Michael Burgess

Mr. BURGESS

Mr. BURGESS. Mr. Speaker, I thank the ranking member for yielding. Mr. Speaker, the speed of scientific investigation certainly exceeds that of the legislative process. Medical research, especially in the field of regenerative medicine, holds great promise, and it is our responsibility to strike an appropriate balance between that which is ethical and the promise that regenerative medicine holds. Science is resolving and providing answers to this ethical dilemma actually without the help of legislation from this Congress, but really through the hard work of dedicated medical researchers. Yesterday, in an article published in the scientific periodical ``Nature,'' several teams of researchers have been able to make stem cells from a mouse skin cell, a mouse fibroblast, by genetically modifying it with a special technique that they have developed. So here we have a stem cell that was created from a skin cell without destroying an embryo. These researchers have already shown success with mice by reprogramming mature cells to act like stem cells. This field of cell signaling is going to be very important in the field of regenerative medicine in the decades to come. These researchers are also working to see how these reprogrammed cells may limit the growth of tumors, a problem identified when using human embryonic stem cells from destroyed embryos. When we had this discussion last January, Dr. Anthony Atala from Wake Forest University and his Institute of Regenerative Medicine have found that stem cells derived from amniotic fluid, no harm to the baby, no harm to the fetus, cells derived from amniotic fluid have the same or similar characteristics of stem cells derived from embryos. He has been able to build on this research and regrow human organs, bladders in mice, in a handful of cases to do the same thing in humans. Because these stem cells are not from embryos but from the amniotic fluid or from the placenta, there is much less risk of tumors developing than there is in embryonic stem cells. Because these cells are not from embryos but from the amniotic fluid, there is no harm to the embryo. Over 40 cell lines are available in Dr. Atala's lab. Mr. Speaker, I am extremely disappointed that we have brought this bill to the floor without a hearing in our committee. The science has moved tremendously. This is the same bill we debated 2 years ago on this House floor. Not a single committee hearing, not a single consideration of how the science has advanced in the past 2 years. That is a shame, and for that reason this bill should be defeated. We should go back to the committee and go through regular order. Once again, we are debating a bill on the House floor which science has lapped multiple times. We all agree that medical research, especially in the fields of regenerative medicine hold great promise, but our responsibility is to strike an appropriate balance between the ethical challenges of stem cell research and the promise that it holds. Science is beginning to address this ethical dilemma without the help of legislation from this Congress, but through the hard work of hundreds of medical researchers. I would like to call an article in the recent edition of Nature to the Speaker's attention. Several teams of researchers have been able to make stem cells from a certain type of skin cell genetically modified with retroviruses, without destroying embryos. These researchers have already shown success with mice by reprogramming mature cells to act like stem cells. These researchers are also working to see how these reprogrammed cells may also limit he growth of tumors, a problem identified when using stem cells derived from destroyed embryos. Dr. Anthony Atala, director of Wake Forest University's Institute of Regenerative Medicine, has also found that stem cells derived from amniotic fluid have the same or similar characteristics of stem cells derived from embryos. He has been able to build on this research and re-grow bladders in mice and in a handful of cases do the same in humans. Because these stem cells are not from embryos but from amniotic fluid or placenta, there is less risk of tumors. Over 40 lines are available in Dr. Atala's lab already, and he has the ability to collect more of these very plastic cells in any birthing center. In fact, I am disappointed that instead of considering a bill that actually does something, which I have cosponsored and introduced by Congressman Lipinski, is not before us in place of S. 5. This bill would provide funding to bank amniotic and placental cells and make them available for research and at some point in the future for actual medical treatments. This Congress and its leadership has missed an opportunity to hold hearings on this important field of medical research and bring something to the floor that would actually move the science forward. Instead, we have before us today, an uninformed, morally objectionable bill designed to inflame political divisions when what America needs is a Federal medical research policy that moves forward in an ethical and responsible manner in real-time, adapting to the needs of science.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, on Thursday, May 17, 2007, I missed six recorded votes due to a family obligation in Texas. Had I been present, I would have voted in the following manner. H.R. 1427, Federal Housing Finance Reform Act of 2007 Rollcall No. 378 H. AMDT. 203 (Bachus R-AL) Amendment No. 001-- ``yes''; rollcall No. 379 H. AMDT. 205 (Hensarling R-TX) Amendment No. 003--``yes''; rollcall No. 380 H. AMDT. 209 (McHenry R-NC) Amendment No. 007--``yes''; rollcall No. 381 H. AMDT. 21O (Kanjorski D-PA) Amendment No. 008--``no''; rollcall No. 382 H. AMDT. 211 (Roskam R-IL) Amendment No. 009--``yes'' and rollcall No. 383 H. AMDT. 213 (Garret R- NJ) Amendment No. 011--``no.''

Mr. BURGESS

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

Mr. BURGESS

Mr. BURGESS. Mr. Speaker, I come to the floor tonight for what time is left to us to talk a little bit about health care. I do try to do that every week because this is such an important issue that faces our country, and over the next 18 to 24 months we are going to see perhaps some significant changes proposed and some, in fact, enacted in the Nation's health care system. Mr. Speaker, I wanted to draw your attention, today there was an excellent piece written in today's Wall Street Journal. This piece was on the editorial page, it was written by Dr. Robert A. Swerlick. It is entitled, ``Our Soviet Health System.'' Mr. Speaker, Dr. Swerlick does such a good job of encapsulating a lot of the issues that I have been talking about here over the past several weeks and I just wanted to share a couple of quotes with you from his article as we get started. He is talking about the imbalance between supply and demand. He became aware of it when he found no trouble finding a veterinarian for his pet, but found difficulty finding a pediatric endocrinologist for a diabetic child. And the reason for the imbalance, Mr. Speaker, according to Dr. Swerlick, is because of some of the distortions of the marketplace and the inaccurate signals delivered to the marketplace because of our manipulation of those signals and of those market forces with the pricing structure we have in our Medicare system. I am quoting from the article from today, and it says, ``The roots of the problem lie in the use of the administrative pricing structures in medicine. The way prices are set in health care already distorts the appropriate allocation of efforts and resources in health care. Unfortunately, many of the suggested reforms of our health care system, including the various plans for universal care or universal insurance or a single payer's system that various policy makers espouse, rest on the same unsound foundations and will produce more of the same.'' Going on and continuing to quote, ``The essential problem is this; the pricing of medical care in this country is either directly or indirectly dictated by Medicare. And Medicare uses an administrative formula which calculates appropriate prices based upon imperfect estimates and fudge factors rather than independently calculate prices, private insurers'', and Mr. Speaker, this is key, and many House Members don't realize this, let me slow down and say this again. ``Rather than independently calculate prices, private insurers in this country almost universally use Medicare prices as a framework to negotiate payments, generally setting payments for services as a percentage of the Medicare fee structure.'' Then further on into the article, again quoting, ``Unlike prices set on the market, errors in this system are not self-correcting.'' That is, we make a mistake in our policy meetings, in our committee hearings, we make a mistake in setting the actual value to a medical service, and that mistake never gets corrected by market forces. It is insulated, it is anesthetized from market forces, and the consequence is it gets worse over time. And then we compound the error when we try to fix things at the committee level or at the level of the Federal agency. One last thing that I would like to point out that the article does state so succinctly. Markets may not get all the prices exactly correct all of the time, but they are capable of self-correction, a capacity that has yet to be demonstrated by administrative pricing. Again, a very worthwhile article. And I commend it, Mr. Speaker, to you. And perhaps some of our colleagues will also be interested in that article as well because I think it very succinctly sums up a lot of the things that I have been pointing out over the past several weeks here. Mr. Speaker, in the few remaining minutes that I have left, I wanted to talk just a little bit about the physician workforce of the future, because that is something we have to focus on as we have this health care debate. A lot of times I worry we are getting the cart before the horse. Here is a cover of the Texas Medical Association's professional magazine back in my home State of Texas. Texas Medicine last March devoted a lot of the issue to the concept of running out of doctors. As a consequence, I am introducing three physician workforce bills tomorrow that will deal with the person perhaps thinking about a career in medicine, the young physician just starting out in either medical school or residency, and then finally, a third bill to deal with the iniquities in the Medicare pricing system that I just referenced in the article of today's Wall Street Journal. The physician workforce crisis has to be approached on several fronts. The issue of medical liability is one that we need to take on, and we need to be quite serious about that. But when we look at perhaps the largest group of doctors that we may not have in the very near future because of the things we are doing in our Medicare pricing schedule, these are the areas where we really need to concentrate. Baby boomers are going to retire, they are going to get older. Demand for services are going to go nowhere but up. If the physician workforce continues its downward trend, as it is doing year over year, we may not be talking any longer about funding a Medicare program, we may be talking about why there is no one there to take care of seniors. Year after year reduction in reimbursement plans from the Center of Medicaid and Medicare Services to physicians for services they provide for their Medicare patients. This is wrong. It is not a question of doctors wanting to make more money, it's about a stabilized repayment for services already rendered. And it isn't affecting just doctors, it is affecting patients every day. It becomes a real crisis of access. Not a week goes by that I don't get a letter or a fax from some physician who says, you know what? I've just had enough and I am going to retire early, or 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. Unfortunately, I know this is happening because I saw it in the hospital environment before I left practice to come to Congress a few years ago. And I hear it in virtually every town hall that I do back in my district. Congressman, how come on Medicare, you turn 65 and you've got 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, they weren't able to cover the cost of providing the care. Medicare payments to physicians are modified annually using a formula called the Sustainable Growth Rate. I won't bare you with the intricacies of that formula tonight, I may do that at some other time. But because of flaws in the process, physicians get a mandated fee cut every year, year over year for several years to come. If no long-term congressional action is implemented, the SGR will continue to mandate fee cuts. Unlike hospital reimbursement rates, unlike reimbursement rates to HMOs or drug companies, those closely follow the cost of living index, but the physician's formula does not. In fact, Medicare payments to physicians cover only about 65 percent of the actual cost of providing the services. Can you imagine, Mr. Speaker, any industry or company that would continue in business if they received only 65 percent of what it cost to cover the care? Currently, the SGR links physician payment updates to the gross domestic product, which has no bearing in reality as to what it costs to deliver those services. The problem is repeal of the SGR is very costly. The Congressional Budget Office currently scores that at about $280 billion. There are ways to approach this. There are short term and long-term ways. And we need to have the political courage, we need to have the political will to do the things necessary to ensure that we do repeal the SGR and the formula and pay doctors on a more rational Medicare economic index such as hospitals are paid that recognizes the increase and cost of delivering care. All of this information is technicomplex and it is even boring to listen to, but it is an incredibly important story for our country. It is a story of how the most advanced, most innovative and most appreciated health care system in the world needs a little help. The end of this story should read ``happily ever after,'' but I am not sure we can reach that conclusion given where we are today. The last chapter should read ``a privatized industry leads to a healthy ending.'' As I stated in the beginning, before I began this talk, we are in a debate that will forever change our health care system. We must understand what is working in our system and what is not. We cannot delay making changes and bringing health care into the 21st century. The only way that we can have this to work is to allow the private sector to lay the foundation for improvements. The pillars of this health care system we have must be rooted in the bedrock of a thriving public sector and not the shaky ground of a public system that has proven costly and inefficient in other countries and in fact in our own back yard. Again, I reference the article from today where the errors are self-perpetuating in the system and market forces are never allowed to correct those errors. We must devote our work in Congress to building a stronger private sector in health care. History has proven this to be the tried and true method. We can bring down the number of insured, we can increase patient access, and we can stabilize the physician workforce, modernize our technology, and bring transparency to the system. All of these things are within our grasp if we have the foresight, the determination, the courage and the political will to get things done. Thank you, Mr. Speaker, for your indulgence. The day is concluded, and I will yield back the balance of my time.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to congratulate Charles McMillan, a constituent of the 26th District of Texas, who has been elected the new President for the National Association of Realtors for 2008 and will subsequently serve as Chairman for NAR in 2009. Mr. McMillan, a Realtor' for more than 20 years, is director of realty relations and principal broker for Coldwell Banker Residential Brokerage, Dallas-Fort Worth. At the national level, McMillan was NAR 2006 first vice president-elect. He has twice served as NAR regional vice president of Region X, which includes Texas and Louisiana. He is a member of the NAR Leadership Team, the executive committee, and the Strategic Planning committee. He has also been recognized by NAR as an expert in the areas of agency, antitrust, misrepresentation, fair housing, and diversity. In 1998, he was president of the Texas Association of Realtors', and was vice president and secretary-treasurer before that. He was Texas ``Realtor' of the Year'' in 2000, and now has risen to the leadership role of president of the National Association of Realtors for 2008. Mr. McMillan is also very active in his north Texas community as a life member of the Texas Real Estate Teachers Association. He is a past chairman of the Community Development Council of Fort Worth, the Tarrant County Affordable Housing Task Force, and the Housing Subcommittee of Fort Worth, and a past director of the United Way of Tarrant County and of the Fort Worth Chamber of Commerce. It is my honor to congratulate Mr. Charles McMillan for his recent election to president of his association. He is admired in the community for helping others, and I am glad that his work is being recognized at a national level. I am honored to represent him in Congress.

Mr. BURGESS

Mr. BURGESS. I thank the gentleman for yielding. Mr. Speaker, I have grave concerns about the bill before us today, specifically the lack of clarity in defining ``unconscionable.'' I believe this term to be ambiguous, and, in fact, could lead to severe supply shortages in times of national emergency. Under this proposal, a gasoline station owner could receive civil and criminal penalties totaling $5 million and 10 years in prison for charging ``unconscionable'' prices. Yet there is no clear definition for what is unconscionable. To add insult to injury, if a station owner were to charge less than the market price, he could also be subject to charges of undercutting the market. Were I a gasoline station owner in a time of crisis, I likely would shut down my pumps and sell Snickers bars and Coca-Colas and try to make money that way. I am not defending those who would charge unfairly. I firmly believe, and, in fact, in my home State of Texas, we have a strong antigouging price statute already on the books. If it is determined that illegal pricing has occurred, the individuals should be prosecuted to the fullest extent of the law. But let's be sure we do not create a climate which causes business owners to stop selling gasoline at a time in crisis when we so clearly will need those resources.

