in through some type of waiver, we are not doing a good job with the moneys that we intended to put forward to cover children. And the reality is until we have covered all the children who need coverage in this country, we shouldn't be taking those dollars away from the children to cover adults in the system. Once we have covered all the children in the country, then perhaps it is time to talk about a waiver. If we want to cover other nonpregnant adults, let's find another program to do that. Let's not steal money from the SCHIP program to provide that coverage. Another thing that we don't really talk about a lot on the House floor, last year in my committee, the Committee on Energy and Commerce, we reauthorized the federally qualified health center statute. We never got that completely finished in the House. We should take it up again this year. It should be taken up by the Senate, and this is a program that fully deserves reauthorization by this Congress. The federally qualified health center statute provides in federally qualified health centers coverage for about 15 million uninsureds. That is access to medicines, access to a medical home, access to mental health services, access to treatment for substance abuse, a significant set of services that are available to people who otherwise would not have access to medical care. Federally qualified health centers do a good job. Both SCHIP and the federally qualified health center system deserve to be taken up and reauthorized by this Congress. If there are improvements that we can make, then by all means let's have the debate and make those improvements necessary, but let's not let those two programs languish and by default be sunsetted and not continue. Now, the two gentlemen that were here talking earlier were talking about some of the problems that people get into when they lose their health insurance and wanting to extend COBRA benefits, a noble exercise. One of the things that I have really thought is a forward- looking way to go with health insurance, and it kind of gets at what they were talking about, that is the individual ownership of an insurance policy. The point made by Mr. Kirk of Illinois, gone are the days where a person gets out of high school or college, works in one job, one factory, one manufacturing plant for the remainder of their work life, then retires and gets a gold watch and goes off to a well-deserved retirement. People change jobs in today's economy. Their health insurance ought to be able to be flexible to change with them, to move with them. One way to ensure that is to allow an individual to own their health insurance policy. Back in the days when I was practicing medicine in the middle 1990s, this Congress passed a bill called the Health Insurance Portability Act of 1996, the Kennedy-Kassebaum bill. In it, it provided for a demonstration product for what were then called the medical savings accounts. Bill Archer, chairman of the Ways and Means Committee at the time, was a champion of the old MSA. I had an MSA when I was a practicing physician. It allows you to build a tax-deferred savings account that is dedicated to your medical expenses. You buy an insurance policy that is yours. You do pay for it with after-tax dollars, but the advantage is that since it has such a high deductible, it typically has a lower premium. Now, there are some problems with the previous MSAs that were first passed by this Congress. This Congress put a lot of regulations on those insurance policies, and as a consequence, in my home State of Texas, we only had two insurers who were willing to take people on with a medical savings account. When we did the Medicare bill that I referenced earlier in the talk, back in 2003, when we did the Medicare Modernization Act, included within that language was language that allowed for a significant expansion of what we now call health savings accounts. The central concept is still there. It is a high deductible insurance policy owned by the individual, not the employer, or the individual can own the policy. Some employers have now begun to offer health savings accounts. A high deductible policy with a lower premium, and you put money into a tax-deferred savings account. Remember Albert Einstein said there is no power in the universe as strong as the miracle of compound interest. Put that as a pretax expense, and that can be something that grows significantly over time. Imagine that. A health-based IRA or a health savings account, an account that is dedicated only to your health care needs. Start that when you are young. It grows over time, and that can be an incredibly powerful tool to combat problems that might occur with health later in life. But even if someone has a high deductible policy in their younger years and maybe they don't have quite as much stored up in that health savings account that would cover the deductible, still you get into a catastrophic situation, or it doesn't even need to be a catastrophic situation. In today's environment you have a single car accident and the medical costs can just be astronomical after spending an afternoon in the emergency room, a couple of hours in the CAT scanner, maybe a day or 2 in the intensive care unit, 3 or 4 days in the hospital, and by the time you get out, you have got a bill that will literally shock you. And a health savings account would provide that type of catastrophic coverage. Why is this important? Say a young person just getting out of college decides they want to go off on their own and they want to be the next Bill Gates. They want to be an entrepreneur. They want to develop their own company. They don't want to work for a large company with its attendant benefits and health care insurance. They just want to go out on their own. Ten years ago you went into the private individual market and said, I want to buy some health insurance because I am going