Mr. BURGESS

Mr. BURGESS. Mr. Speaker, I am coming to the floor tonight, like I have so often in recent weeks, to talk a little bit about health care in our country. The delivery of health care services is one of the things that may not be the first thing that registers in any poll that's taken in this country, but it's sure third or fourth, and it appears in every poll that is taken in this country. We are, indeed, on the threshold of what might be called a transformational time as far as how health care services are delivered in this country. Certainly, over the remaining 18 months of the 110th Congress, we are going to have several different issues before us, several different times, where we will be able to talk about and debate various aspects of our health care system. Of course, just of necessity, as a big part of the Presidential election that will occur in the 18 months time, we will deal with the issues surrounding health care and the delivery of health care services in this country. We will be deciding, what road do we want to go if we have a system in our country now where about half is delivered, half of every health care dollar that is spent originates here in the U.S. Congress, and the other half comes from the private sector, uncompensated care and so-called charity care. What do we want to see grow? What do we want to see encouraged? What do we want to see improved? Do we want to grow the public sector or do we want to grow the private sector? Certainly expanding the government sector and its involvement in delivery of services, terms you will hear talked about on the floor of this House, things like universal health care, health care for all--in the early 1990s, we called it ``Hillary care''--or do we want to encourage the private sector? Do we want to encourage the private sector to stay involved in the delivery of health care services in this country, to be sure, to be certain, whether it's public or private, that the dollars that are spent are spent wisely to expand the coverage that's generally available for our citizens of this country. But these two options, and all of the questions and concerns that surround them, this is what we are going to have to decide in this House, certainly within the 18 months that remain in the 110th Congress, or very quickly after we enter into the 111th Congress. I am hopeful that by visiting with you on some of these things tonight, providing some explanations and some insights into the directions that we might go, or we could consider going, and at its heart, at its core, I think we need to bear in mind that for all of the criticisms that are out there, and we have heard several of them here in the last hour, but for all the criticisms out there about this country and, in particular, its health care system, we do have a health care system that is indeed the envy of the world. We have people from all over the world who come to the various medical centers over the United States to receive their care there. I believe, my position is, that we want to be certain that we maintain the excellence in the health care system that we have today, improve those parts that need improving, but don't sacrifice the excellence that exists in many areas of our country. Some people are going to say, well, that's an overstatement that the United States health care system is a good one. They will look at, cite the numbers of the uninsured, they will start to cite the high cost of prescription drugs. There is no question that these are tough issues that this House is going to have to tackle. Face it, you can pretty much manipulate statistics and numbers any way that you want to. The old adage is that there are lies, there are darn lies, and there are statistics. We have to be careful about how we ask the question and how we frame the question. We have to also be careful that we don't frame the question just so we get the answer that we want, and that we don't effect any improvement for the American people. But let's talk a little bit about the history, about the background of how we got the system that we have today, how we got where we are today. So, actually, if we go back and look at our country during the time of World War II, President Roosevelt felt that he had to do something to prevent wartime inflation from simply overtaking the economy. In an effort to do that, he put in place wage and price controls and told employers that, well, employees' wages would be frozen at certain amounts. Well, employers were having a tough time keeping employees anyway. Many people were off fighting the war or were otherwise involved in the war effort. So employees that were here in this country and available were at a premium. So the employer wanted to do something to ensure that he kept his workforce on the job. And one of the things that they thought about doing was, what if we offer a health care benefit? Is that something that we can do that we will still not violate the spirit of the wage controls that President Roosevelt has imposed? Indeed, they got a Supreme Court ruling on this subject, and the Supreme Court said that, no, health care benefits would be outside the scope of the wage and price controls. Health care benefits are something that you can make available to your employees, and in fact, you can make those available to employees, and neither the employee nor the employer will be taxed on those dollars that are so spent. We came out of the Second World War, of course, victorious; at the same time, we had an economy that was just beginning the postwar boom. That economy that was so robust after the war led to the creation of more jobs, more employment. Indeed, the health care benefit was a benefit that was attractive; it was one that people liked. Indeed, it was one that stuck around and persevered and grew over time. But we were also right at the beginning of a lot of pent-up demand as far as people starting their families, and we saw families start to have children. Boy, did they have children. This was the initiation of the so-called baby-boom generation. The United States, like many other allies coming out of the Second World War, the United States was really in a unique position, both economically, and from the standpoint that the war was not fought in our backyard, in contrast to Western Europe, we actually were in pretty good shape coming out of the Second World War. Contrast that to Western Europe, and even Great Britain, ostensibly a victor in the Great War, but at the same time, their economy was in much tougher shape; and when you get onto the continent of Europe, indeed, a good deal more difficulty with the economic recovery in the time immediately following the Second World War. So a single-payer health care system of necessity was a requirement that the government needed to stand up and stand up in a hurry in order to prevent a significant humanitarian crisis that might otherwise have existed. In order to uphold the health care of their citizens, these governments were required to set up systems in a fairly short period of time. Fast forward 20 years from 1945 to 1965, and we have the initiation of Medicare, and, shortly thereafter, of the program now known as Medicaid. These programs were signed into law by another Texas President; agreeably, of note, he was from across the aisle, but another Texas President signed these programs into law. Today, these large government-run programs are focused. Initially they were created to focus on hospital care for the elderly and basic health care services for individuals who are less well off. Now, decades later--1965, when the Medicare program was started--decades later it was evident that the government-run program was slow to change, in need of reform, and it operated at an expense that was just unthought of at the time of the inception of the program. The expense of running Medicare was truly extraordinary. By 2003, Congress certainly recognized the outdated model, and was called upon by the President here in this Chamber. President Bush in the first State of the Union Address that I attended as a Member of Congress stood in this House and said: The problem of providing a prescription drug benefit to our seniors is too important to wait for another Congress; it is too important to wait for another President; and it is work we are going to take up this year with this Congress, and we are going to get this done. Indeed, the President was correct, and that happened. By the end of 2003, the Medicare Modernization Act, that did provide for a prescription drug benefit we now know as the part D section of Medicare, was signed into law, and 2 years later it began to deliver on that promise and deliver prescription benefits to senior citizens who previously had not had access to a prescription drug program. But it was clear that the government system needed to catch up to what by comparison was a relatively robust private system that was already doing the things required, focusing on things like disease management and disease prevention. The good work done by the people at the National Institutes of Health over the previous 40 years had certainly set the stage for what we now recognize as a virtual explosion in preventive care. The premature cardiac deaths prevented by research done and delivered by the National Institutes of Health, probably somewhere between 800,000 and 1 million lives from the mid-1960s to the present time, over that 40-year interval, probably 1 million lives that have been saved or 1 million premature deaths that have been prevented by advances in treatment and prevention of heart disease, which in 1965 was certainly a more serious illness or affected a good number of people. And the problem was that oftentimes the first symptom of cardiac disease in 1965 was sudden death. We no longer think in terms of cardiac disease as extracting that type of toll from our citizens, and that is largely because of the benefits that are there, benefits provided by the medicines like the statins that lower cholesterol, that are able to prevent and postpone the serious aspects of cardiac disease. So Congress passed the Medicare prescription drug plan that gives seniors coverage for medication. The program has been successful, providing greater benefits for seniors. It did not come without considerable discussion and considerable argument back and forth. But with a massive push by the Department of Health and Human Services, the success of the Medicare prescription drug program now, I think, is clearly evident. But, at the same time, the private sector also continued to improve and expand, and it kind of brings us to the crossroads where we find ourselves today. Again, at the present time the government pays for about half of all health care administered in this country. The current gross domestic product is roughly $11 trillion, and the Department of Health and Human Services, with its Medicare and Medicaid services alone, costs this country each year upwards of $600 billion. Add to that the expense for the VA, Indian Health Service, Federal Prison Service, and clearly you can see that we are getting quickly to that number which represents 50 percent out of every health care dollar that is spent in this country originating in this Congress. Again, the other half is broken down, with the primary weight being carried by private industry, commercial insurance. There is also some charitable and some self-pay accounting for the balance of that number. As the numbers increase for just the overall expense of health care, and the Federal Government continues to have to put more and more of the American taxpayers' dollars into health care, we have got to ask ourselves, are we using the taxpayer dollar wisely? Is the government providing excellence as far as managing money when it spends dollars for health care? Is the government better suited to make decisions about health care than families? Who is better suited to handle the growing health care requirements in this country? Now, a government-only universal health care system tends to be more inflexible. In America, my concern is that it will hamper our innovation and delivery of some of the most modern health care services available anywhere in the world. Two specific examples that a private-based system is more flexible and less expensive. Look at what goes on to our northern neighbor in Canada, a government-run system that took over health care shortly after the Second World War. It is a universal system, and the Canadians are very proud of their system, and rightly so. But there are some trade-offs, and one of the trade-offs is there can be a wait for health care services. In fact, the Canadian Supreme Court ruled in 2005 that access to a waiting list was not the same thing as access to care, and that in some instances the waiting list was, in fact, health care denied to Canadian citizens. And the Supreme Court required that the Canadian system remedy that. But in Canada, if you find yourself with a diagnosis and a treatment, but a long time between that diagnosis and treatment, people who have the cash can certainly travel across the border to the south into the United States and find that they can have whatever it is they have been placed on a waiting list that seems interminable; whether it be a cardiac catheterization, a CAT scan, an MRI, they find they get it much more quickly than if they simply waited it out in Canada. So, we have to ask ourselves, is our health or the health of someone in our family something with which we are willing to gamble that that length of time, that that delay won't cause problems, won't increase the morbidity for that particular disease process, won't lead to a lower expectation of a cure or salvage with whatever that particular diagnosis is? The British Isles, where they have a similar type of system, they have a National Health Service. Again, very famous. Britons love the system. But, in fact, they also have a private system that coexists within their country. And if the National Health Service is not able to get to someone in a timely manner, and if that patient or their family has the funds available to expend, then indeed they can be seen in the private system. And for patients who are concerned that they might not survive their wait, or they are living with significant disability, this is a choice that they are willing to make. But the reality is, again, our population is getting older and older, and if you ask someone who is in their sixth decade, seventh decade, eighth decade of life to wait for 4 months, 6 months, 8 months, 12 months or longer for a procedure or a diagnostic test, we, in fact, are consuming a significant amount of the available time they have left, and this, in fact, is not a fair allocation of health services. So my premise would be that the private sector, with all of its difficulties, with all of its faults, is more nimble and is a more suitable and stable arena from which we can build our health care system in the future. This is a complex relationship; and how Congress instructs the medical care in this country be done is largely going to determine if we have the best health care system possible. Certainly, it is incumbent upon Congress to promote policies that help the public sector maintain efficiency and become efficient in areas where it is not efficient, and, at the same time, allow the private sector to lead the way with innovation and development of new therapies, new techniques, and new ways of tackling old problems. Now, one of the things that immediately comes to mind any time you have a discussion about health care is the issue with the uninsured. The uninsured population in this country is estimated by the United States Census Bureau to be somewhere around 46 million people. Now, within that group, I would argue that access to health care is not frequently the issue; it is the coverage that is the issue, because there always exists an emergency room someplace where care can be delivered urgently. But we all know the problem there is you don't always get your best result if you put off the treatment or the diagnosis until such time as it just no longer will allow itself to be put off, and we can increase the cost of health care by delivering health care under that model. But I would stress that in this country, it is not lack of access to health care, because those access points do exist, but it is lack of access to coverage that drives a lot of this debate. Now, some of the things that have happened, and two examples that we should talk about, and, in fact, they are issues that we are going to need to take up within this Congress, because both programs require reauthorization, are the State Children's Health Insurance Program, or the SCHIP program, and Federally Qualified Health Centers. Now, currently the children's health insurance operates as a joint Federal-State partnership. It certainly provides some flexibility for States to determine the standards of providing health care and funding for those children who are not eligible for Medicaid, but whose parents truly cannot afford health insurance. The program has been successful, and it has been successful across the board. As we look to reauthorize the program this year, I think one of the things we can do and should do is clarify the fact that it is children's health insurance. While the intent of the legislation is clear, some States have opted to spend their funds on individuals other than children or pregnant adults. In an effort to correct this process, I introduced H.R. 1013, making certain that the SCHIP funds are spent exclusively on children and pregnant women, not on other groups. We don't cover every child who should be covered under the SCHIP program; and, until we do, it only makes sense that we restrict the funding, again, for children and for pregnant women, who are obviously going to be having a child in the near future, so that child can be covered during the prenatal period. But to take those dollars that should be spent covering children when not every child is covered in this country and spend that covering nonpregnant adults seems to undo the intent of the legislation. Now, if our intent is to provide other coverage for other individuals, let's have that debate, let's have that discussion, let's have that vote. But let's keep those dollars that are designated to provide health care for children providing health care for children. But SCHIP is an example where children and pregnant women can receive additional medical coverage which otherwise would not be available to them through the Medicaid program. And, certainly, there are some people who are now covered by SCHIP who previously would have fallen into the broad category as the uninsured. Other ways of coverage for those individuals who are not children, who are not pregnant, there is access to care. If a Federally Qualified Health Center is available in the area, certainly health care can be gained through an FQHC. The patient has access to health care without insurance. In fact, 15 million of that number of the uninsured can access their health care through a Federally Qualified Health Center. A medical home, continuity of care, see the same doctor every time, in some instances have dental and other coverage, have some coverage for prescription drugs. This is real care available to real people, and it is care that should not be discounted, because it is available to all persons in the community regardless of ability to pay, and it is a program that has been up and running for 35 years. It is a program that is providing care today. Both SCHIP and the Federally Qualified Health Center program were designed to help the poorest, the youngest, and those underserved in our communities. What about individuals that can afford to pay some of their health care services? Two programs that would assist individuals and their companies in receiving health care coverage, health savings accounts and association health plans. Health savings accounts, previously known as medical savings accounts, are a tax-advantaged savings account that is available to taxpayers who are enrolled in a high-deductible insurance plan, an insurance plan with lower premiums and higher deductibles than a traditional health plan. Sometimes that is referred to as a catastrophic health plan, but it is with a difference, because you can put money away up to an amount that is $5,000 for a married couple. You can put money away in a tax-deferred or tax-free savings account. That money must be used only to pay for health care services in the future, but that money grows over time and can be a significant source of health care funds for an individual or a couple as they go through life. For the health savings accounts, the funds are contributed to the account, they are not subject to income tax, and they can only be used to pay for qualified medical expenses. But the best part of having a health savings account is that all deposits to an HSA become the property of the policyholder regardless of the source of the deposit. So that means whether it is the individual themselves or their employer who deposits that money into the health savings account, the actual policyholder is the owner of those dollars designated for health care. And patients have a say in how and when they spend their health care dollars; any funds deposited but not withdrawn each year carry over to the next year. And the popularity of HSAs has grown considerably since their inception. Now remember, medical savings accounts were started a little over 10 years ago in the Kennedy-Kassebaum bill that was passed in 1996. With the Medicare Modernization Act in 2003, the health savings accounts became the follow-on from the medical savings account. These were expanded. The number of companies offering insurance greatly expanded, a lot of the restrictions were removed, and health savings accounts really represent the full measure of what the old medical savings account attempted to achieve, but it just simply had too many regulations in its way to allow itself to come to fruition. But numbers from 2005, by December of 2005, some 3.2 million individuals had coverage from a HSA. Of that number, 42 percent of those individuals or families had incomes below $50,000 and were purchasing health savings account-type insurance. The HSAs are an affordable option. In addition, the number of previously uninsured HSA plan purchasers over the age of 60 nearly doubled, proving that plans are accessible to people of all ages. And really, the proof of that, for a young person in the mid-1990s, getting out of college, perhaps going to go into business for themselves, didn't want to go to work for a big company, no longer can be carried on their parents' health insurance, almost impossible to buy health insurance coverage at any price. I know, because I tried in the mid-1990s to do just that for one of my children. Fast forward to the present time. Go on the Internet, your search engine of choice, type in health savings accounts, and very quickly, with a few clicks, you'll be with a menu that has a number of options available as far as health savings accounts are concerned. And a high deductible, reputable company, PPO plan in the State of Texas for a male, 25 years of age, nonsmoker, these premiums run about $65 a month. Yes, you do have a high deductible. Yes, until that high deductible is funded with tax-deferred, pretax dollars that are going to go into that health savings account to grow over time and provide the offset for that high deductible, sure, during the first year or early years of having a health savings account, things like preventive care are not necessarily going to be covered. Those are expenses that will have to be paid for out of pocket because most people, fortunately, will not get to the limit of their deductible. A young person needs a flu shot. They're probably going to have to write a check for that out of personal funds. But over time, that so- called medical IRA will grow and, again, it grows tax deferred and so it can begin to grow quite quickly. Albert Einstein one time said the most powerful force for good known to man was the miracle of compound interest. That money will grow over time. So for a young person especially, starting that type of account, again, that that can be very powerful. Now, of the 46 million Americans who are uninsured, nearly 60 percent of them are employed, and they're employed within a small business. Some of these individuals prefer a more traditional health plan than a HSA, but their employer, the small business for whom they work, find offering a health benefit is either nonexistent or just quite simply too expensive for them to provide. To take some of the burden off of the small employer who wants to provide insurance for their employee, Congress has devised the concept of what is known as association health plans. This allows small businesses a similar business model, or business plan, to band together to get the purchasing power of a much larger corporation in order to provide more cost-effective insurance coverage to their employees. A group of realtors, for example, or a group of Chambers of Commerce, or medical offices or dental offices or insurance offices, these groups would be able to form a purchasing unit that would be able to purchase health care, again, get the purchasing clout of a much larger group than a small office could ever provide by itself. This legislation has passed the House of Representatives twice in the 108th Congress, twice in the 109th Congress. It never could get through the Senate, and I believe it is still an important concept and one which we need to come together and work on. We heard the group before me talking about how important it was to have a bipartisan effort on these issues, and I certainly welcome that spirit, and would suggest we do need to have a bipartisan effort on working out these types of problems for the American people, because association health plans might not bring down the number of uninsured acutely, right away, but it will certainly help stem the number of small employers who are finding it increasingly difficult to provide insurance for their employees. So it will bend that growth curve of the uninsured that has gone inexorably upward. It will bend that growth curve of the uninsured in a much more favorable direction. But I think we also heard from the President this year when he talked in the State of the Union address, he talked a little bit about perhaps providing some tax relief to individuals who are self-employed, who would purchase insurance but, gosh, I've got to buy it with after-tax dollars, and that just adds to the expense. So the President was talking about providing some measure of tax relief for individuals who wish to have their own insurance policy. He also talked about putting a cap on the upper limit of insurance benefits that would be able to be offered by a company to an employee and come to that employee as an untaxed benefit. One of the things in addition to the issues that the President brought up and one of the things that I think this Congress should look at as perhaps a follow-on or extension to what the President was talking about, would be to provide, whether you call it vouchers, whether you call it tax credits for people who lack insurance, whether you call it premium support, to buy down the cost of the premiums so that a person who is employed, but says those health insurance premiums are just too expensive for me to afford. If we can help that individual pay that premium cost, that keeps the individual off of the Medicaid rolls. So it keeps them from being a governmental expense and allows them to participate in their employer's insurance plan, which has an advantage of keeping the insurance plan that the employer offers a viable one because more employees will be participating; and over time, perhaps that employer will find that they can indeed reach a stage in their employment where they are, in fact, able to carry the cost of the premium expense themselves. But the concept of premium support not mentioned by the President during his State of the Union address, but one which I feel very strongly is an issue that should be explored by this Congress, it is a concept that we should study, and I think come up with a solution that would be a benefit for the American people. Well, one of the other things that I do want to talk about in the context of all of these things that I've discussed with health care is, we've got to be careful we're not putting the cart before the horse. A conversation with Alan Greenspan about a year and a half ago, just as he was leaving the Federal Reserve Board, the obvious question came up, how in the world is Congress ever going to pay for Medicare in the future? He thought about it. He said, at some point, when the time comes, the Congress will do the right thing and figure out a way to pay for Medicare. He paused and then said, what concerns me more is, will there be anyone left to provide the services that you desire when you get to that point? And that is a very valid observation, and certainly one that drives a lot of my thinking when I study the issues surrounding health care and health care delivery in this country. Because the question legitimately can be asked, is our country heading into what might be described as a crisis in physician staffing, a crisis brought on by a physician shortage in the country? And I reference back in my home State of Texas. The Texas Medical Association puts out a magazine every month, a periodical every month, called Texas Medicine. I stole the cover of their March issue because it really says what Mr. Greenspan was telling us that day. The title of the lead article in the periodical last March was, Running Out of Doctors. And that is a concept that I think this Congress, we need to pay some attention to that. And if we don't, I think we put the system in this country in greater peril than it needs to be. And we need to ensure that the doctors who are in practice today stay in practice, that they stay engaged, they stay there providing care to their patients. These are doctors who are at the peak of their clinical abilities, they're at the peak of their diagnostic abilities. We want them to remain active in their practices and providing services and, honestly, services to the patient who have, who provide them with their most complex medical challenges, our senior citizens. So what steps do we need to take to ensure we have an adequate physician workforce going forward into the future and ensure that the doctors of today stay engaged in the practice of medicine, and that the young people of tomorrow come to realize that a career in health care is one that is not only viable but one that is going to be rewarding for them as well? Well, tackling a problem that has plagued the medical community for years and years revolves around the issues of medical liability. My belief is that we need a commonsense medical liability reform to protect patients, to stop the escalation of costs associated with lawsuits, and to make health care, to keep health care more affordable and thereby more accessible for more Americans, and to keep the necessary services in the communities that need them the most. My belief is that we do need a national solution. The State-to-State solutions that have grown out of necessity do leave vast populations in jeopardy, and have the undesirable effect of actually increasing health care expenditures in this country all of the time that we leave that condition unsolved. I like the system that was developed by my home State of Texas that placed caps on noneconomic damages in medical liability suits. I think it is one that certainly is worthy of study by this body, and perhaps worthy of consideration by this body. Texas brought together all the major stakeholders in the discussion, doctors, hospitals, nursing homes and patients. The State was able to have these discussions and bring the stakeholders to the table and come up and craft legislation that really put the brakes on the escalation that was going on in medical premiums; and just as importantly, to keep medical liability insurers involved in writing policies in the State of Texas. We'd lost most of our medical liability insurers from the State. They had simply closed up shop and left because they could not see a future in providing medical liability insurance in Texas. We went from 17 insurers in 2000 down to two in 2002. Rates were increasing year over year. In my personal situation, before I left medical practice, my rates were increasing by 30 percent to 50 percent each year. So, in 2003, the Texas State Legislature passed a medical liability reform based on a much older reform passed in the State of California. California, in 1975, passed the Medical Injury Compensation Reform Act of 1975, which essentially put a cap on noneconomic damages in medical liability suits, and it has worked extraordinarily well in the State of California. The Texas law was modified a little bit, I'd say made ready for the 21st century. Instead of a single $250,000 cap, there is a $250,000 cap on noneconomic damages as it pertains to a physician, a $250,000 cap on noneconomic damages as it pertains to a hospital, and an additional $250,000 cap as it pertains to a nursing home or a second hospital, if one is involved, for an aggregate cap of $750,000. So the question is, how has the Texas plan fared? It actually came into law September 12th of 2003, and remember, I said the State had dropped from 17 medical liability carriers down to two because of the medical liability crisis in the State. Now we're back up to 14 or 15 carriers. And most importantly, they came back to write business in the State of Texas without an increase in their premiums. This is, indeed, a significant reversal. More options mean better prices and a more secure setting for medical professionals to remain in practice and certainly provides physicians the certainty that they need to keep their practices open in Texas. And one of the most astounding and unintended beneficiaries of this was that of the small, community, not-for-profit hospital that was self- insured for medical liability. These small community hospitals have been able to take money out of those escrow accounts that they were having to hold in abeyance in case they found themselves involved in a liability suit, and have been able to put more money back into their community hospitals, been able to spend money on capital expenses, been able to spend money on nurses' salaries, precisely the types of things you want your small, community, not-for-profit hospital to be doing, rather than just holding money against a day where they might be involved in a large damage suit. So I took the language of the Texas plan and worked so it would fit within our legislative structure here in the House of Representatives, and actually gave this legislation to the ranking member of our Budget Committee, and he had that bill scored by the Congressional Budget Office. So the Texas plan, as applied to the Texas house of representatives, to the entire 50 States, would yield an average savings of $3.8 billion over 5 years. Not a mammoth amount of money, but when you are talking about a $2.99999 trillion budget, this savings would amount to moneys that we could use on any of the other number of spending priorities that we hear so much about in this Congress. And consider this: A study done in 1996 by Stanford University revealed that in the Medicare system alone, the cost of defensive medicine was approximately $28 to $30 billion a year, 10 years ago, Mr. Speaker. I suspect that that number is significantly higher today. Defensive medicine, those additional tests and procedures that are ordered by doctors in order to help them provide a good defense should they have a bad outcome and should the case go to litigation in the courts, again, moneys expended on medical care not for the care of the patient, but to provide the best possible defense for a physician if a case is taken into court. Another consideration is young people getting out of college who are considering a career in the health professions, whether it be medical school, nursing school, dental school, or one of the allied professionals, the current system keeps young people out of the practice of health care for their livelihood because of the burden that we put on them. One thing we have to consider: They are graduating from school with massive amounts of debt, and then immediately upon getting out and emerging on the world and starting into practice, they have to come up with another $100,000 for their liability insurance. It is an untenable position, and it drives young people away from considering a career in health care. One of the things that I think we really need to focus on, getting back to the cover of Texas Medical Association and running out of doctors, part of ensuring that the workforce for the future includes helping younger doctors and younger students with residency programs, one of the strange things about doctors is we do tend to have a lot of inertia. A lot of us tend to practice very close to where we did our training. Studies have shown that many doctors will stay within 100 miles of where they trained. They like to practice in communities similar to the communities in which they did their training. So it would be a great asset to look at areas in this country where there is high need for certain types of physician specialties, areas that are currently medically underserved, and encourage young doctors to get their training in these locations where they are actually needed. Now, a bill that I am going to introduce, called the Physician Workforce and Graduate Medical Education Enhancement Act, 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 to build a physician workforce of the future. This bill would create a loan fund available to hospitals to create residency training programs where none has operated in the past. The programs would require full accreditation and be generally focused in rural, suburban, inner-urban community hospital locations. On average it costs a hospital $100,000 a year to train a resident, and the cost for smaller hospitals can be prohibitive. Another concern stems from the 1997 congressionally passed balanced budget amendment that set a residency cap that also limits resources to nontraditional residency hospitals such as smaller community hospitals. In my bill the loan amount to any institution would not exceed $1 million, and the loan itself would constitute start-up funding for a new residency program. As we all know, the start-up money is essential. Since Medicare graduate medical education funding can be obtained only when a residency program is firmly established, the cost to start a training program for a smaller, more rural, or suburban hospital can be cost- prohibitive because these hospitals operate on much narrower operating margins. The overall bill would authorize a total of $25 million to be available over 10 years. The fund, of course, would be replenished because these are constructed as loans, and the Health Resources Service Administration may make the loans available to new applicants. These moneys would be repaid, and the residency slots in existing programs would continually work to bring new residents into the program and keep the program self-perpetuating. To be eligible, a hospital must demonstrate that they currently do not operate a residency program, have not operated a residency training program in the past, and that they have secured preliminary accreditation by the American Council on Graduate Medical Education. Additionally, the petitioning hospital must commit to operating a residency program in one of five medical specialties or a combination of specialties: family medicine, internal medicine, emergency medicine, OB-GYN, or general surgery. Again, the hospital may request up to $1 million to assist the establishment of this new residency program, and funding could be used to offset the cost of residents' salaries and benefits. The bill would require that the Health Resources Services Administration study the efficacy of the program in increasing the number of residents in family medicine. The loans would be made available beginning January 1, 2008, and the program would be sunsetted in 10 years' time, in January 2018, unless Congress voted to reauthorize the program. Now, locating young doctors where they are needed is just part of solving the impending physician shortage crisis that will affect the entire health care system. Another aspect that must be considered is training doctors for high-need specialties. My High-Need Physician Specialty Workforce Incentive Act of 2007 will establish a mix of scholarships, loan repayment funds, tax incentives to entice more students to medical school, and create incentives for those students and those newly minted doctors. This program will have an established repayment program for students who agree to go into, again, family medicine, internal medicine, emergency medicine, general surgery, or OB-GYN, and practice in an underserved area. The Health and Human Services Department will administer and promulgate the requirements. The recipients must practice in the prescribed specialty and the prescribed area, which is designated as a medically underserved area, and the practices may include solo or group practices, clinics, public or private nonprofit hospitals. And it will be a 5-year authorization at $5 million a year. The bill would provide additional educational scholarships in exchange for a commitment to serve a public or private nonprofit health facility determined to have a critical shortage of primary care physicians. Such scholarships will be treated as equivalent to those under the National Health Service Corps, and penalties apply for those that take advantage but do not go into one of those practice areas. This will establish the Primary Care Physician Retention and Medical Home Enhancement grants to help ensure that primary care physicians continue to provide coordinated care to patients in underserved areas or high-risk populations. And the reality is we can all think of areas like that back in our home States or, indeed, back in our districts. In other areas such as the Louisiana gulf coast, where so many doctors left after the devastating hurricanes of Katrina and Rita 1\1/ 2\ years ago, it has been very hard on the doctors in this area, very hard to keep doctors in this area, very hard to encourage and entice new doctors to come to the area; and this would be one more tool, one more way, to keep the rather fraying social safety net from becoming completely undone in that area. Every year there would be a report back to Congress about the effectiveness of the program. This would allow us to assess if we are spending our dollars wisely and getting what we thought we would get when we initiated the program. Again, oversight is going to be key to this process. Well, so far in addressing the physician workforce crisis, we have discussed the medical liability, the placement of doctors in locations of greatest need, and the financial concerns of encouraging young people to go into medical school in the first place and to remain in high-need areas in high-need specialties. The next portion of this has to deal with perhaps the largest group of practitioners affected in this country and certainly the still- growing group of patients, our baby-boom generation, within the Medicare program. The baby boomers, and we have already talked about it, as they age and retire, the demand for services has nowhere to go but up. And if the physician workforce trends continue as they are today, which is downward, we may not be talking about funding a Medicare program. We may be talking about what are we going to do to take care of our senior citizens when there is no one there to take care of them? I often tell people if you see a train wreck coming, you have two options. One is to stop the wreck and avert the wreck from happening in the first place; and the other is to run home and get your video camera and be the first to get it up on YouTube. I believe the responsible approach is to avert the crisis in the first place. Year after year there is a reduction in reimbursement payments from the Center for Medicare and Medicaid Services to doctors for the services they provide to their Medicare patients. This is not a question of doctors wanting to make more money; it is about a stabilized payment system for the services that are already rendered. And it isn't just affecting doctors. It affects patients. It becomes a real crisis of access. Not a week goes by that I don't get a letter or fax from some physician who says, you know what, I have just had enough, 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 my Medicare patients. Unfortunately, I know this is happening because I saw it in the hospital environment before I left the practice of medicine to come to Congress, but I also hear it in virtually every town hall that I do back in my district. Someone will raise their hand or come up to me after the town hall is over and say, how come on Medicare, when you turn 65, you have to change doctors? And the answer is because their doctor found it no longer economically viable to continue to see Medicare patients because they weren't able to keep up with the cost of delivering the care. They weren't able to cover the cost of providing the care because of the cuts that are happening year over year in the Medicare reimbursement formula. Now, Medicare payments to physicians are modified annually using a formula called the sustainable growth rate. Because of flaws in the process, the sustainable growth rate formula has mandated physician fee cuts in recent years that have only been moderately averted by last- minute activity by Congress. If no congressional action is implemented, a cut goes through. And if no long-term action is taken, the SGR will continue to mandate fee cuts for physicians. And unlike hospital reimbursement rates, which closely follow the Medicare Economic Index, a cost of living index, if you will, which measures the increasing cost of providing care, physician reimbursements don't do that. In fact, Medicare payments to physicians cover only about 65 percent of the actual cost of providing patient services. Can you imagine any other industry or service or company that would continue in business if they received only 65 percent of what they spent to deliver the service? Not 65 percent of what they needed to make a profit; 65 percent of what they need to simply keep the doors open in the first place. Currently, the sustainable growth rate formula links physician payment updates to the gross domestic product, which has no relationship to the cost of providing patient services. But the simple repeal of the sustainable growth rate formula can't happen, or we are told it can't happen, because it is too cost- prohibitive. Two hundred and eighty billion dollars is what it would cost this year to repeal the sustainable growth rate formula. But perhaps if we approached it as something we could do over time, we could bring that cost level down to an area that is manageable. And paying physicians fairly will extend the careers of many physicians who are now in practice who would either opt out of the Medicare program, seek early retirement, or restrict those procedures that they offer to their Medicare patients. It also has an effect on ensuring an adequate network of doctors available to older Americans in this country that make the transition to the physician workforce in the future. In the physician payment stabilization bill that I will introduce, the SGR formula would be repealed in 2010, 2 years from now, and provide incentive payments based on quality reporting and technology improvements. These incentive payments would be installed to protect practicing physicians against the program cuts that are likely to occur in 2008 and 2009. The incentive payments would be voluntary. No one would be required to participate in a quality program or the technology improvement, but it would be available to those doctors or practices who wanted to offset the proposed cuts that will occur in physician reimbursement in the 2 years until a formal repeal of the SGR happens. Now, I do know from talking to my friends who are physicians and my friends in organized medicine that it is an alarming thought that we would have to wait for any period of time before repeal of the SGR. If we step back and look, in terms of a long-term solution, the only practical approach is, in fact, to deal with it on a long-term basis. The reason we are in the deep depression we find ourselves in is because year over year we've only provided these last-minute fixes, which have only served to exacerbate the problem, not solve the problem. Well, why not just do away with the SGR once and for all and get it done? Remember, the cost for doing that is going to be about $280 billion. One of the problems that we have in Congress is the Congressional Budget Office is the group to which we must petition and the group to which we must look for advice about how much things are going to cost. If we are going to be spending the taxpayers' money, how much are we going to spend, over what time will we spend it? Because of some of the constraints of the Congressional Budget Office, we are not allowed to say, look, we are doing things so much better now within the system that give us credit for that going forward so we can, in fact, reduce that number from $280 billion down to something that is more reasonable. We all saw the Medicare Trustees Report from about 2 weeks ago. It said that in the year 2005, there were 600,000 hospital beds that were not filled as a result of improvements that have occurred because of disease management, because of doctors doing things more efficiently. These are dollars that have been saved out of the part A portion of Medicare, but it's because of work done in the part B part of Medicare, and that is, after all, where we are all focused within the part B world. By postponing the repeal of the SGR by 2 years' time and taking the savings that occur during those next 2 years and applying it back to the SGR formula, we may actually get a number that is doable as far as releasing the SGR and replacing it with the full Medicare economic index so we can pay doctors the same way hospitals, HMOs and drug companies are reimbursed. One of the main thrusts of this bill is to require the Center for Medicare and Medicaid Services to look to their top 10 conditions that drive the highest percentage of payment. It's the old Willie Sutton argument: He robbed banks because that's where the money is. Let's look at the top 10 drivers of health care expenditures in this country, and look at ways where we can improve the care that is delivered in those 10 areas, and look to those areas to give us the savings that will, in fact, deliver the benefit towards the ultimate repeal or retirement of the SGR. The same conditions actually apply to the Medicaid program as well. It will be a useful exercise. It helps not only Medicare, but would also help CMS with the Medicaid expenditures as well, and will just help physicians in general provide better care for their patients. It will include some reporting back to doctors and back to patients as to their utilization amounts; these numbers will not be made public generally, but will allow doctors to individually modify their own practices if they see there are ways where they may improve. Health information technology, it is something which, I will admit, I have been slow to come to the table with as far as looking for improvements in health information technology to provide substantial savings. And I will tell you what changed my mind on that. In January of 2006, with our Oversight and Investigations Committee down in New Orleans, Louisiana, to look at the recovery from the hurricane as it impacted the health care system in that part of the world, this is the medical records department at Charity Hospital, one of the venerable teaching institutions in our country. When the city of New Orleans was flooded, these records were completely under water. Now the basement has been all but completely emptied of water. There is probably about a foot of standing water that doesn't show up in the photographs. But look at the records. This is not smoke or soot damage, this is black mold growing on these records. So how do we know that there is a patient in there that is on dialysis waiting for a kidney transplant? We will never know. We couldn't ask anyone to go in there and go through those records, it would be hazardous to their own health. How do we know about where a person was in their cancer treatment? We will never know that information; that information has been lost to the ages. This is the kind of problem that you can get into with paper records. You know, the youngsters of today, the college students of today, indeed, the young physicians of today, they understand this very well. They are connected, they are wired in, they all have flash drives and zip drives. They would no more imagine preparing a term paper for one of their classes and then only keeping one paper copy. No. They've got it on their hard disk. They've got it on a floppy disk. They've got it on a flash drive. They have probably e-mailed it to someone back home. The old adage of ``The dog ate my homework'' just won't wash anymore. We need to evolve into the 21st century when it comes to medical record keeping. It costs money to do this. It is going to require a big push from both the public and the private sectors. I prefer to think of the bonus payment as being an inducement and enticement for physicians offices to participate in this program. But on the face of it, it's just good medicine, it's just good patient care. Now, we all heard about the troubles at Walter Reed Hospital a few months ago. I went out to Walter Reed shortly after the story broke in the Washington Post, and here is Master Sergeant Blades. And he took me around building 18, and yeah, it was a crummy building. We could certainly have done a lot better than we were doing for our soldiers on medical hold in building 18. But the real thing that bothered Master Sergeant Blades was the fact that they had to wait so long to get in to see someone. And when they did, oftentimes their records that they had worked on and they had prepared and they had organized, sometimes those records, after they delivered them to the appropriate clinic, their records would get lost. His specific complaint to me was, I can spend 20 man-hours putting together my medical record and highlighting the areas that are of significance and importance to me. This goes over to one of the clinics. It sits on someone's desk until it is no longer retrievable, and I have to start all over again. Now, the VA has been very forward thinking in its embrace of electronic medical records and its investment in medical technology. The problem is the Department of Defense medical records do not interface with the VistA system at the Department of Veterans Affairs. So if delivering value to the patient is of paramount importance, it is critical that we make this type of service generally available to our patients. Mr. Speaker, I was also going to address some of the issues on health care transparency; I probably don't have time to do that. I will simply mention that I have introduced a bill dealing with health care transparency that provides for keying off what is happening in the States, and making certain that every State would have at least some level of transparency in health care pricing. In Texas, up on the Web right now, and I realize it is going to go through several different iterations and it will evolve considerably over time, but TXpricepoint.org, available on the Internet, allows patients to compare prices on hospitals in their area. Again, a lot of things we have to consider when we work on the transformation of the health care system in this country. There are good things as far as the public system, there are good things as far as the private system. We have got to be certain that we build on the good things present in both systems, and that we stop doing the things that no longer deliver value to our patients.