to work for myself and start a small business and be my own boss, you couldn't get anybody to talk to you for any price. There just wasn't a policy available. Fast forward to the present time, and with the changes we made with health savings accounts in the Medicare Modernization Act of 2003, you can go on the Internet. You can type in ``health savings account'' into the search engine of your choice. And in my home State of Texas for a male age 25, just out of college, nonsmoker, you can pick up a high deductible policy in the range of $65 to $75 a month. Not an astronomical expense. Sure, there is a high deductible associated with that. So if you want a flu shot next fall, you are probably just paying for that out of pocket. But if you get pneumonia and you end up in the hospital in the ICU for several days, you are going to have coverage for that so-called catastrophic event because, even though it is a high deductible, your medical expenses will quickly exceed that. So that is a good thing to have so that you do have coverage. For a young family where a husband and wife want to have the coverage, want to do the responsible thing if they have small children, a health savings account may provide the way to do that and have that coverage beginning at an early age. And over time the money will grow in the actual savings account portion of that. It grows tax deferred. It can accumulate quickly. And as a consequence, the specter of having a very high deductible is something that is now not such a big deal because there is easily money within that health savings account to pay for those health care needs. Even the routine care if someone chooses to do that, the dollars are there to be spent for that purpose. The popularity has grown a lot. When I first got mine back in 1997, my old Archer medical savings account, I worried because they said we're going to put a cap on this; we're not going to allow more than 750,000 of these to be sold in the United States of America. I thought golly, I better get out there and get one fast or they are going to all be snapped up. It turned out I didn't need to worry because those original insurance policies, probably less than 100,000 were sold. But the health savings accounts, when the conditions changed in 2003, have been significantly popular. The last year for which I have accurate and verifiable data is 2005. But by December of that year, the end of calendar year 2005, 3.2 million individuals had coverage through a health savings account; 42 percent of those individuals had families with incomes below $50,000 purchasing an HSA type of insurance. Certainly that is indicative that this is an affordable option. In addition, the number of previously uninsured HSA plan purchasers over the age of 60 nearly doubled, proving that the plans are accessible to people of all ages. And again, out of that number, over 3 million, probably about 40 percent of those individuals were previously uninsured. So it did have the effect of, at least temporarily, bending the growth curve of the uninsured in this country. Of those 46 million people that we talked about before that are uninsured, over half, 60 percent, are employed in small businesses. Some of these individuals prefer a more traditional health plan. They would like to have what we talked about earlier, an employer-derived health insurance. But their employers, their small business employers look at those premiums going up every year and they say, you know what, I just cannot do it anymore, and so they drop the benefit because it is simply too expensive. Now, Congress has had before it, over the last 4 years I think we've had at least three votes on this concept; it has always passed the House of Representatives; it always stalled in the Senate. I don't know if we will take it up this year, but I think we should because I think it is fundamentally a good idea. And maybe at some point we will get some cooperation from the other body. But to unburden small business owners, Congress has devised the concept of what are called Association Health Plans, essentially allowing a group of small businesses with a small business model to band together to get the purchasing clout of a big corporation. It is really not too hard a concept for most people to understand. It is, again, something that has passed this House at least three times that I am aware of. It is a sensible solution. It allows the spread of the insurance risk amongst a larger group. A small employer, say a realtor in your hometown who has 3 or 4 people working in the office, very difficult, very expensive for them to get insurance, if they can find it. Well, imagine if you let all the realtors in Texas band together and form a single group that was negotiating for the sale of insurance. Now imagine that you couple that with the realtors in Oklahoma, Louisiana and New Mexico. Then you've got a group of people that really is beginning to have some significant financial clout and may be able to get a much better price in the group health insurance market. Well, all of this, from the insurance side, is extremely important. You've got to worry though, are we putting the cart before the horse? About a year and a half ago, Alan Greenspan, just as he retired as Chairman of the Federal Reserve Board here in Washington, D.C., met with several groups. He met with a group of us one morning, and he was asked the inevitable question, well, Chairman, what about the ability of the Federal Government to pay for Medicare in the future. He alluded to how that was going to be a problem that was going to have to be faced. But at the end of it all, he felt that Congress would be able to come up with an equitable solution to that. And he paused and he said, what concerns me more is will there be anyone there to provide the services that you want when you get there. That is a pretty profound statement, certainly