Mr. BURGESS

Mr. BURGESS. Mr. Speaker, I thank the gentlewoman for yielding, and I want to talk about something that really may be a fairly small part when we talk about the overall $2.99 trillion Federal budget. But in the Republican budget, in the minority's budget, that was not passed when we did our budgetary work 2 months ago, I included some work on a bill, a medical liability reform bill based off of law that was passed in Texas in 2003. This bill is essentially a bill that limits, that it does cap awards on noneconomic damages a little different from the bill that we passed several times on the floor of this House in the past 4 years. The bill that we have had on the floor of the House the past 4 years has been based off the California law, the Medical Injury Compensation Reform Act of 1975 which caps noneconomic damages at $250,000. Now, in Texas, back in the legislative session that occurred in 2003, an effort was made, Texas was in a significant problem as far as medical liability was concerned. We had lost most of our medical liability insurers from the State. They had simply closed up shop and left because they could not see a future in providing medical liability insurance in the State of Texas. We went from 17 insurers down to two by the end of 2002. Rates were increasing year over year. My personal situation, rates were increasing by 30 to 50 percent a year. The State of Texas, the State legislature, passed a medical liability reform based off the California law, but updated for the 21st century. Instead of a single $250,000 cap, there was a $250,000 cap on noneconomic damages as it pertained to the physician, a $250,000 cap on noneconomic damages as it pertained to the hospital, and an additional $250,000 cap as it pertained to a second hospital or nursing home, if one was involved, so an aggregate cap of $750,000. Well, the States are great laboratories for public policy. How is it done back in the State of Texas? Remember we dropped from 17 insurers down to two because of the medical liability crisis in the State? We are now back up to 14 or 15 carriers; and, most importantly, those carriers have returned to the State of Tex tech without an increase in premium. What about the physicians who were paying the premiums that were inexorably going up? Again, a 20 to 50 percent per year increase that I saw myself, in my practice. What has happened? Texas Medical Liability Trust, my last insurer of record before I came to Congress, has reduced rates for physicians now an aggregate of 22 percent in the past 3 years. That is significant, because, remember, the rate of rise was going up 20, 30, 40 percent a year. Now it's back down 22 percent and aggregate since this bill was passed. Probably one of the most important unintended beneficiaries of this was the small community not-for-profit hospital, who was self-insured for medical liability. They have been able to take money out of those escrow accounts and put it back to work for those hospitals capitalize improvements, paying nurse's salaries, the kinds of things you want your small not-for-profit community-based hospitals to be doing, not holding money in escrow against that inevitable liability suit that might occur. Well, under the Texas plan, I took the language of the Texas plan, worked it so it would fit within our constructs here in the House of Representatives, offered it to the ranking member of the Budget Committee. He had scored by the Congressional Budget Office, and the Texas plan, as applied through the House of Representatives to the entire 50 States, would yield a savings of $3.8 billion over 5 years. Not a mammoth amount of money when you are talking about a $2.999 trillion budget, but savings nonetheless, monies that we will leave on the table in this budgetary cycle that could have gone to some of the other spending priorities that we hear so much about. It could have gone for anything else so far as increase in providing medical services. We will have to reauthorize SCHIP this year. We will have to find billions of dollars for that program. Here is $3.8 billion that he with left on the table because the majority chose not to look at this in the budgets that they passed. The other thing that is missing in this debate which we just cannot pay enough attention to, people say, well, you are from Texas, Texas has done the work. Why do you even care if there is any type of national solution? Well, it's not just the $3.8 billion that we would save under the budgetary cycle over the next years. It's the cost of defensive medicine. It is very, very hard to get a handle on the cost of what that defensive medicine is. But consider this, 1996, a study done, Stanford University, revealed that in the Medicare system alone, in the Medicare system alone, the cost of defensive medicine was approximately 28- to $30 billion a year. That was 10 years ago. I suspect that number is higher today. That's why we can scarcely afford to continue the trajectory we are on with the medical liability issue in this country. Another consideration, young people, getting out of college, considering medical school, put the brakes on their dreams. I don't know if I want to do that. I don't know if I want to face all of the hassles you have to face in the practice of medicine and those large liability insurance payments as well. We are keeping young people out of the practice, of considering the practice of a health care profession for their livelihood because of the burden that we put upon them, not just with how we reimburse physicians at a Federal level, that's a discussion for another day, but with the burden that we put on them with health professions, loans that they have to take out to get through school, they carry a big debt load when they get out of medical school. Then on top of that, they will have to go out and borrow huge sums of money just to pay their liability insurance. Many of them simply turn off that dream and say I will do something else. There is another path for me. I don't need to choose a career in health. This is the thing that we have to consider. We have to focus on how we are affecting our physician workforce for the future, how we are affecting the health care that you are our children and our children's children will receive. I appreciate the opportunity to talk on this subject. As you know, I will do it at almost any time and work it into any context. But it does have a budgetary role. It is a significant one. We shouldn't turn our backs on that $3.8 billion that's lying on the table right now waiting for us to pass the sensible legislation.