something that has stuck with me since that time. No question about it in my mind, our country faces a crisis in health care manpower, a physician shortage, if you will, in the future. We need to ensure that the doctors who are in practice today, those physicians I like to call ``mature physicians'' at the peak of their clinical abilities, at the peak of their diagnostic abilities, at the peak of their surgical expertise and abilities, we've got to be sure that they stay in the game, that they continue to practice, that they don't retire early, that they don't wander off and do something else. We need to keep them involved. At the same time, we need to ensure that the younger physicians, the doctors of tomorrow, those that are in residency programs today, those that might be thinking about going to medical school or into nursing, that those individuals stay involved and in fact pursue their career dream of working in health care. The first issue that always comes to my mind when I think of what are some of the things that drive doctors out of practice or keep people from going into the practice of medicine, and that is, of course, the conundrum of medical liability. Again, we faced it in this House of Representatives probably four times in the time that I have been in Congress. It is an issue that has never gotten through the other body. Again, I believe we need to continue to push that as an issue because in so many ways we just need some commonsense medical liability reform to protect patients, stop the escalating costs associated with lawsuits that are not well-grounded, and to make health care more affordable, ensure that health care is in fact even available to Americans all across from coast to coast in Alaska and Hawaii, and make sure that those physicians stay in the game and continue to provide the needed services. I believe we do need a national solution. State to State coverage is always going to be tenuous. My home State of Texas did a great thing as far as medical liability reform is concerned back in September of 2003, but you worry every time the State legislature comes into session every 2 years, is something going to happen that undoes those great steps forward that were taken back in 2003. I do think that modelling after the concept that was developed, actually originally in the State of California back in 1975, the Medical Injury Compensation Reform Act of 1975, signed into law by Governor Jerry Brown, a great step forward that put a cap on noneconomic damages in medical liability suits. Fast forward to 2003, and the Texas plan came forward. Indeed, the basis of the program or the basis of the reform does lie in a cap on noneconomic damages, but I like to say it's got a 21st century angle to it. There is a $250,000 cap on noneconomic damages for the doctor, a $250,000 on noneconomic damages for the hospital, and a third cap of $250,000 for noneconomic damages from a second hospital or nursing home, if one is involved. In fact, the original cap legislation that worked so well in California, in Texas it has been trifurcated. It is in the aggregate of a $750,000 cap. Well, how does that work? Did that fix the problem that the State of Texas faced the year I ran for Congress 2003? Well, in Texas, we've gone from 17 medical liability insurers down to two. My personal situation, running my own practice, really having not had a problem that would take me into the courts, but my rates were increasing by 25, 30, 40 percent a year. Well, in 2003, the Texas legislature passed medical liability reform based off that California law, again, updated for the 21st century, for an aggregate cap of $750,000. What has happened since then? Well, remember I just said, we dropped from 17 liability insurers down to two because of the medical liability crisis. We are back up to 14 or 15 carriers. And most importantly, those carriers have returned to the State of Texas without an increase in their rates. They have held their rates down. My old insurer of record, Texas Medical Liability Trust, between rate reductions, rebates and dividend payments to physicians over the 3\1/2\ years since this law was passed, the actual net effect is a 22 percent reduction in premiums for physicians across the board in the State of Texas. Again, remember premiums were going up by 20, 25, 30 percent or more a year, now they are coming down, and over the last few years they have come down 22 percent. One of the most significant, unintended benefits of this was what happened with the small not-for-profit, community-based hospitals, those hospitals that were essentially self-insured for medical liability. They have been able to take money that was in those escrow accounts against the uncertainty of the medical liability climate that they faced in 2001, 2002 and early 2003, now that money has been able to go to hiring nurses, capital improvements, just the very things you would want your smaller not-for-profit, community-based hospital to be able to do. This is certainly one of the good news stories. And again, the smaller hospitals were not the intended beneficiary of this legislation when it passed in the State of Texas. I took the language of the Texas-passed medical liability reform, worked it into the type of language that we have to have here in the House of Representatives, ran it through legislative counsel and offered it to Mr. Ryan, Paul Ryan, the ranking member of the Budget Committee on the Republican side, when we were doing our budgetary work in March. He had that bill scored by the Congressional Budget Office. And the Texas plan, as applied through the House of Representatives language, applied to the entire 50 States, would yield a savings of $3.8 billion over 5 years. Now, not a mammoth amount of money, but when you are talking about a $2.999 trillion budget, savings is savings. And these are monies that we are in a