Mr. BURGESS

Mr. BURGESS. Mr. Speaker, I want to come to the floor tonight and continue on a theme that we were discussing last night, and that theme revolves around delivery of health care in this country. Some of the discussion last night dealt with the future of medical care in this country, whether we expand the public sector involvement, whether we encourage and continue the private sector involvement in the delivery of health care in this country; and those are extremely important questions, and questions that I suspect that this Congress will be debating at length over the coming 18 months and well into the next Congress, the 111th Congress that convenes in 2009. If we don't pay attention to the physician workforce that is going to be providing that health care, those discussions may be all for naught. We are obligated, in this Congress, to pay attention to access for our patients, patients in Medicare. You heard reference to the SCHIP program; patients in the SCHIP program are all going to need access to physicians. It doesn't matter whether a patient is a participant in the Medicare system, the SCHIP system, private insurance, pays cash for their care, they need access to a doctor, and that access will be unavailable if we don't preserve and protect our physician workforce going forward. This really came home to me about a year and a half ago in a conversation with Alan Greenspan. He commented on the concern for the future viability and stability of the Medicare program, of the system as a whole, is it ultimately sustainable. He felt that it would be. But his greater concern was is there going to be anyone there to deliver the services when you require them? Of course, he is talking about our physician workforce, our nursing workforce, the ancillary health care personnel, all of whom we depend upon to deliver health care in this country. We have an overburgeoning and overregulated governmental system that continues to sort of move along. We have got the other aspect of ever- increasing liability costs. If we have time tonight, I do want to touch on that just a little bit. But not just the cost of medical liability insurance, but also the aggravation of dealing with a system that, on its face, sets doctors and patients against each other. We do have to deal with that. The consequence of this is we have physicians who are my age who are leaving the profession early, earlier than the generation before them. It was very common for a physician to practice into their 60s and 70s and not at all uncommon to continue to read about physicians who continue to practice right up until the time that they no longer could. You don't see that as much any more. Physicians are making plans to leave the practice of medicine at an earlier point now than, I believe, ever before in our Nation's history. At the same time, at the other end, are we having any problems filling our residency programs? The answer is yes. Are we, in fact, encouraging the young people of this country to look upon health care as a career, as a profession? The answer to that question may not be affirmative either. So we have got an increasing number of physicians who are making early retirement plans. We are not sure it's difficult to measure the number, but it doesn't seem that the younger generation is showing up in the numbers that we would expect. Both of those pose a significant concern nationally, because we have got a society that's aging. We have a society with the so-called baby boom generation coming up, and the demand for services is going to be ever-increasing during that time. Suffice it to say, whether it's, again, the Medicare, SCHIP program, Medicaid, private insurance, cash on the barrel head, patients are going to need doctors; and it is incumbent upon this Congress to make certain that we do the things necessary to preserve the physician workforce in this country. The patients who need care, maybe a patient is in a city, or they may be a patient in a rural area, they may be a patient in an area that has been devastated by gulf coast hurricanes in the past couple of years. The reasons are complex, and we debate them at some length up here in Washington in the various ways that we can seek to improve our health care system. But even as we engage in these issue, our physician workforce is crumbling. In order to keep this scenario from becoming worse, I am proposing a series of physician workforce pieces of legislation that will consist, essentially, of three different parts. I would just draw your attention to the cover of Texas Medicine. This is a periodical put out by the Texas Medical Association every month. This is the cover of the March issue. The title is, ``Running Out of Doctors: Medical Schools Unable to Keep Residents in Texas.'' This is one of the things that we really do have to focus on. When you look at the Medicare system, one of the biggest problems we have is the formula under which physicians are paid, and addressing the declining Medicare physician payment issue has almost become an annual rite here in Washington, DC. But every time we do that, we actually make it harder to ultimately reform the system. Every time we come in at the end game, at the end of the year, to try to prevent further cuts to the physician reimbursement system and the Medicare system, we actually make the overall solution to that problem harder and harder. The chance, then, for real reform, the opportunities for real reform, become smaller and smaller with each succeeding year. The current payment system in the Medicare system, the current payment system rewards ordering labs and performing procedures, necessary or not. In fact, not often are the questions asked, if those services, not even if they are necessary, but are they, perhaps, overvalued. Is Medicare getting its best value for its dollar? The current system is indifferent to the fact that the procedures or the tests ordered may be questionable or may have significant merit, may, in fact, be critical for a patient's well-being. The fact is that the system doesn't work. It doesn't work for doctors, it doesn't work for patients, and certainly not working for the American taxpayer. Yet, year in and year out, Congress allows it to persist. Well, if we continue to allow this condition to stagnate, there will be fewer and fewer physicians accepting Medicare payments. This will result in reduced access for beneficiaries and a restriction in the physician workforce pipeline over a period when the demand for medical service is projected to explode. Fewer students are pursuing a career in medicine. More and more doctors are retiring early. Even fewer will choose primary care fields in their study of medicine, and all of this happens against a backdrop of more and more Americans growing older. As Americans grow older, they do face greater and greater health challenges. So, arguably, our sickest and most complex patients are going to need to rely on an ever- dwindling physician workforce. Now, if, indeed, we do nothing, the picture I have just painted may, indeed, become a reality. But again, the three pieces of legislation that I plan to introduce will start with one that will ensure stability of the physician work force by ensuring stability of the payment system within Medicare. There is a formula under which physicians are paid in Medicare, and I'm going to talk about this in a little bit more detail in just a few minutes, but it's called the sustainable growth rate. And the net effect of the sustainable growth rate formula is really anything but growth. It, in fact, results in a reduction over time, 5 to 10 percent reduction in physician payments year in and year out. And that number is brought to us every year by the Center for Medicare and Medicaid Services out of the Department of Health and Human Services. We'll actually receive data on that, what that number of that percentage cut will be this summer, sometime in July. The first bill that I'm proposing would, in fact, eliminate that sustainable growth rate formula and replace it with a different formula. It's called the Medicare Economic Index, really not so important what it's called, but it is a cost of living update, if you will, a market basket update based upon the cost of input. What does it cost the doctor to run their office, to run their practice? And if they're going to be able to sustain that over time, obviously, the Medicare reimbursement rates are going to have to keep up with the cost of living adjustment, or keep up with inflation. It only makes sense. We do it in almost every other aspect of Medicare. And again, I want to discuss that in some detail in just a moment. One of the other things that happened in 2003 was we reset the SGR baseline to reduce the level of those cuts, and, in fact, that's a budgetary maneuver that may well be available to us again this year and, in fact, is one that I think we should take advantage of. So this legislation does, in addition to repealing the SGR, it does so in the year 2010. In the 2 years prior to that time, reset the baseline so that the depth of those cuts are not so significant. In order to protect physician practices against a reduction in income and, hence, encouraging physicians to leave the Medicare system, in order to protect during that 2 years time, allow bonus payment of 3 percent for voluntary reporting on quality measures and 3 percent for those practices that choose to increase or improve their health information technology that almost every practice will be relying on with greater and greater need in the years to come. So in aggregate, those bonus payments are 6 percent. And by resetting the baseline, the reduction in payment will be in the 5 percent range. So the net effect will be either a 0 percent update or possibly even a 1 percent update, which I think would be welcomed by most physicians in practice. And that's a temporary situation. What is the reason to delay the SGR repeal? Why not just do it straight up? The reason is because of the projected cost by the Congressional Budget Office, and that projected cost makes it almost impossible to do that without making some significant adjustments in other aspects of payments for medical care that, quite frankly, I don't know that Congress has the will to do. But the reality is, we are saving money year over year in Medicare by providing services in a more timely fashion. The Medicare prescription drug benefit passed in 2003, a case in point. The trustees, the Medicare trustees report released just a few weeks ago said that in 2005 there were 600,000 hospital beds that weren't filled in Medicare. This was a savings to part A in Medicare, which really should accrue to part B and go to offset the cost of repealing the SGR formula. We are not allowed, under the rules of the Congressional Budget Office, we are not allowed to look ahead and say well, we are going to get savings in this system because of changes that we've made. But what we can do is sequester and aggregate those savings over the next 2 years, and then use those actual dollars to buy down or reduce the amount of dollars that it's going to cost to repeal the SGR. Again, a small bonus update for beginning in the year 2008 for some health information technology implementation. These measures are in a large part well overdue. And this Congress, the last Congress was unable to come to an agreement, the House and the Senate, over the type of health information technology that we wanted doctors offices to pursue. But the reality is, delaying that implementation further only tends to cost more money to the system. So we do need to get on about the business of encouraging physicians' offices to do this work. Not only is it necessary, I think, to provide that bonus payment, but it's also necessary to provide some safe harbor provisions in laws that are known as the Stark clause, the anti-kickback, and anti-compete laws that we know in aggregate as Stark 1 and Stark 2. Additionally, if physicians voluntarily report quality data, that additional bonus payment will be there for them as well. So collect an aggregate. All of that data within the Center for Medicare and Medicaid services, money to save from part A, part C and part D as well. Aggregate, sequester those savings and use that to offset the cost of the ultimate repeal of the SGR. And in addition to that, there is the Inspector General in Health and Human Services, along with the Department of Justice, have gotten very aggressive about going after areas where health care monies are spent inappropriately, the so-called fraud and abuse that exists within some aspects of the Medicare system. And a recent newspaper article disclosed a significant amount of money that was recovered by eliminating an episode of fraud and abuse that was occurring I believe in the State of Florida. Well, those monies need to be, again, reallocated back to the part B part of Medicare again to pay down or buy down the cost of that SGR appeal when the time comes. Now, one of the issues that was addressed in the Texas Medical Association article is that because of the lack of residency programs within the State of Texas, Texas is doing a good job with, they've expanded medical schools and they're doing a good job with medical instruction, but the doctors that they're educating in Texas are having to leave Texas to get their specialty training or their residency training. And the fact is that most physicians practice within 100 miles of where they did their residency training. So to be able to increase the amount of residency programs that are available in rural areas, in midsize or small urban areas, it is going to take some effort by this Congress for that to happen. The United States does have good residency programs. They're the envy of the world, and people come from all over the world to participate in our postgraduate education in our academic medical centers. But that's just the point. A lot of residencies do exist in conjunction with large academic medical centers and, as of a consequence, that's in a large urban area. Again, doctors are more likely to practice close to where they train and in similar environments. So most American trained doctors, as you would imagine, stay in urban areas and practice specialty or subspecialty medicine, which is not a bad thing. And that's not to say that that is necessarily wrong, but we do need more physicians who are going to set up their practices in primary care in more of the generalist theme rather than the specialty theme. The second bill that would be introduced would be the Physician Work Force and Graduate Education Enhancement Act. And it establishes an interest free loan program for eligible hospitals in rural, small and urban areas to attract residency programs in specialties like family medicine, internal medicine, pediatrics, emergency medicine, OB/GYN or general surgery. This would require an authorization of $25 million over 10 years from 2008 to 2018. And of course the Secretary of HHS would report back to Congress on how the program is doing with achieving its stated goals. Well, let me talk for just a moment about the Medicare payment formula, because this is an important point, and it is difficult to understand. It's a program that obviously was created by Congress and Federal agencies and one that is understandable by perhaps very few. But looking at this graph, the colored bars on this graph represent the years, 2002, 2003, 2004, 2005, 2006, I'm sorry, 2007, 2006 does not appear on this graph because it was actually a 0 percent, 2006 is the blue bar on the graph. If you look at the four parts of Medicare, the hospitals representing Medicare part A, doctors, Medicare part B, Medicare Advantage, part C, including nursing homes on this graph as well, and you look at the Medicare Advantage plans, the hospitals and the nursing homes, and each of those year over year receive a market basket or a cost of living upgrade year over year. You can see for hospitals, for example, it's ranged about 3 percent a year, sometimes a little bit lower, sometimes a little bit higher. The Medicare Advantage plans have done a little bit better. Nursing homes very similar to hospitals. But look over at the physician reimbursement. In the year 2002 there was about a 4\1/2\ percent reduction in physician reimbursement. Then, in 2003, 2004, 2005, very, very modest, 1.8, 1.7 percent cost of living updates. Lower, I would point out, than hospitals, nursing homes or certainly the Medicare Advantage plans. In 2005, this was actually part of the Deficit Reduction Act that was passed in 2005 and held physicians at a 0 percent update. Projection for 2007 was for a significant reduction, but the reality was, again, we made an adjustment at the end of last year to once again hold that at a 0 percent update. But you would have to ask yourself, how long, at running a small business, could you continue without any attention being paid to what does it cost to run the business? At some point, if this line stays flat or continues to diminish, at some point you don't have to have an MBA from an elite Eastern institution to figure out that you cannot continue to sustain that. Again, physician offices, in the main, are small businesses and as a consequence, a continued reduction in payment or even a flattening of payment which when everyone else is seeing a cost of living adjustment of between 2 and 4 percent, that's indicative of the inflation rate for medical offices. And they in fact are on a significant downward trajectory, one that ultimately is not likely to be sustainable. Now, last year, in an attempt to deal with this, I introduced legislation that was a little bit different from the bill that I've introduced this year. It was H.R. 5866, and it was aimed at tackling this problem with the sustainable growth rate formula and replacing it with a cost of living update, a cost of living adjustment update. The primary focus was to ensure that seniors have better access to the health care that they need, that, acknowledging that the SGR reductions of 5 percent every year, year over year, makes it less likely for doctors to continue to see Medicare patients. The plan then had four main goals. Ensure that physicians receive a full and fair payment for services rendered; secondly, to create quality performance measures to keep consumers informed. Are you, in fact, getting value for your dollar when you purchase medical care. We have well established, in fact, they've been around for 20 years or so, institutions in each State called quality improvement organizations. Well, I wanted to, in fact, embellish or augment the quality improvement organizations and increase their accountability and flexibility so that they would be able to provide the feedback to physicians and to patients as to how they are doing; are they able to provide the services for a reasonable amount of money? Are they able to provide the services in a timely fashion? Do they provide the services that people in fact want? Well, the problem with 5866 is that once again there was a significant number of dollars that would need to be identified to offset the cost of going from the sustainable growth rate formula to the cost of living update formula. That figure last year was about $218 billion. And that is a significant amount of money to come up with over 1 year's time. Hence, the reason that this year the trajectory that I have introduced has lengthened that timeline out a little bit longer in order to identify where some of those pay fors may be found. The other option, following along the lines of 5866 from last year, would just simply be to take the money from other aspects of Medicare and other parts of the Federal payment for health care in this country. The problem is that each of those areas finds great difficulty if indeed a proposal is made to restrict or reduce the Federal expenditures that come their way and, as a consequence, 5866 never enjoyed very widespread support because of the fact that, like so many things here in Washington, DC, you end up having to pick winners and losers. That is the reason that I have taken the approach that I have for this year to expand out the timeline for the elimination of the SGR, to identify pay-fors in advance that are going to be going on anyway, but we just simply sequester them, collect them, attribute them to the part B part of Medicare. Savings that occur in hospitals, if you fill 600,000 hospital beds a year fewer than was intended, that is going to be a significant savings to the part A part of Medicare. But the reality is that savings occurs because of work that is done in part B. More doctors doing more procedures in their offices, doctors treating disease in a timely fashion so that fewer hospitalizations are required, doctors doing procedures in ambulatory care centers so that the high expense item of a hospital expenditure is, therefore, avoided. But all of those expenses come back to part B. It is only fair, then, that the savings that result to the system, the integrated Medicare system, those savings that come to the Medicare system, need to be attributed to the part B, especially when we have got this large price tag for repealing the SGR that confronts us. Well, again, this year I want to approach things a little differently. But, again, first and foremost if you are talking about preserving the physician workforce, you have got to protect those men and women who are on the ground, in the trenches, delivering care right now. If they get dispirited and walk off the job or say, I am no longer going to care for Medicare patients or I am going to restrict Medicare patients from my practice or begin restricting the procedures that I offer to Medicare patients, we don't get good value for our dollar that way. So getting that Medicare payment policy right has to be the first aspect of this physicians workforce consortium that will preserve our medical workforce for the future. Paying physicians fairly will extend the careers of many doctors who otherwise will simply opt out of the Medicare program or seek early retirement. The principles of the new bill: Again, eliminate the SGR. It is critical that the SGR be eliminated, and we can't lose sight of that fact. The problem is right now I don't think there is the savings identified to eliminate the SGR nor am I convinced that the will in Congress is to eliminate the SGR in one chunk. So extend that timeline out a little bit and allow that price tag to be reduced because of the lengthening of the timeline. But eliminating the SGR is the fundamental principle that has to be followed, and the bill that I am going to introduce will eliminate the SGR in the year 2010 and in the meantime provide incentive payments based on quality reporting, technology improvement that could total as much as 6 percent to protect the physicians over these next 2 years where the cuts in the SGR arguably will be about 5 percent. In both 2008 and 2009, physicians' practices can opt to take advantages of those bonuses and may, in fact, be returning value back to their businesses, and this would be a good thing. If you expand the ability to monitor patient care through health information technology, that is not just for your Medicare patients. That is going to be for all patients. So there would be a general improvement that would permeate throughout a physician's practice. Most physicians in this country don't just see Medicare or don't just see Medicaid. In fact, they see a mix of patients, some Medicare and some Medicaid, some private insurance; but all patients under a doctor's care would benefit from the advances in health information technology. Let me digress for just a moment and talk a little bit about health information technology because I was a late arrival to the concept of the necessity of improving health information technology, but it really came home to me in October of 2005 when I took a trip to New Orleans. I was invited by several of the hospitals down there to come down to see how their doctors were coping with the after effects of the storm, see what had happened to some of the physical infrastructure. We spent part of the afternoon in Charity Hospital in downtown New Orleans. Charity Hospital, one of the venerable old training hospitals that has been around for generations. In fact, most of my professors at Parkland Hospital had trained a generation before at Charity Hospital in New Orleans. And here is a picture of the medical records department in Charity Hospital in October of 2005. Katrina, as you recall, came through right at the end of August of 2005. It doesn't show up well, but there is still probably three or four inches of water on the floor. Like many hospitals, Charity's medical records department was in their basement. The lights that you see overhead were actually pretty dim. I was able to get a good photograph because of a television crew that was following along behind us with their very bright lights. But look at the medical records, and you can see the black mold that has grown on these because of, again, the water on the floor and probably 110 percent humidity in this hot, damp basement. The records had been flooded. And then after the water had been mostly evacuated, of course, the water damage has already happened and now you have the growth of the black mold on the records. And, really, I don't think anyone would be too interested in handling those records. And even if you just look at the overall arrangement of this medical records department, you can see some records stuffed in on their sides up there. Some others have fallen down over there. It just makes you wonder about how good this paper system is if everything goes well. And if things go badly, as you can see, they can go very badly indeed. Well, another aspect that clarified in my mind the importance in upgrades of health information technology, a couple of months ago, of course, when all of the newspaper stories were going on out at Walter Reed Hospital, I took a trip out there to visit with the soldiers and see for myself firsthand what the situation was in Building 18. And, correct, Building 18 was an old building and it really wasn't that nice. And I think we are all better served by the fact that our soldiers who are on medical hold are no longer being housed in Building 18. But the bigger problem, Master Sergeant Blade was kind enough to explain to me what he saw as a greater degree of difficulty for our soldiers who were on medical hold waiting to see if they could rejoin their units or if they were going to be discharged from the service on a disability. And you see this rather large stack of papers that he has in front of him. That is his medical record. He is going through it with a yellow highlighter to make his case in regards to a particular disability claim. And his largest concern was, after spending hour after hour after hour going through his medical record and documenting the points that he thought were critical for him to receive the proper consideration from the Disability Board, he said it wasn't uncommon for that medical record to go sit on someone's desk for a couple of weeks and then ultimately be lost. So he was advising the men in his unit. In fact, I think it was either the second or third copy of his medical record that he was marking up in this manner so that he wouldn't run the risk of putting all his time and effort into documenting the issues surrounding his disability only to have the medical record disappear because the system really wasn't well suited to handle that. And that really brought home for me the fact that, well, of course, the VA system has a relatively forward thinking electronic medical record, but the problem is the record produced by the Department of Defense doesn't talk to the VA record system, and as a consequence, the poor soldier in the middle has to spend the time and the effort going through their individual record to make certain that, again, their case gets the proper disability consideration that it deserves. So just two reasons why I have become a believer in the past couple years that improving the information technology aspect of medical practice, true in hospitals but also true in physicians' offices as well, why I have become a believer that that is, indeed, something we do need to be devoting time and resources to. There are certainly problems with some of the systems that are out there, but ultimately the payoff is going to be that we will be able to deliver care faster, cheaper, smarter, and as a consequence, deliver more care and more value for our patients. One of the other things that again I think is important in this endeavor and the reason I have included part of the bonus payment for quality reporting is that you can't change a system if you don't know what is going on within the system. Now, again, I would stress that this would be voluntary quality reporting, that no physician or physician's office would be required to provide quality reporting. The risk to run there is that the SGR reduction would affect that physician's bottom line in 2008 and 2009. But if a physician or medical practice opted not to do quality reporting or improvements of health information technology, beginning in the year 2010, they would indeed see a repeal of the SGR, replacing that with the Medicare Economic Index. So beginning a series of positive updates of about 2 to 2\1/2\ percent in the year 2010, but, again, to forestall the pain that would go on in the years 2008 and 2009, reset that SGR baseline so the cuts are not so deep, and then provide protection for voluntary reporting measures on quality, voluntary improvements in an office's health information technology, and make these things so that they are generally available, which CMS would be tasked with making the quality reporting measures generally available, and really sort of zero in on the top 10 conditions or diagnoses where the bulk of the money is spent in the Medicare system. Not so much to emphasize quality reporting measures for esoteric diseases or diseases that are encountered once in a career but those things that are encountered over and over and over again: hypertension, diabetes, congestive heart failure. These are the types of things where the concentration of dollars is going to be located, and these are the areas where the quality reporting really needs to be focused. The part of the issue there is that the quality reporting measures do have to be generally available to physicians in all specialties and all practices. We certainly don't want to see someone who is not able to participate because their particular specialty does not have an identified quality reporting mechanism. CMS and some of the specialty organizations are already pretty far down the road on this, and really at this point it has not been identified to me that there is a problem or would be a problem for a particular specialty with not having a mechanism to report quality. Well, dealing with the other aspects of the physician workforce, the other two aspects of the three pieces of legislation, one would deal with physicians in residency and one would deal with those individuals who are looking to become physicians or those individuals who are in medical school. The Physician Workforce Graduate Medical Education Enhancement Act of 2007 would acknowledge that it is costly to educate medical students and it is costly to get medical students through a residency program. The big programs are in more heavily populated areas that tend to attract more residencies, but we need to get the physicians out into the smaller and rural communities where the medically underserved populations actually exist and get them out there in high-needs specialties. So developing a program that would permit hospitals that do not traditionally operate a residency training program would be the second aspect of establishing and protecting the future physician workforce. So this bill would create a loan fund available to hospitals to create residency training programs where none have operated in the past. And, again, that is a critical aspect to this. This is not something that is to go in and layer on top of existing programs, but this would be to create residency programs where none has existed previously. Communities like the community of Denton, Texas, that I represent, a community like the community of Lewisville, Texas, that I represent, smaller community hospitals, 150 to 200 beds, no residency program has ever existed in those communities. These would be the types of targeted communities that perhaps we could look to for establishing residencies in primary care, OB/GYN, pediatrics, general surgery. On average, it cost $100,000 a year to train a resident, and that cost for some institutions can be prohibitive. In addition, the Balanced Budget amendment, passed 10 years ago in this Congress, has a residency cap that limits resources to hospitals, such as smaller community hospitals. The loan amounts available under this bill would not exceed $1 million, and the loan would constitute start-up funding, again, for new residency programs. The start-up money is essential. Since medical graduate, medical education funding can be obtained only once a residency program is established, the cost to start a training program for a smaller, more rural and/or small urban hospital can be cost prohibitive because these hospitals do operate on much narrower margins. Identifying high-need physician specialties and getting young people to consider medical school, to getting young medical students to consider going into a primary care specialty, to going into one of those medically underserved areas, again, going back to the Texas Medical Association article, the Texas Medicine article, most physicians practice close by where they did their residency. And as a consequence, there are areas in the country that do lack medical care by trained professionals. So the third aspect of this three-part health workforce, physician workforce trio of bills, the third part would ensure the availability of the adequacy of the future physician workforce in providing medical students with incentives and assistance to practice in shortage areas and shortage specialties in those shortage areas. So the third bill would be to establish a mix of scholarships, loan repayment funds, and tax incentives to entice more students into medical school in the first place, and then create incentives for those students, those newly minted doctors, to become the family physicians, the general surgeons, the OB/GYNs, the pediatricians, the gerontologists, to become those practitioners of the future that are going to more likely stay in shortage areas, such as rural and small urban areas. There is no question that the issues in front of us as far as the physician workforce are serious, they are significant. But the feeling is that once you have established measures that will allow the medical workforce of the future, then you can begin to refine other aspects of the health care system. And, again, as I stressed last night, we are going to have that tension between what is public and what is private. What is paid for by the government, what is paid for by insurance, what is paid for by people who wish to pay cash. Is it better to have a health savings account or rely on SCHIP or Medicaid? Those arguments we are going to have, but those arguments are going to diminish in importance if we don't do the things necessary to create and retain the physician workforce that is going to be necessary to take care of people in the future. One of the greatest frustrations that I hear all the time from medical professionals, and since we are on the subject of medical professionals and how to keep physicians engaged in practicing medicine and how to get more people to consider health care as a career, obviously medical liability plays a big part in that. My home State of Texas has done an excellent job of dealing with the medical liability issue. We, on the floor of this House in Congress, in fact for the last two Congresses over the previous 4 years have passed several medical liability bills that have had at their heart a cap on noneconomic damages patterned after the Medical Injury Compensation Reform Act of 1975 out in California that has been so effective in keeping the cost of providing liability insurance within reason. Now, my home State of Texas, the year that I ran for Congress the first time in 2002, was in a crisis situation. We were losing insurers from the State liability. Insurers were leaving Texas because the climate was so pernicious. Rates were going up for physicians. For those companies that stayed behind, their rates were going up, doubling and sometimes tripling. The State of Texas and the State legislature passed a bill in the summer of 2003 that actually again was patterned after that Medical Injury Compensation Reform Act of 1975 out in California that capped noneconomic damages. The Texas approach was a little different from the approach that we took in Congress. The approach we took in Congress had a $250,000 flat cap for noneconomic damages. The Texas solution actually took that cap and spread it out three ways; a $250,000 cap for the physician, a $250,000 cap for the hospital and a $250,000 cap for a nursing home or a second hospital, if indeed there was a second hospital involved. That required a constitutional amendment in order to become law. And that constitutional amendment was passed in September of 2003. It was not passed by a very large margin. It was essentially the grass-roots efforts of physicians, their families and their patients that got the constitutional amendment passed that allowed the Texas law to take effect. But the effect of the Texas law over the ensuing 3 or 4 years has been significant. Medical liability premiums have now fallen 20-22 percent. My last insurer of record, Texas Liability Trust, has reduced insurance rates by 20 to 22 percent, depending upon the length of time that the doctor has been with the company. More importantly, insurance companies have come back, liability carriers have come back to the State of Texas. We diminished from about 17 carriers to 2 in 2002. Now there are 13 or 14 carriers back in the State. And most importantly, they have come back to the State without an overall increase in their premiums. One of the big beneficiaries of the law that was passed in Texas has been the smaller community-based not-for-profit hospital. The money that they were previously having to--these hospitals largely self- insured and the dollars that they were having to put in escrow against possible claims was significant. And now these hospitals have been able to put more of that capital back to work for them: capital expansions, hiring nurses, paying nurses' salaries. Exactly the kinds of things you would want your smaller community hospitals to be able to do they have now been able to do under the legislation passed in Texas. Well, if Texas is in such good shape from its liability reform, is it still important to consider passing a law at this level, at the Federal level, to deal with our medical justice system? And the answer still is yes. Legislation in draft form that I had scored by the Congressional Budget Office right before we did our Republican budget a few months ago, at the request of the Budget Committee ranking member, we put forth that legislation, the Congressional Budget Office scored it as savings of $3 billion over 5 years. Well, we are already talking about other areas in the Federal expenditure of health care funds where that money is needed. And that $3 billion, in fact, it's wrong, it is unconscionable to leave that money on the table and not provide that money to other areas of the Federal expenditure for health care where it might come in handy. And the bigger aspect for me, the more important aspect for me in dealing with the problem of the medical justice system at the Federal level is the dollars that are spent on defensive medicine in the Medicare system, in the Medicaid system. A study from 1996, so that is 10 years ago, over 10 years ago, out in Stanford, California, estimated the cost of defensive medicine in the Medicare system, just in the Medicare system, not in the entire health care system, but just in the Medicare system, amounted to about $28 billion a year. Again, that is money we can scarcely afford to leave on the table. If those savings are available to us, indeed, we do need to be getting those dollars back. But it is not just a dollars-and-cents issue. Nome, Alaska. I happened to be through there in the summer of 2003, stopping in Nome, Alaska, with a group of other Congressmen. You can imagine the Chamber of Commerce wanted to have a big lunch, so they invited us all there. And of course being a physician who was also a Member of Congress, about the entire medical staff from their hospital, all 19 physicians turned out to talk to me during the course of our stopover in Nome, Alaska. And one of the points that they wanted made was that they needed help because they couldn't afford the medical liability cost for having an anesthesiologist in their hospital. And the doctor who was telling me this story, I asked, well, what is your specialty, sir? And he said, well, I am an OB/GYN doctor just like you. And I said wait a minute, you're an OB/GYN doctor and you work in a hospital that doesn't provide anesthesia services. How do you do that? Ignore for a moment the woman who may need an epidural during child birth, what do you do if you're faced with having to do a C-section? He said, well, we get that patient and put her on an airplane and take her to Anchorage. Anchorage, probably 3 hours away. I am given to understand that they sometimes have bad weather in Nome, Alaska. It just makes no sense that we would allow a system like that to continue. We are doing nothing to enhance patient safety; we are doing nothing to enhance the ability to deliver care by allowing a system like that to continue. Again, we are talking about the workforce issues. Talking to a residency director from one of the large residencies up in New York City a couple of years ago, I asked her what effect the medical liability problem was having on attracting young physicians into their residency program. And she replied to me that we are now taking people into our residency program that 5 years ago we wouldn't even have interviewed. So these are our children's doctors. We are driving away some of the best and brightest from the desirability of the practice of health care, and we need to do better. So once again I would add that, while the three bills that will establish and encourage and protect and preserve and defend the existing physician workforce and the physician workforce of the future in this country, we also need to pay attention to the medical justice system in this country. We have had a number of hearings in my committee, the Committee on Energy and Commerce, and our health subcommittee on this issue. There are some other suggestions out there in addition to or instead of the caps on noneconomic damages. I am willing to listen to other philosophies, but the reality is in my home State of Texas. Caps on noneconomic damages again are working. They are delivering lower premium rates for physicians. They are delivering on the promise of more flexibility for capital expenditures for small community-size hospitals because of the dollars they don't have to tie up in escrow because of the way their self-insurance plans are constructed. And, again, we've seen the insurance companies come back to Texas. And I do from time to time hear people say, well, it's just the insurance companies wanting to make more money. The reality is, my old insurer in Texas was a physician-owned company, a physician-run company. It was essentially a company where all of the profits were returned back to the insurance company. We have several of those in Texas. So I don't believe it is all just a question of a profit-driven motive from the liability insurer. One of the things that I think we lose sight of, and there was an article in one of the papers today that talked about the fact that America was not the premier as far as the delivery of health care. We can have a lot of arguments around that thought, around that philosophy. The American health care system in general, and certainly the Medicare program in particular, has no shortage of critics here at home and certainly abroad. But it is the American system that stands at the forefront of innovation and new technology, precisely the types of system-wide changes that are going to be necessary to efficiently and effectively provide care for Americans, and particularly for America's seniors in the future. There was an article, and please don't tell anyone back in my home State of Texas that I read the New York Times, but there was a New York Times article published last October, October 5, by Tyler Cowan who writes: When it comes to medical innovation, the United States is the world leader. In the past 10 years, for instance, 12 Nobel Prizes in medicine have gone to American-born scientists working in the United States, three have gone to foreign-born scientists working in the United States, and seven have gone to researchers outside of the country. He goes on to point out that five of the six most important medical innovations in the past 25 years have been developed within and because of the American system. The fact is the United States is not Europe. American patients are accustomed to wide choices when it comes to hospitals, wide choices when it comes to physicians, and choices in their pharmaceuticals. Because our experience is unique and different from other countries, this difference should be acknowledged and certainly expanded when reforming either the public or the private aspect of healthcare delivery in this country. Mr. Speaker, in the time that I have remaining, let me just recap again the three aspects of physician workforce that I am going to be introducing. This will be a bill to repeal the so-called sustainable growth rate expenditure and replace that with a Medicare Economic Index or cost of living index for physicians beginning in the year 2010; protections in the year 2008 and 2009 for voluntary reporting and voluntary compliance with improvements in health information technology. The second bill will deal with the physician workforce and graduate medical education. This will establish an interest-free loan program for eligible hospitals in rural and small urban areas to establish residency training programs for primary care, family medicine, internal medicine, pediatrics, emergency medicine, general surgeon and OB/GYN. The authorization for this will be $25 million over 10 years, those 10 years being 2008 through 2018 inclusive. Of course, the Secretary of HHS will report to Congress on the efficacy of the programs and how they are going about achieving their stated goals. Finally, and interestingly enough, we voted on a bill on the floor of this House just a few hours ago that would be a loan forgiveness package for lawyers who graduate from law school with large student loans and are willing to practice as prosecutors in high need areas. This would be a very similar structured bill that would establish a scholarship program for physicians who are wanting to practice in primary care in high need areas to alleviate shortages in the fields of family medicine, internal medicine, pediatrics, emergency medicine, general surgeon and OB/GYN, again the so-called generalist physicians. This authorization would be for $5 million for each of 5 years, fiscal year 2008 through 2015, a $25 million total authorization that would establish a loan repayment program for generalist physicians who agree to serve in medically underserved areas. A second authorization for an additional $25 million total would make grants to States to provide financial aid to physicians agreeing to serve in medically underserved areas and to support patient-centered coordinated care in qualified medical homes. There would be additional authorizations to make grants for board certified entities to establish or expand geriatric program fellowships in rural, suburban or medically underserved communities, and, finally, a report to Congress on the efficacy of the program. Then lastly, but certainly not least, amend the Internal Revenue Code so that gross income does not include compensation received by a physician from a local government for a qualified medical service that is performed in a medically underserved community and under contract with the local government for 4 years. This compensation will be taken into account as wages and must still be reported, but it just won't count toward that individual's adjusted gross income. Mr. Speaker, I appreciate very much the time allotted to me this evening. These are important issues. Again, whether one comes down on the side of increased governmental control of medical care or continuation of some aspect of the private practice of medicine in this country, the critical thing is that we have the doctors there who are willing and able and trained to provide the services that we all want. Additionally, for those individuals who would say expansion of the government program, the government-funded side of medical care is the only way to adequately cover people in this country, I think we have to look at how good a job we are doing right now with about the 50 percent that is devoted to the public sector in the practice of medicine. About 50 cents out of every health care dollar spent in this country has as part of its origin the United States Congress at some point or other. So we have to ask ourselves, are we doing a good enough job there? And I would suggest, particularly when you look at things like the sustainable growth rate formula under which physicians are paid, I think the answer to that question would have to be no, we can do a better job with that. So certainly before any consideration for expanding any part of the public part of paying for medical care in this country, we have got to be sure that we have our figures straight. We have to be certain that we are willing to tackle the tough problems of paying for those things, and certainly the SGR formula needs to be sunsetted and needs to be no longer part of the parlance and discussion on the floor of this House of Representatives.