sense just going to leave on the table in this budgetary cycle that could have gone to some of the other spending priorities, some of which I have already alluded to in the SCHIP and the Federally Qualified Health Center statutes. But anything, even those things not dealing with health, $3.8 billion, as the old saying goes, you keep leaving that amount of money on the table and pretty soon you're going to be talking about some real dollars. And also consider this: A study done in 1996, that's over 10 years ago, out of Stanford University, revealed that in the Medicare system alone, the cost of defensive medicine was approximately $28 to $30 billion a year. The cost of Medicare, not the entire cost of the health care infrastructure of the United States of America, the cost to Medicare was $28 to $30 billion a year 10 years ago. I submit that that number has likely increased today. We can scarcely afford to continue this trajectory that we are on with regards to medical liability in this country. And again, remember when I started this part of the discussion talking about are we going to have anyone there to provide the services when we want them. And another consideration is that young people today entering college, in college, just getting out of college, who wanted to consider a career in health care, are looking at the crisis that we face in medical liability in this country, and it's keeping them out of the game, and that's not right. One of the obstetrics residency directors from a big New York program was down here actually a couple of years ago now, and I asked her, is the medical liability crisis, is it having an effect on your residency classes that you're recruiting? And she told me that right now we are taking people into our residency program that we wouldn't have interviewed 5 years ago. In other words, we are lowering the class and the capabilities of those people who are willing to go into obstetrics as a specialty. Well, these are our children's doctors, these are our children's children's doctors that are being trained in the residency programs today. I fail to see how it advances the case for patient safety and the well-being of Americans to continue to allow this condition to exist without addressing it. Again, we voted on the bill several times in this House over the past several years. My understanding is the bill was just recently reintroduced last week. I hope we will have a chance to address it in this House. And I hope we can get some activity from the other body. I am not optimistic, but I believe this is so important that we have got to continue to try to get this done. This brings me to one of the things I initially spoke about, one of three health care bills, H.R. 2583, the so-called Physician Workforce and Graduate Medical Education Enhancement Act of 2007. There is a Washington-type title that everyone can love. Well, part of ensuring the future health care workforce in this country is going to be to make certain that there are the types of residency programs in the types of communities in which we want doctors to consider going into practice. You know, the funny thing about physicians is they do have a lot of inertia. They tend to stay where they're dropped; that is, they tend to work and have their practice in communities where they trained or close to where they trained. A lot of us have followed that trajectory, and I suspect there is nothing unique about that. It will continue to be the way physicians behave for probably well into the future. So the bill introduced just last week was designed to get more training programs in areas that are underserved, like rural areas, inner-city areas, to get young doctors- in-training in locations where they are actually needed. The Physician Workforce and Graduate Medical Education Enhancement Act of 2007 would develop a program that would permit hospitals that do not traditionally operate a residency training program that will allow them the opportunity to start a residency training program and in fact build that physician workforce of the future on site in those communities where they are in fact needed. On average, it costs $100,000 a year to train a resident, and that cost for a smaller hospital is clearly prohibitive. Because of the cost consideration, the bill would create a loan fund available to hospitals to make residency training programs where none has operated in the past. The programs would require full accreditation and be focused obviously in rural and suburban inner-urban or other smaller community- type hospitals. I can think of several communities in the congressional district that I represent that might benefit from such a program. Clearly, it is one thing to say we are just going to educate more doctors, but to get them to practice in the areas where they are needed, and, boy, an area that comes to mind is the area around New Orleans, Louisiana. They have lost doctors. The wholesale loss of doctors since the twin hurricanes of August of 2005, it is going to be very difficult to encourage people to come back to that area. But the reality is if someone trains in that area, the likelihood of them staying in that area is increased. It is all well and good to create new residency programs, but if you don't have anyone interested in filling that residency slot, it is not going to be really something that does all that much good. So the second bill, H.R. 2584, the High Need Physician Specialty Workforce Incentive Act of 2007, would help locate young doctors where they are needed to solve part of the impending physician shortage crisis that likely could affect the entire country. We have got to consider training doctors for high need specialties. This act will establish a mix of scholarships, loan repayment funds and tax incentives to entice more students to medical school and create incentives for those students and newly-minted doctors to help them go into healthcare. The program will have a established repayment program for students who agree to go into family practice, internal medicine, emergency medicine, general surgery or OB/GYN, and practice in underserved areas. It will be a 5-year authorization at $5 million a year and it will provide additional educational scholarships in exchange for a commitment to serve in a public or private nonprofit health facility determined to have a critical shortage of primary care physicians. Again, the Gulf Coast area comes to mind, but there are plenty of areas in my home State of Texas, West Texas and in fact East Texas, that would fit the bill for something like that. It is very similar to what used to be called the Berry Plan. The armed services used to offer a scholarship and some loan forgiveness to encourage physicians to go into one of the branches of service. This is modeled after those plans that were so popular in the early 1970s. Again, it is an important step in getting doctors into the communities where they are actually needed. The third bill of the three that I introduced last week, H.R. 2585, really deals with the heart of the problem, which is stabilization of the current physician workforce. When we talk about the current physician workforce, discussing things like medical liability, placement of doctors in locations of greatest need and financial concerns, encouraging doctors to remain in those high-need specialties, the next step is to fix on that largest group of doctors in the country and certainly the largest and still growing group of patients, those baby-boomers that you heard Mark Kirk talk about in the last hour. Baby-boomers are going to continue to age. They are going to retire, and the demand for services has no where to go but up. If the physician workforce trends continues as they are today, we may no longer be talking about trying to fund the Medicare program. We may be talking about trying to find the Medicare physician. We may be talking about the fact that there is no one there to take care of America's seniors. Year after year, there is a reduction in reimbursement payments from the Center for Medicare and Medicaid Services to doctors for services that they provide their Medicare patients. This is not a question of doctors just simply wanting to make more money. It is about a stabilized repayment for services that are already rendered. It is about a question of fundamental fairness. And it is not just affecting doctors. It is affecting patients, and it becomes a real crisis of access. Not a week goes by that I don't get a letter or fax from a physician back in Texas who says, you know what? I have just had enough of this, and I am going to retire early. I am no longer going to see Medicare patients in my practice or I am going to restrict the procedures that I offer to Medicare patients. In fact it happened to me while we were home on the Memorial Day recess. A woman came up to me, someone I had trained with, and said, look, I just can no longer do these long, involved operations and be paid literally a pittance for the service, when I could spend my time doing other things that would actually pay for the cost of running my practice. I certainly understand that. I certainly sympathize with that. It is a difficult situation for doctors to find themselves in, because they want to do right. These are difficult operations that they trained for years to be able to provide for people. Now, the fact that they are so poorly compensated by Medicare, they are simply having to turn their back on these challenging, technically difficult procedures, and say I will just see the well patient in the office and stay out of the operating room. I saw it happen in the hospital environment before I left the practice of medicine to come to Congress. But I hear it in virtually every town hall that I do back in my district. Someone will raise their happened or come up to me afterwards and say, how come on Medicare, you turn 65 and you have to change doctors? The answer is because their doctor found it no longer economically viable to continue to see Medicare patients because they weren't able to cover the cost of delivering the care rendered. They weren't able to cover the cost of providing the care. Medicare payments to physicians are modified annually. They use something called the sustainable growth rate formula. A lot of the people around here call it the SGR rate. Because of flaws in the process, the sustainable growth rate formula, mandated physician fee cuts in recent years have only been moderately averted by last-minute machinations and fixes that the Congress has provided. In fact, if no long-term congressional action is implemented, the SGR will continue to mandate cuts for physician reimbursement as far as the eye can see, cuts in aggregate between 35 and 40 percent over the next 10 years. Now, unlike hospitals, who are reimbursed under essentially a cost of living adjustment every year known as the Medicare Economic Index, physicians are reimbursed under the SGR, which says there is a fixed amount of money to pay for all of the doctor-derived healthcare in this country, and there is more demands on that volume, then the slices of that pie are just going to get successively thinner year after year. Medicare payments to physicians cover only about 65 percent of the cost of providing the patient services. That doesn't figure in anything for the doctor's take-home pay. That is the cost of providing the services. That is the office rent. That is the nurse's salary. That is keeping the lights on. That is paying for the medical equipment. That is buying the syringes and the medicines that might be administered in that office. Can you imagine any industry, any business, any company that would continue in business if they received only two-thirds of the cost of what it costs