Mr. BURGESS

Mr. BURGESS. Mr. Speaker, I come to the floor tonight to talk a little bit about the Nation's health care system, some of the challenges that face us and some of the successes that have happened in spite of the fact that they aren't generally noticed by the people who report on things. Mr. Speaker, my career prior to coming to Congress was that of a physician. A lot of people will ask me how did we end up with the situation that we have, how did we end up with the system of health care that we have in this country? After all, Western Europe, we are not that much different from our Western European friends, and yet they have largely single-payer, double-fund systems, and why is the American system so different? Mr. Speaker, there are a lot of reasons for that, but at the risk of oversimplification, if we look back to the days when the country was involved in the Second World War, of course President Roosevelt at that time had put in place wage and price controls in order to keep down trouble from inflation. Employers who were anxious to keep their employees working, and there was competition for the workforce that remained behind and was not called off to fight, in order to keep that workforce employed and to keep that workforce interested in working, and not being able to expand wages like an employer might like to do, they offered benefits. They actually sought an opinion, and the United States Supreme Court ruled that health insurance benefits could be provided and would be outside of the wage and price controls. And in fact, a tax advantage was given for employer-derived health insurance, and it made the program popular, not only during the war years but in the years immediately after the Second World War. While this country was undergoing a significant economic expansion, this type of insurance policy remained in effect. Now, contrast that with Europe, and even though some countries in Europe had emerged victorious, others were vanquished. Their backyard was the site where that war was fought. They faced significant humanitarian issues if they did not quickly stand up health care systems and other social systems in order to take care of their citizenry. So, it was an entirely different landscape presented to the people who represented constituents in this Congress during the war years and immediately thereafter. I reference an article from Health Affairs from December 2006, just a few months ago, an article by Dr. Einthoven who's been a prolific writer. I don't always agree with him but a prolific writer on health issues, and he talked about employer-based health insurance past, present and future. Talking about the past, the most familiar aspect of employment-based insurance past is its rapid growth in the first three decades after World War II, the relative stability that followed for about a decade. And then he talks about the declining coverage that has occurred since the late 1980s, the exemption of employer payments for health insurance from employees' taxable income, combined with substantial efficiency advantages of group over individual insurance, fueled a rapid expansion. And he goes on to cite that by the mid-1950s, 45 percent of the population had hospital insurance. Coverage increased to 77 percent by 1963, and coverage peaked sometime during the early 1980s and, as he points out, declined in the late 1980s. Lest anyone think that I'm in complete agreement with the article, he does end up his piece that the most likely trajectory in the near term is continued erosion of employer-based health insurance. In the long term, we think that the likely and most desirable income is replacement of job-based insurance with some form of universal health insurance that encompasses choice competition. Again, we may disagree with his conclusion, and I will go through during the course of this hour some of the reasons why I do disagree with that conclusion, there are a number of things that would need to be taken into account. But other things that we need to consider with this balance of the hybrid system that we have, the public and private, we do need to talk a little bit about the uninsured in this country, what's happening with the reauthorization of the State Children's Health Insurance Program, what's going to happen with the reauthorization of federally qualified health centers, a bill we took up last year but didn't complete before the end of the 109th Congress and will have to face again this year. I'd like to talk a little bit about health savings accounts and some about association health plans. Of course, it is hard for me to talk about health care without addressing medical liability reform, and I do want to spend a few minutes on that in the hour that we have ahead of us. One of the most pressing needs and one of the issues that is brought to my attention with increasing regularity is the whole issue of maintaining our physician workforce. We have a problem in the Medicare system as to how we reimburse physicians. So certainly physicians who are in practice are feeling that burden right now. We also have physicians in graduate education and young people who are perhaps thinking about whether or not they want to go into medicine as a career, and all of those aspects of the physician workforce I think require some of our attention. Some of the things that the States are doing right now, things that are happening in Massachusetts, California, some recent developments in Illinois, indicate some of the efforts that are going on at the State level, and largely that's because of flexibility we provided to State governors when we passed the Deficit Reduction Act in December of 2005. Other health care issues, if time permits, I'll try to get into. We talked a little bit about the trauma bill that was recently signed into law by President Bush 2 weeks ago, some aspects of transparency within the health care system, and how we are going to approach coverage for long-term care, particularly as the so-called baby boomers continue to move along in the demographic chain in this country. Again, we talked about how we got this system that looks the way it does, the hybrid system that is a combination of both public and private systems. I referenced the activity that was going on right after the end of the Second World War. Fast forward 20 years and a new system into effect in 1965 that was called the Medicare system primarily focused on coverage for hospitalization and some doctor services for elderly Americans. In 1965, my dad was a doctor when Medicare came into being in 1965, and I used to tease him that in 1965 you only had two medicines, penicillin and cortisone, and you used those interchangeably. So it didn't really matter that you didn't have a prescription drug coverage when Medicare was first passed. I know he didn't think that was very funny either, but that is a discussion we have had on several occasions. Now, 40 years later, 40 years after the enactment of Medicare, how different the world looks just from the standpoint of the pharmaceutical agents that are available in the physician's armamentarium to not only treat disease when it strikes but to prevent the disease from ever manifesting itself in the first place, for keeping that patient in the state of relatively good health and not coming in, sweeping in at the end stage when the disease has already struck and caused the heart attacks or caused some of the problems that happens with untreated or poorly controlled diabetes over a lifetime. To be able to reach in and control those medical conditions on a chronic, ongoing basis ahead of time results in a reduction in the overall health expenditure for that particular disease for that particular individual, and you don't have to take my word for it. The Medicare Trustees Report that came out about a week-and-a-half ago pointed out that in the year 2005 there were about 600,000 hospital beds that were not filled that were expected to be filled, and they were not filled because America's physicians are doing a better job of diagnosing conditions early and treating them early and keeping people out of the hospital when the full-blown effects of the disease might be manifest that in many cases can, in fact, be avoided all together. So when we did the Medicare prescription drug plan back in 2003, it was a fairly lengthy and involved debate. I remember the President of the United States standing in this very Chamber during his State of the Union during 2003. Remarkable for me, because it was the first State of the Union that I got to see here as a new Member of Congress at the time. He said the issues facing Medicare are too important to be left to another President. The issues facing Medicare are too important to be left to another Congress. So, this Congress, at that time the 108th Congress, was going to tackle the problem of providing prescription drug benefits to America's seniors. Heretofore, prior to that time, they had not been available. Arguably, there were some ups and downs with that, but the fact is today more American seniors have more access to coverage than at any time in Medicare's history. The coverage that is available to them is certainly vast and extensive. Generally there are at least two medications in every one of the six major disease categories. I know Administrator McClellan worked on that very diligently in the years between the time the Medicare bill was passed and the actual rollout of the Medicare prescription drug plan. But that was simply setting the stage for the debate that continues today. Who is better suited, is it the public sector or the private sector? Who is better suited to handle the health care of this Nation? Now, currently, the Federal Government pays for roughly half of health care in this country. I know I am oversimplifying, but the numbers actually back me up on this, the gross domestic product last year was approximately $11 trillion, and we spent $1.4 trillion on health care. The Health and Human Services budget for Medicare and Medicaid alone was in excess of $600 billion. Add the Federal expenditure for the VA system, for the Indian Health Service, the Federal prison system, and you can see we are quickly going to be at that mark. It is about half of the health care expenditures in this country. The other half is broken down with a significant amount, the lion's share, being covered by people who have traditional insurance, commercial insurance, HMO coverage and all the things that we generally associate with insurance in the private market, and then smaller amounts would be attributable to individuals who simply pay for their care out of their pocket, and are uninsured, but are available to pay for their care. There is no question that there is some care rendered in this country, no doubt about it, given by the good graces of either the hospital or the doctor involved, so-called charitable care or uncompensated care, which does account for a significant amount of the care given in this country. Well, what is the best way, this tension between public and private. Should we expand the public sector? We are going to have that debate in a big way, probably in the months to come regarding the expansion of the public sector, the public side of health care. Certainly we can look to Canada as an example of a country that has done, essentially done away with the private practice of medicine and put a publicly funded payment plan in place. But even the Canadian Supreme Court a few years ago said that, you know what, access to a waiting list is not the same thing as access to health care. They acknowledge some of the problems that exist in the system, some of the problems that exist within the Canadian system. The British National Health Service, again, I go back to my comments earlier about the time during World War II and its immediate aftermath, the British National Health Insurance came on the scene earlier in the last century, and has evolved essentially into a two-tier system. You have patients who are taken care of in the National Health Service, to be certain, and everyone has coverage to the National Health Service. But, again, there may be issues with waiting times, there may be an issue to waiting to see the practitioner or the specialist that you wish to see. As a consequence, some of the most expensive health care available today is in the private system that exists, that coexists, with the British National Health Service. Another aspect to that that is troubling to some people because of the wait. How long is it reasonable to ask someone to wait for an artificial hip replacement, for example? Certainly some of the studies done at the National Institutes of Health have shown that with today's minimally invasive surgery, and the in-joint replacement surgery, the savings to the economy are significant because of the minimization of the lost days of work, the lost productivity by a worker who is having a problem. But, if you have to wait, as in some systems you do, if you have to wait 1 month, 2 months, 3 months, is that such a big deal; 6 months, going on a year? Well, I would submit that if a patient is in their 70s or 80s, that length of time is a significant electricity of time and, in fact, may increase the morbidity and, in fact, the mortality of people who are suffering from those types of diseases. So those systems are not inherently fair if someone is in their seventh or eighth decade of life, or they may not survive the wait for the care that is involved. So, expanding the private sector, is that the answer? I don't know if it's the entire answer, but it's certainly a big part of what must be the ultimate answer that we come to. I would reference what has happened with medical savings accounts. They just turned 10 years old last year. The Kennedy-Kassebaum Act was passed in 1996. I was a practicing physician at the time with no thought of ever running for Congress, but I knew I wanted a medical health savings account as soon as I could get one. In fact, 750,000 policies was the cap placed under the Kennedy- Kassebaum legislation. I was significantly concerned that I would not be able to get signed up for one before the cap was reached and no more were available. Turns out, I needn't have worried, because the cap was never fully prescribed because of some of the restrictions that were placed on the old medical savings accounts that were the original type of policy that was available. In my home State of Texas, because of the restrictions placed on insurance carriers, only two carriers were really interested in providing what might be regarded as an account, a high deductible account, that could be coupled with a medical IRA or a medical savings account, which would continue to earn interest, be available to pay that high deductible if someone got sick, but in the event that it was not required to be used, would grow over time. These were pretax dollars that were put away into the savings account, again, much like an IRA, but the only difference being that these dollars would be earmarked, and I realize that's a bad word, but these dollars would be sequestered only for paying for medical care. Well, that changed in 2003 with the advent of the health savings accounts, as we passed the Medicare Modernization Act. Health savings accounts today are accounting for a significant number of policies, and I don't have the most recent statistics at hand, but 3- to 4 million policies that have now been obtained, and about 40 percent of the people who have a health savings account today previously lacked health insurance coverage. Now, one of the great things that I tell, particularly younger audiences, when I address them about health insurance, 1994, trying to buy a health insurance policy for someone who was not employed, someone who didn't get their insurance through their employer, just wanted to go out on their own and get a policy that would provide them coverage, if they needed it, and pay for it themselves. Number one, they are paying for it with aftertax dollars, so that's a more expensive way to go about getting insurance, but the other thing was, in 1994, you couldn't get it at any price. It just was not available. I know this, because I attempted to buy a policy for a family member who was not working at the time, but I thought needed insurance coverage. Well, fast forward by 10 years. A young American getting out of college today, 24, 25 years old, now not able to be carried on his parents' insurance any longer, wants to go into business for himself or herself, wants to be a entrepreneur, wants to take part in the American dream but also wants to do the responsible thing and have health insurance. That individual can go to the Internet, go to the search engine of choice and type in ``health savings account.'' Very quickly, they will find a vast array of insurance products that are available to them at a high deductible, PPO product, may cost in the range, in my home State of Texas, for a male, age 25, nonsmoker, those premiums are going to be in the range of about $65 a month. It is eminently affordable for someone just getting out of college who wants to do the right thing and have that insurance coverage. Moreover, if they want to further do the right thing and save some money towards that high deductible, should they ever be called on to make that expenditure, those monies can go into that account as pretax expense, and they will grow tax deferred over the life of the account. Now, why is that significant? It's significant in that, correct, it's a high deductible policy. So if that person needs a flu shot, their insurance is not going to cover it. That is going to be contained within the deductible. Yes, they will, in all likelihood, either pay for it out of the money they have held in the health savings account, or they may just choose to pay for it out of pocket. But, if they have a motorcycle accident some night and wind up with an evening in the emergency room, and 3 or 4 days in the intensive care unit, and face a hospital bill of $15- to $25,000, guess what, that bill is going to be covered. That is a significant difference from what was available in this country in 1994. I would also reference the expansion of, well, you think, gosh, that high deductible policy, if you need anything more than a flu shot, who is going to want that because the cost of health insurance is so high, or the cost of health care is so high? In today's Wall Street journal on the back page, the op ed page, there's an article about customer health care. One of the things it talks about is the growth of so-called minute clinics or urgent care centers. Quoting from the article now, written by Grace-Marie Turner, these new retail health clinics are opening in big box stores and local pharmacies around the country to treat common maladies at prices lower than a typical doctor's visit, and much lower than the emergency room, no appointment necessary, open daytime, open evenings, open weekends, most do take insurance. Prices vary from services like from flu shots from $15- to $30 to care for allergies, poison ivy, pinkeye, $50- to $60 and tests for cholesterol, diabetes, less than $50. Competition is already starting to drive these prices down. So there we have some good news. We have the health savings accounts, which are now available and sold on the Internet, and that competition has driven those premiums down, and we have the growth of people who are providing care for someone who is willing to pay for it out-of- pocket, whether they be someone who just wants to have the convenience of a walk-in clinic, or someone who perhaps has one of the consumer oriented products, one of the high deductible products, and wants to, is shopping around for that bargain in health care. Now there are other options available that weren't there before. Other things to talk about within the private sector, association health plans, that's legislation that we have passed before in this House, both in the 108th and 109th Congress. Clearly, we need to take a look at that again in this Congress. Association health plans allow groups of employers who have a similar business model to band together and buy insurance in the larger group market to take advantage of some of those economies of scale that may be gleaned by a larger employer, make those available to small businesses as well. Again, we have passed that legislation twice in the House of Representatives, in the 108th and 109th Congress, and something that we do need to consider taking up again this year. When I talk about consumer oriented health care, when I talk about the health savings accounts or the growth in health savings accounts, one of the things that is so important for consumers, if they are going to be educated consumers, if they are going to make informed decisions about when and how they purchase their health care, we are going to have to make more information available to people to rationally make those decisions. Information about cost, price and quality is going to have to be more generally available, and I recognize that there is a value in opacity, or it wouldn't have developed in the first place, but more information available to the health care consumer. In fact, in my home State of Texas, this recently has happened with hospital charges. In all except for the smallest of hospital markets, an individual can go to a Web site, txpricepoint.org, and find out information about the hospitals in their area for given classes of hospital care, childbirth, for example, fixing a broken leg, for example, with or without complications, all listed there. Very quickly you can get information about how hospitals in the area compare and how the hospitals compare with other hospitals statewide that are of similar size and have a similar patient mix. This is just the first step in providing that information. I recognize there is only so much that can be gained from looking at the overall hospital charge for a particular diagnosis, but as more information becomes available, and as more information is placed up and available on these Web sites, consumers are going to be able to make more informed choices about how they spend their health care funds. One of the biggest problems ahead us and one of the biggest problems we have to tackle is the uninsured. Currently the United States Census Bureau says that there are over 46 million people who lack health insurance in this country. And I know we can have the arguments about who is represented in that 46 million and that there are some people who lack insurance only during part of the year. But they're still counted toward the total number. But the reality is it is a significant number of Americans who lack health insurance. As a physician, first, I will be the first to point out that having no insurance does not equate to having no access to health care because every physician can tell you about cases they've had where reimbursement either never arrived or they just simply did the case knowing that the person was uninsured and no reimbursement would be forthcoming. But I think we also recognize that delivering care in that manner, it is not always delivered in the most timely of fashions, and you don't always get your best health outcome. Now, one of the solutions that we will have to deal with in Congress is the reauthorization of the Children's Health Insurance Program. Again, that program is 10 years old and had a 10-year reauthorization requirement upon it. It's not different from Medicaid. It's not an entitlement. It is a block grant to States to provide coverage for uninsured children within that State. It does provide flexibility for the States to determine standards and providing health care funding for those children who are not eligible for Medicare, but whose parents truly cannot afford health insurance. The bill, when we work on that in committee, there are several things that I think are important that we do need to look at. One the problems of course we have run into with S-CHIP is that some States have found themselves in a shortfall situation. And one of the things that is troubling about the reason some States are in a shortfall situation is that they are covering adults and not just children. Now, providing health care insurance or providing health insurance for children is less expensive than providing health insurance for adults because children obviously, are younger, they tend to be healthier, they tend to get better quicker. And although there are some illnesses that are particular to children, in general, the children's population in this country tends to be very healthy. And if you provide a modicum of health insurance and a modicum of prevention on top of that population, they are going to be even healthier still. So States that cover adults as well as children, if a State is not covering all of the children that it could cover under its S-CHIP program, perhaps it's not a good idea to be covering adults, non- pregnant adults. Pregnancy should rightfully be covered under an S-CHIP program. And, in fact, Mr. Speaker, there are four States that cover more adults than children. And I do hope we will look at this when we take up our S-CHIP reauthorization in our Energy and Commerce Committee, in the Subcommittee on Health, I certainly hope we will look at that. One of the ongoing arguments with the Children's Health Insurance Program is, do we tend to drive out the private sector by the State taking on the burden of insurance children whose parents make too much money for Medicaid but not enough money to provide them health insurance. If an individual has insurance through their employer, but they cannot afford the dependent coverage that the employer offers, and therefore don't take advantage of that dependent coverage that the employer offers, we should allow the flexibility for S-CHIP funds to be used to purchase that, or at least buy down the cost of that dependent coverage. We'll leverage our S-CHIP dollars so that they go so much further if we will do that. Indeed, we heard testimony in a hearing the other day from an individual who said that as much as 10 percent of a State's S-CHIP funding may be used for so-called premium support. And if that is the case, I think we need to, but most States find that that is a program that is not well subscribed to. So we need to get that information out there. And if we need to make more dollars available for that type of premium support, then, indeed we should do that. Now, that's not going to take care of all the problems within S-CHIP, but we certainly don't want to crowd the private sector out with a Federal program or a State program because there is value, I believe, in keeping the private sector involved and invested in providing health care for children. A number of other things we could do during the authorization of that bill, it's a great opportunity to perhaps expand some of the health information technology that everyone talks about but no one ever seems to be able to get done, and the opportunity for providing some demonstration projects in, say, two or three States, a large State, a small State and one somewhere in between might provide us some of the background, some of the tools, some of the data that we need to be able to make rational decisions when it comes to health information technology, and to also get some of the advantages that's going to come from a well-functioning information system that provides almost instantaneous feedback on what things are working, what things aren't, where can we best spend our health care dollars so we maximize the return on the taxpayers' investment. These are just a few things that I hope we'll take up when we have the opportunity to look at that bill in committee. It will be of necessity. That has to be reauthorized before the end of the fiscal year, and I feel certain that Congress will do that. Federally qualified health centers I've already referenced. We did do the reauthorization last year, but that did not get completed before the end of the 109th Congress. I trust that we will take that up again this year. That is an important program that does provide a medical home and does provide an insurance equivalent to 15 million Americans. 