them to provide the services? Currently the sustainable growth rate formula links physician payment updates to the Gross Domestic Product, which actually has no relationship whatsoever to the cost of providing those services. But simply the repeal of the SGR, one of the big stumbling blocks for that is it is very, very costly when figured in the overall Federal budget. But the reality is we have to do it. Maybe if we do it over time, perhaps we can bring that down to a level that is in fact manageable. Paying physicians fairly will extend their careers for many of those doctors now in practice and those who would otherwise opt out of the Medicare program or seek early retirement or restrict those procedures that they offer to their Medicare patients. It also has the effect of ensuring an adequate network of doctors available to older Americans as this country makes the transition to the physician workforce of the future. In the physician payment stabilization bill, the SGR formula would be repealed 2 years from now, in 2010. There would be some incentive payments based on quality reporting and technology improvements installed to protect the practicing of physicians against the 5 percent cut that will likely occur each in the years 2008 and 2009. Those things would be voluntary. No one would have to do them. No one would be required to participate in the quality program or the technology improvement, but it would be available to those doctors and those practices who wanted to offset the proposed cuts that would occur in physician reimbursement over the 2 years until a formal repeal of the SGR would be allowed to happen. Now, for most doctors, that is unacceptable. They say, well, I want the SGR repealed now, not 2 years from now, and I want it repealed this year and I want a positive update or I am going to stop seeing Medicare patients. The reality is that possibly if we do this over time, we will be able to get it done. The other reality is I wish we had started this when I first got to Congress 4 years ago, and we might be well on our way or well past the where we would have in fact solved this problem. So, it is time to begin that journey of 1,000 miles with the very first steps, and we do have to focus on the fact that this is a long-term solution. A lot of people say why do it that way? Why not just bite the bullet and get the SGR out of the way and get it repealed? It costs a tremendous amount of money. The other unfortunate aspect of that costing a tremendous amount of money is it may make the premium for the Part B recipient, it may make that premium go up significantly. In Congress, we are all required to submit legislation to the Congressional Budget Office to find out how much it costs. If we are going to spend the taxpayers' money, how much are we going to spend, over what time will we spend it? Because of constraints at the Congressional Budget Office, we are not allowed to do what is called dynamic scoring. We are not able to look at changing a program or a new program and say if we did things this way, we would save money in the future. That is well and good, but we can't claim those future savings to offset the cost of doing it a new way. And that is what static scoring tells us, and that is why dynamic scoring would be so beneficial in a situation like this. But we are not able to use that. If we look at some of the things we have done already in the Medicare system we can say, you know, if we do it this way, we are actually going to save some money. We are not allowed to capture those savings. The Trustees Report that came out just a few weeks ago, there were 600,000 hospital beds in the year 2005 that weren't filled because of things that doctors and hospitals are doing better, improvements that have been made in the healthcare system. 600,000 hospital beds that weren't filled. Do we get the financial credit for those 600,000 hospital beds that weren't filled? No, we can't claim that. That is just something that is absorbed by the system, and we go on and reset things for the next year and continue on our merry way with the SGR. But the reality is if we could capture those savings, if we could aggregate those savings, it is not just in hospital beds, there are other areas where savings are occurring at the same time, if we could capture those savings, aggregate those savings, and use those savings to offset the cost of the SGR repeal, we might very well come down to a much more manageable number. The old bank robber, Willie Sutton, was famous for saying he robbed banks because that is where the money is. Well, let's go after the procedures where most of the money is spent in CMS, identify where the savings are in delivering the care for people who are in those diagnostic groups, and let's keep that money, capture that money, and use it to offset the cost of the SGR. I think that is the greatest return on investment that we could expect from those savings that we are likely going to see from Medicare in the future. The same considerations apply to the Medicaid program as well. Again, it could be a useful exercise to go through and identify the top 10 conditions and see where the easy savings are in taking care of patients with those conditions. How can their care be better managed? How can things be prospectively managed? What types of intervention might keep a patient out of an expensive hospitalization or away from an expensive dialysis unit? These are the times of savings we need to gather. I see that I am going to run up against some time constraints. I just want to mention health information technology is something that we do have to pay some attention to. In the SGR reform bill that I introduced, there is some language about moving us down the road on information technology, embracing information technology. I haven't always been a big proponent of that. When I was practicing medicine, if