15 million uninsured individuals actually have a medical home and continuity of care and identified provider through a federally qualified health center. And one of the things that we talk about, relief of mandates on private insurance, one of the things that always gets my attention is that we seem to have so much difficulty when we sit down and talk. And we saw this last year in our Health Subcommittee. When a bill was put forward to allow insurance companies to sell insurance that didn't have all the mandates that some States will put on an insurance policy, and we had a dreadful fight about that one, it went late into the night. And a lot of hard feelings were expressed during the debate on that bill. But the fact is, not in this Congress, not in the last Congress, but several years ago, Members of Congress came together and agreed on the types of benefits that should be covered in a basic package, and those benefits are the benefits that are mandated to be covered under a federally qualified health center. Any community that wants to petition for a federally qualified health center will have to show that they are going to provide at least this level of care for an identified number of illnesses or ailments. And it seems to me, if we could extrapolate that experience from the federally qualified health center legislation that, again, is almost 35 years old, if we could extrapolate that cooperation that had to have been required to get that legislation up and moving over 3 decades ago, perhaps we could come together on the basic package of benefits that should be available in an insurance policy that's going to be sold in the private market. I have trouble understanding that a private insurance company would not look at 46 million people as potentially market share if they had a product that people could afford to buy. And I do think that's one thing that this Congress does need to take up. Health savings accounts I've already talked about. There are some additional improvements that we can make to health savings accounts, although they have been improved significantly in 2003 with the Medicare Modernization Act. The HSA, the so-called flexible spending account or the health reimbursement arrangement that an employer may provide, a flexible spending account of course is money that an employee may sequester, pre-tax, and use that money on health care expenditures, but if they don't use it by the end of the year it goes away. It disappears, the so-called use it or lose it phenomenon. Similar situation with the health reimbursement arrangement. If an employer is willing to provide additional dollars to take care of an employee's health care, why not allow those dollars, if they're not used at the end of the year, to become a part of that employee's health savings account, to become part of that medical IRA, to be able to grow over time? We already heard the previous speaker reference Einstein's comment about the miracle of compound interest. And this is exactly the type of power that we could tap into if we were to be able to increase the amount of money that either the employee or the employer could put into that savings account that will be dedicated exclusively for that person's health expenditures. Some of the other improvements that we could make in health savings accounts would be allow individuals to purchase their health savings account with pre-tax dollars. That would leverage so much more, the purchase of so much more insurance, even for someone in a relatively modest 15 or 20 percent tax bracket. They'd still be buying their insurance with 80-cent dollars, and that means that their insurance, that part of their budget that they allow for insurance, would go a great deal farther. Perhaps we could allow early retirees to pay some of their continued premiums out of money they've saved in a health savings account. There is lots of flexibility that we could build into the program, and I believe that we've only just started to tap into the power that is available, the power that we can put in the health care consumers hands to be able to provide for themselves and their families with this type of insurance. Again, I had a medical savings account when they first became available back in 1996. The reason I did it wasn't because I got to have an additional IRA, though that was a great benefit. But the main reason I did it was because it left me in charge of health care decisions. I didn't have to dial 1-800-California and talk to an HMO director somewhere. I was in charge of the expenditure of those medical dollars, and I made the decisions for myself and my family. And realistically, that is a lot of power that we should put back in the hands of the health care consumer. Well, a lot of the things that we've talked about so far, about the public and private, the creative tension, if you will, that exists between the public and private aspects of providing for health care in this country. But one of the things that I've referenced before, and I think we do need to spend a few minutes on, is we've got to be careful we don't put the cart before the horse, because if we are not careful, this country could face a significant shortage or a significant crisis in manpower, in physicians, in nurses, in other health care providers, other people that we rely upon to give us the health care that we need when we need it. We need to ensure that doctors in practice today, those at the peak of their clinical abilities, aren't driven out of the system by decisions that we make here in this Congress. And we need to make certain that the best and brightest that are in training programs now, and those that may be looking at going into medicine or nursing as a career, that we don't, because of our decisions in this Congress, that we don't drive them out of, we don't drive them away from their career goals. Now, about a year and a half ago, Alan Greenspan, just before he retired as the Chairman of the Federal Reserve Board, was talking to a group of us one morning and talked about, someone asked him a question about the, being able to afford Medicare in the future. And he said, yes, he was concerned about that. But he felt certain that when the correct time came, Congress would deal with how to pay for Medicare. He said, what concerned him more was, is there going to be anyone there to deliver the services when you want them. And those were words that really stuck with me, because I'm afraid if we don't take some steps to acknowledge and encourage the health care work force in this country, we may find we get to that point where a substantial number of baby boomers have retired and we face manpower shortages, and then it's going to be very difficult to deal with the situation. So I do encourage us in this Congress, just like the President said when he talked about Medicare. It's too important to wait for another Congress. We need to take up those issues in this Congress and deal with them. Now, perhaps one of the most striking things that we have to deal with every year since I've come to Congress is in the Medicare system we get toward the end of the year, and physicians in part B of Medicare face a 5 percent pay reduction. And every year, they become very concerned about that. And every year, except 2002, we've come in at the last minute and done something to help. Now, it may be nothing more than just holding off the cuts for that year, but we come in at the 11th hour and do something to help. Last year, in an effort to prevent that from being an 11th hour decision, I introduced a bill, 5866, to do away with the formula under which physicians are paid. And not to go into too much detail, Mr. Speaker, but when you look at Medicare part A, part C and part D, hospitals, HMOs drug companies, each year get, if you will, a cost of living adjustment, a market basket update that increases the reimbursement for each of those three entities. Physicians, for whatever reason, are treated differently, and there is a finite number of dollars allocated for the part B expenditure; and the more people who put claims in against that finite number of dollars, the thinner the slices of pie are that are ultimately distributed to the providers. So Congress's attempt many years ago to control Medicare expenditures by controlling volume and intensity of services has created this system, which every year causes a significant amount of strife not only for Members of Congress, not only for practicing physicians, but just tension in general in the medical profession that, since Congress doesn't value the work that we do, maybe we ought not to work for Congress any longer. And I hear that frequently when addressing groups of physicians. And, of course, this time of year, Mr. Speaker, as you know there are a large number of physician groups through town. So last year I introduced 5866 that said let's do away with the SGR; let's replace it with the Medicare economic index. That is not some formula that I was smart enough to think up. That is basically a market basket index, a cost-of-living update that would occur for expenditures under part B of Medicare. And this formula was worked out by the MED PAC folks many, many years ago. And a lot of physicians asked why we don't use the Medicare economic index. The main problem with going from the SGR to the Medicare economic index is it scores as an extremely high expense when the Congressional Budget Office looks at the bill and says this is how much it costs to do it. In fact, last year when I introduced 5866, the cost of going from an SGR formula to the Medicare economic index minus 1 percent was about $180 billion, and it was just a bridge too far, a hill too high, and we didn't get that done. This year, for me, it is not just about looking at the Medicare payment problems but also looking at physicians at the beginning of their time in the workforce as well. But getting the Medicare payment policy right has to be one of the main pillars, one of the main things that we do to effect reform that stabilizes the physician workforce. So paying doctors fairly will increase the career of many physicians who will either opt out of the Medicare system altogether or perhaps seek early retirement, or you never know. They might run for Congress. But principles of the bill that I am introducing this Congress will eliminate the SGR, but it is going to eliminate it in 2 years' time rather than this year. And I know that is a point of contention for a lot of people, but the reality is we are not allowed to look at dynamic scoring. The Congressional Budget Office simply looks at a static model and tries to make predictions on the future with that static model, and by law we are not allowed to use dynamic scoring. And yet in the Medicare Trustees Report that I earlier referenced, 600,000 hospital beds were not filled in this country because of the things that doctors are doing in their offices, in their ambulatory surgery centers, in their outpatient imaging centers. These were dollars that were savings to part A; but, actually, the reimbursement for those was drawn from part B. So if we could somehow gather and collect and sequester those savings that are happening every day from part A and offsetting the cost of the ultimate repeal of the SGR formula, perhaps we could get to a number that would be much more workable. Additionally, there is the audit enforcement that has increased lately. The Inspector General of Health and Human Services came and talked to our Oversight and Investigations Committee earlier this year, and they talked about the dollars that they were recovering in various areas of Medicare. These dollars that are recovered were stolen from part B; so these are not dollars that go to the Department of Justice or the Department of Health and Human Services in some other form. They go to part B to offset the expenditure for repealing the SGR. And I think if we will collect and allocate and sequester those funds and use those against the scoring for repealing the SGR, within 2 years' time we should have a significant dollar amount to be able to use to offset the expense of the SGR repeal. Now, in the meantime, yes, it is necessary to protect physicians who are practicing against the cuts that are already programmed to happen in the SGR formula for 2008 and 2009, and I would propose voluntary reporting, voluntary health information technology upgrades, and if a doctor or medical group is willing to do that, they could achieve as much as a 6 percent bonus payment for those 2 years to offset the reduction in payment that would come about as a result of the SGR formula. But the reality is that if we don't put a premium on prevention, if we don't put a premium on timely treatment of disease, and if we continue to drive mature physicians out of the workforce, we are probably not going to get our best fiscal results with the Medicare program, not to mention our best medical results. Well, what about the other aspects of the physician workforce? What about graduate medical education? And currently we know we are going to need more physicians in primary care, OB/GYN, pediatrics, those specialties that are devoted to treatment of aging individuals. And it only makes sense to increase the number of residencies, particularly in or near communities where the need is the highest. So high-need areas with high-need physician specialties is something that we could bring together and allow hospitals that haven't previously offered a residency program the ability to do that. We know, for example, in Texas that a physician who trains is likely to practice within 100 miles of where that training occurred. We are losing Texas-educated medical students who are going to other parts of the country for their training and they are not coming back to Texas, and the same thing is happening in other States as well. In an effort to deal with that, if we were to allow medium-size hospitals to start up residency programs, provide some Federal grants and loans for these residency programs to start up, it would encourage physicians to be in practice in high-need specialties in medically underserved areas for those high-need specialties. Now, further expanding that to the younger individual who is perhaps thinking about a career in medicine, if we expanded the old health profession scholarship loan concept and provided loan forgiveness, provided tax forgiveness for individuals in medical school, in training, who are willing to go and serve after their training is complete in a medically underserved area in a high-needs specialty, and again, family practice, pediatrics, OB/GYN, and gerontology would be the specialties that immediately come to mind; so all three aspects, keeping the physician workforce of today involved and providing care to arguably that group of the population that is our most challenging, our senior citizens, providing help to physicians who are in training today, and providing some additional help for young people who are looking at medicine as a career but might be concerned about their ability to deal with the large number of dollars that they would owe at the end of that training, to provide some loan forgiveness and some tax incentives for these individuals to, indeed, practice in medically underserved areas in high-need specialties. Well, I almost can't talk about reform in the Nation's health care system without at least talking briefly about medical liability reform. We have passed medical liability reform in both the 108th and 109th Congresses. We passed it, in fact, a couple of times in each Congress. And this medical liability reform, H.R. 5, that we passed in this Congress in my first months here, in March of 2003, was legislation that put a cap on noneconomic damages in medical liability lawsuits. Modeled after the 1975 Medical Injury Compensation Reform Act from California, this legislation was scored by the Congressional Budget Office as a savings of $15 billion over 5 years back in 2003 when this was first proposed by Congressman Greenwood of Pennsylvania. A savings, Mr. Speaker, and we held many hours to spend looking for savings that the Congressional Budget Office would allow us to credit against additional spending. Well, here was savings that we essentially just walked away from. Now, in my home State of Texas, we passed a medical liability reform in 2003 for the State of Texas that has been enormously effective in keeping physicians in the State. Previously, physicians were leaving the State. Keeping insurance companies providing the coverage in state. We had gone from 17 insurers down to two the year I first ran for Congress in 2002. And now we are back up to 13 and 14. And, most importantly, those insurance companies that stayed and those that have come back to the State have done so without increasing their rates. And over all, Texas Medical Liability Trust, my last insurer of record before I left my practice at the end of 2002, has dropped their premiums for their medical liability insurance by 22 percent since this law was passed in September of 2003. And mind you Texas Medical Liability Trust in the State of Texas was increasing my premiums by 20 to 50 percent each year for the 3 years preceding 2003. So a real victory as far as providing some relief in medical liability premiums. The real beneficiary of this law when it passed has been the smaller or the midsize community not-for-profit hospital, and these hospitals, largely self-insured, have now found millions of dollars that have come back to their bottom line that they are able to use to reinvest in capital expansion, to pay nurses' salaries, exactly the type of thing that you want your smaller community not-for-profit hospital to be doing. So this is important legislation that passed in Texas. I have drafted legislation that essentially copies the Texas law. The Texas law was a little different from what we passed in this House that never got through the other body. The cap on noneconomic damages in the House- passed bill, H.R. 5 in 2003, was a $250,000 cap on noneconomic damages. The Texas plan actually trifurcates the cap. There is a $250,000 cap on noneconomic damages in regards to the physician, a $250,000 cap for noneconomic damages for the hospital, and an additional $250,000 cap for a second hospital or a nursing home if one is involved. So basing off the Texas plan, I think, could give us at least room for discussion about how we might provide some stability, some fairness in our medical justice system in this country. Other things that we have talked about in our committee, we have had hearings on concepts like arbitration and mediation, the concept of an early offer, where a medical entity, be it a doctor or hospital, could make an early offer to an injured party or a family that would put the reimbursement or the cash in the hands of the person who is injured much more quickly. The current system that we have doesn't do a good job of delivering dollars to people who are injured. And the time it takes, average 8 years time, between the injury and the time of any payment or any settlement is further injury to the person who has already suffered something. Now, we do need to look at how we structure reporting to the National Practitioner Data Bank if we were to have the concept of an early offer. But again, it's something we talked about and had testimony about in our Subcommittee on Health and I think is something that is worthwhile for us to consider. One of the other things that I just want to bring up because it is so important, we passed the Deficit Reduction Act in December of 2005. A lot of stuff has been written about the Deficit Reduction Act, but one of the little noticed things about the Deficit Reduction Act was it did allow of State Governors a good deal more flexibility to do things within their State if they thought they had a plan that would provide more people with insurance coverage. And of course the prototype is the Massachusetts plan that has been talked about so much. And I recognize that there are plenty of things that you can talk about in Massachusetts that would not extrapolate to my home State of Texas, but still it is a significant feat where a Republican Governor working with a Democratic legislature and State senate could get this legislation through. Now, the proof is going to be in July, when the program actually takes effect and we will see how well it works. But you have also seen California and Governor Schwarzenegger talk about providing a similar sort of plan in his State. Jeb Bush, before he left office in the State of Florida, had additionally a plan for covering more people and providing people more coverage with the dollars that were being spent under the State's Medicare program; again, all because of the flexibility that was brought by the Deficit Reduction Act. We recently saw in Illinois where a bold attempt at universal coverage did not pass the State legislature. And there I think the issue was largely because of the gross receipts tax and not so much the health care aspects. But nevertheless, many States are tentatively trying to see if there may be some system that works better in their State. Again, the one-size-fits-all philosophy may not be in the best interest of every citizen in every State. The States taking the lead in crafting new approaches I think are reasonable attempts, and I think these are attempts that should be encouraged by this Congress and not discouraged by this Congress. Mr. Speaker, I realize that the information that I've been talking about tonight, some of it is technical and complex, some of it is confusing, there are some topics that some people do not even want to think about, but we are in a debate this year, next year, the year after that will forever change how health care is delivered in this country. The decisions we make in this body over the next 12 months, 36 months time are going to affect the health care of our children, of our children's children. And it is important to talk about it, it is important to debate it and it is important to get it right. We must understand the things that are working in our system and the things that are not. Fix the things that are not, and encourage the things that are working. The only way, I believe, is to keep the public private partnership that has developed in this country since the end of the Second World War, to keep that working for providing health care for the American people; plenty of places where it can be improved, and we are obligated to work on those improvements. But to simply scuttle the system because someone thinks they have a different idea, well, we saw what happened back in 1993, the enormous upheaval that happened in this country where people really got concerned about whether or not their doctor would be there and able to see them if they got sick. We want to reassure the American people that, indeed, their doctor will be there, their hospital will be there. And keep the thriving private sector, keep the growing public sector and allow that creative tension that exists between the two to expand coverage for more Americans, and most importantly, so that we keep it affordable for our children, our children's children and into the future. Mr. Speaker, it has been a long day. Many of us traveled today. And I appreciate your indulgence. I am going to yield back whatever time is remaining.