someone had come to me with proposals like that, I would say, you know, that is going to increase the number of hours I spend every day, not increase my payments to any great degree, and I just don't see how it is going to be economically useful to me as a physician. That was before I traveled to the City of New Orleans for the second time in January of 2006 and was taken into the records room at Charity Hospital shortly after they had gotten all of the water out of the records room at Charity Hospital. It looked like the records room of any big city hospital. There were rows and rows, perhaps hundreds of thousands of records in this large room, tens of thousand of square feet devoted to the storage of medical records. They were ruined. They had been ruined by the water and by the black mold growing on the manilla folders. There was not enough protective gear to protect someone to go in and pull the charts out of the racks and begin to go through them to get the patient's medical history. Clearly, the time has come where we need to have the concept of computerized access to medical records. It is something this country needs to embrace. The old adage when I was in college, you could say, the dog ate my homework. No student today would do a report, a term paper and keep one single paper copy. They have it on a flash drive, on a hard drive, on a floppy disk. They have printed it out several times. They live in the electronic age. It would make no sense to the medical student of today to have a single paper copy of a term paper or lab report that they would have to turn in for a grade. It would never cross their mind. Some of the other things, the interoperability of our systems is key. Right after the Walter Reed story broke, I was there visiting. Yes, the physical conditions were one thing; but one soldier told me the biggest concern he has is as he prepares his records, he is on medical hold and as he is looking to go back to join his unit or be discharged, he has to put in order his medical records to make the case for staying in the service or get the disability to which he is entitled if he is discharged from the service. The biggest fear they have is they will spend hour after hour putting records together and highlighting critical areas, have them sit on someone's desk until they are lost, and then have to start over again. Their biggest concern was the inability of the Department of Defense and the Veterans Administration to interact with each other on the transfer of medical records. Clearly, that is a concept whose time has come. Price transparency. I have talked about HSAs. If we are going to have health savings accounts work for Americans, we are going to have to be able to allow them to access information about price, cost and quality of medical care and procedures. I introduced legislation dealing with price transparency earlier. My home State of Texas has gone a long way in this regard, providing information up on the Internet about the costs at various hospitals throughout the State and how they compare to other hospitals in the State. There is a lot of information. It is technically complex. It may even be boring to listen to, but nonetheless it is part of an incredibly important story. The story of how the most advanced, most innovative health care system in the world itself is in need of a little attention. The last chapter should read happily ever after. How do we get there? The last chapter may read private industry leads to a healthy ending. We are in a debate that will forever change the way health care is delivered in our country. The next 18 months will spell that out for us. We have to understand what is working in our system. How do we make it work better, and how do we extend that to areas where we don't find excellence in our system, whether those areas be public or private. We can't delay making changes to bring our health care system into the 21st century. I believe the only way this can work is to allow the private sector to lay the foundation for further improvements. The pillars of the system we have have to be rooted in the bedrock of a thriving public sector, and a thriving private sector, not in the shaky ground of a public and private system always at war with each other, and many times are inefficient. We need to devote our work in Congress to building a stronger private sector in health care. History has proven this to be a tried and true measure. We can bring down the number of uninsured, increase patient access, stabilize physician workforce and modernize technology if we simply have the political and institutional courage to take the steps necessary.

Mr. BURGESS

Mr. BURGESS. Mr. Speaker, I rise today to congratulate the Dallas/ Fort Worth International Airport for their role in sponsoring the internationally recognized ``Welcome Home a Hero'' program. DFW has been selected by the U.S. Military to host the celebration of the success of this critical program for soldiers and their families. DFW's ``Welcome a Hero'' program has been praised as the premiere volunteer homecoming program for soldiers returning from Iraq, Afghanistan and Kuwait for much needed R&R with their families. On June 12, 2007, the 500,000th soldier to return home during Operation Iraqi Freedom for 2 weeks of Rest and Recuperation (R&R) will travel through DFW International Airport. As a representative of part of the DFW Airport and a frequent traveler between DFW and Washington Reagan, I am grateful that they have taken to heart the mission of our brave soldiers. I have participated in the ``Welcome Home a Hero'' program, and I will always remember the pride I felt and the thankfulness I had for the dedication of those men and women to our country and freedom. I extend my sincere congratulations the Dallas/Fort Worth International Airport and their success with the ``Welcome Home a Hero'' program.