Mr. BURGESS

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

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to celebrate the 50,000th passenger to use the Commuter Express. This is a remarkable milestone for the city of Denton. On Monday, May 7, 2007, the Denton County Transportation Authority transported its 50,000th Commuter Express passenger. The Commuter Express was launched in May of 2006 and works in conjunction with Dallas Area Rapid Transit (DART) to connect Denton, Lewisville, the DART North Carrollton Transit Center and the Dallas Central Business District. The Denton County Transportation Authority (DCTA) was signed into law by the governor in 2001. On June 6, 2003, the North Central Texas Council of Governments presented the Regional Cooperation Award to the DCTA. The award is presented to local governments which promote cooperation to solve regional problems; which do not allow jurisdictional boundaries to the be barriers to solutions; and which demonstrate that joint projects can provide better use of resources as well as quality service. I would like to congratulate the Denton County Transportation Authority and the entire community of Denton County. I am proud to celebrate this occasion with them, and I look forward to working with them in the future as we make our transportation system even more efficient. The people of the 26th Congressional District of Texas are already benefiting from this service, and I know I can expect great things in the future from DART.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to observe National Nurses Week, an annual recognition of the critical role played by registered nurses in meeting the nation's health care needs. The origin of this event can be traced to 1953, when Dorothy Sutherland of the U.S. Department of Health, Education, and Welfare proposed the proclamation of a ``Nurse Day.'' The following year, nurses were celebrated during the 100th anniversary of Florence Nightingale's mission to the Crimea. National Nurses Week now begins each year on the 6th of May, which is National Nurses Day. During the week, we also celebrate National Student Nurses Day, on May 8th, and School Nurses Day, on May 9th. The week concludes on the birthday of Florence Nightingale, which is celebrated around the world as International Nurses Day. National Nurses Week is one of the Nation's largest health care events. Activities include banquets, educational seminars, and other community-wide events. These events draw awareness to the importance of registered nurses in our nation's healthcare system. These nurses compose the largest group of healthcare workers in the United States. Today, I would like to recognize our nation's 2.4 million registered nurses for their passion to the health profession and their commitment to quality healthcare. I support the goals of National Nurses Week, and am proud to represent many of our nation's fine nurses in the 26th District of Texas.

Mr. BURGESS

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

Mr. BURGESS

Mr. BURGESS. My colleagues filled the last hour with discussion of what is sublimely intuitive to the most casual of observers of the American scene, the IRS code. Now we are going to go to something a little more complex and that's health care in the United States. The question I get asked a lot of times, because I spent my precongressional career as a physician, how did we get into this situation? How did we get the health care system that we have today? More importantly, where are we going within our current system? We currently have a system that is based upon both the aspects of the public-provided system, the government- provided system and the private system. We have a system that does have a significant number of individuals who lack coverage. They may not always lack medical care, but they do lack coverage for that care. Some of the things we are going to be, of necessity, focusing on this in Congress is the reauthorization of the State Children's Health Insurance Program. We will also be talking about reauthorizing the Federally qualified Federal health center program. Health savings accounts have actually been around now for 10 years. It's appropriate to look back on where we have been with, first, medical savings accounts and then the expansion that occurred with the Medicare modernization act in 2003 with health savings accounts. Association health plans are not getting as much attention this year as they have in past years, but they are important, and we do need to think about those in the overall picture of where we are going with America's health care. Medical liability reform, probably one of the more contentious things that we have tackled in Congress since I came here in 2002 he 2003. We still, as far as a Nation, do not have an answer for that question, but several States have done things, including my home State of Texas, and also that is one of the things that I want to touch on tonight. One thing that does concern me greatly is the physician workforce today and the physician workforce of the future. I will be spending considerable time talking about things that we might do, the things that are within our grasp to do to help ensure that the doctors of today continue to deliver care for our patients, whether they be in the government sector, or the private sector, and ensure that we encourage the best and brightest among our young people to go into, to look at health care as a profession, whether it be as a physician, as a nurse, and one of the ancillary health services, but it is important that we attract our best and our brightest into those professions and perhaps a look at some of the things that are being tried in some of the States. The States, of course, are the great laboratories in our democracy. There are some interesting occurrences that are going on in some States that are trying to grapple with the problem of coverage for individuals who lack it; and then, finally, some ancillary issues. We recently passed a trauma bill on this House. Last weekend, the President signed that bill into law. Transparency, how do we make the expenditures in health care. How do we make information about cost, price and quality, how do we make that information available in an understandable format to the average consumer of health care in this country, whether they be in the private or the public sector. One of the things that we don't really talk about that often, but is going to be a significant issue, as more and more people my age get successively older and older, is how do we deal with the problem of long-term care facing this country? Well, let's go on a journey. Let's talk about the American health care system. For the purposes of this discussion, we don't have time to go all the way back to the beginning when our country was founded, though it is important to always note that while the forebearers of today's legal profession were drafting documents like the Declaration of Independence and the Constitution, the forebearers of my profession, Dr. Benjamin Rush, was treating people with leeches. We have come a great distance since that time. But if you look at just the modern era, the time since the end of the Second World War, when truly some of the big differences that developed between European countries and America, some of those differences, in fact, have their roots in the Second World War. In America, of course, in order to prevent problems with an inflationary spiral that threatened to go out of control, President Roosevelt put price controls on wages and said people could only earn so much. Well, employers wanted to keep employees working, they wanted to keep employees happy. They asked a question, could we provide benefits to our employees. Can we provide, perhaps, health insurance or health care benefits for our employees and not have that as part of the Federal price controls that were in effect, or Federal wage controls that were in effect at that time? The Supreme Court looked at it and said, that's reasonable. You can do that. You can provide the health care benefit for your employee, and you will not be violating the provisions of the wage control provisions that were enacted in the Second World War. Well, the system was working, and the war ended, and the system continued. Because, in fact, it was working well, and people liked getting their insurance that way. It continued for a number of years. If you look at a country in the European theater, the Second World War, whether they were winners or losers at the end of the war, they faced a humanitarian crisis of almost unbelievable proportion. So it is no surprise that even a country that was victorious, like Great Britain, went down the road of national health insurance, because it needed to provide a great deal of care in a very short period of time, and they didn't have the bedrock of the employer-derived health insurance that was available in this country as a result of wage controls that were put on during the war. We are often compared with Europe and why our health care system looks different from theirs, when both, after all, are modern western nations. Part of the reason does go back to this discrepancy that occurred during the war, and then, of course, the situation, the economic situation, in some cases, a very dire economic situation that occurred on the ground in Europe as the war ended. It's not the purpose of this discussion tonight to actually provide a compare and contrast with the European system, though that might be interesting to do, but take where we were at the end of the Second World War, the beginning of the great economic expansion that characterized the post-war years in this country, insurance being provided by employers, employees very happy with that, employees having good coverage, doctors being happy with that, because that coverage meant that hospitals and doctors were reimbursed, and the situation was going along, some problems, of course, and some people in this body, 20 years later, said, we need to do better than what we are doing, because after people are no longer employed, and they, perhaps, lose that health insurance, what are we going to do then? Twenty years after the end of the Second World War, in 1965, we had the rise of a new system, took probably 4 to 5 years for it to actually work its way through Congress. It was, just like today, a situation like this, was by no means easy. In 1965, President Lyndon Johnson signed into law the Medicare bill that primarily focused on hospital care for the elderly in addition to the hospital care. In addition to the part A of Medicare, there was also developed a part B of Medicare that was a reimbursement for physician-necessitated services. But we had the parts A and B of Medicare that came into being in the mid- 1960s, another 40 years before Congress made a significant change to the Medicare system by passing the Medicare prescription drug act. Now, my father was a physician back in 1965, and I used to tease him that in 1965, when the Medicare system was first enacted, there were, after all, only two medicines, penicillin and Cortizone, and they were used interchangeably. I know, he didn't think it was funny either, but the fact is, we didn't have nearly the tools at hand from a pharmaceutical perspective in 1965. Then fast forward to 2005, 2006 and 2007, ones that are just part of our everyday parlance, our everyday armamentarium in medical practice. We saw this with the trustees' report that was just released last week or the week before, where it was described that 680,000 hospital beds in 2005 were not filled in Medicare, primarily because of the things we are doing better in Medicare, treating that cholesterol at an early stage with a statin and not treating it at the end stage when cardiac surgery or, in fact, sudden death may be the outcome of undiagnosed or untreated heart disease. So we are doing a better job of treating things early at the same time. It does cost more money in the provision of the Medicare prescription drug act. There was a great deal of discussion during the time that we passed that prescription plan, but it kind of sets the stage for the debate that we are going to now have, and going to continue today. Is it better to treat things in the preclinical stage, is it better to treat things in the nonacute stage, or is it better to wait and target your therapy toward the end process of a disease, which, characteristically, is how we handled things in Medicare previously. But the impetus is, of course, to be more preventive and proactive in taking care of patients. That is the direction in which medicine is going, that is the direction in which science is leading, and that is the direction in which Medicare itself should go. So I don't think there is any question about which is better, the, the acute-care model, or the long-term model. Furthermore, we will have additional discussion, should this expand the government share of the program, or is there perhaps some room for the private sector, and can they deliver value within the Medicare system as far as providing care for patients? When I talk about the public and private, let's break it down a little bit. Currently just in rough numbers the government pays about 50 cents out of every health care dollar that is spent in this country. Our gross domestic product is approximately $11 trillion; we spend $1.4 trillion on health care. The Health and Human Service budget alone for Medicare and Medicaid is over $600 billion. Add to that the money that is spent in the Federal prison systems, the VA health system, the Indian health system, all of the other areas where the Federal Government is involved in health care, and it is not difficult to see that you are very close to that number which encompasses 50 percent. The other 50 percent is certainly not all just simply commercial insurance, though commercial insurance makes up a large portion of that. There is certainly that portion which is self-funded by patients. Believe it or not, there are patients who just simply prefer to pay their bills in cash and continue to do so, and there is a significant number of dollars that are just contributed to the system by doctors and hospitals and nurses and ancillary health care providers because the individuals whom they are taking care of have no health coverage. In the debate of how to best expand and give people more coverage, you certainly can make the argument for expanding the government system. My personal opinion is that might not be the best way to go about doing things. On the other hand, there are many people within this body who, Mr. Speaker, will be talking at great length, I suspect, over the 18 months leading up to the next election, a great many people in this body who will be talking about just that, expanding the government's role. Again, remember, we are already doing about 50 percent, and they will be looking to expand that. One of the critical questions we have to ask ourselves in expanding that 50 percent is, are we doing a good job from the government's perspective with the 50 percent that we have now? Are we doing such a superlative job that in fact it is a good thing to push out or crowd out the private sector? Or, are there some areas where the government system perhaps could improve, and some areas that perhaps it is just innately difficult for a large governmental system to improve and where the private sector can in fact do a better job? One of the things that is frequently asked, and I know I got this the years I was in private practice was, why don't we just do what they did in Canada where they have a national health insurance in Canada and everybody is happy, the doctors are paid and the patients are taken care of? Well, it was probably 2004, 2005 that the Canadian Supreme Court came out with a ruling that access to a waiting list did not equal the same thing as access to care. And I know I will get some criticism about this, Mr. Speaker, but one of the secrets of the Canadian system is the fact that they have on their southern border the United States of America with a significant amount of excess capacity in our health care system; and patients in Canada who can afford to pay, who do not want to wait, simply offload their burden from the Canadian system and come south of the border to have their problems taken care of in a more timely fashion. In the British National Health Service, of course they have developed within their country a two-tiered system. Some of the most expensive medical care that you can buy today is in the country of Great Britain where they very famously have free care. The reason you can buy private care more expensively is because, again, people want to buy their way out of a waiting list or buy their way out of the public system so that they can get taken care of in a more timely fashion. One of the problems with a very long waiting list for things like an artificial hip or even coronary angiography for someone who is being worked up for chest pain is you reach a certain point in life, perhaps a person in their 70s or 80s where that 6-month wait, 12-month wait, 14-month wait or longer becomes very detrimental to their overall health because they just simply do not have that many years left from an actuarial perspective. Well, what about the private sector, and what about Congress' interface with the private sector? Are we doing things that are generally helpful or hurtful to the private sector? And what can we do to promote policies that do keep the private sector engaged in providing health care in this country? I already alluded to medical savings accounts. Medical savings accounts started with the Kennedy/Castlebaum bill in 1996. The year 1997 was the first year that a medical savings account was available in this country. I know that because I purchased one myself. I was concerned when I heard about the medical savings accounts becoming available because Congress had restricted medical savings accounts such that no more than 750,000 would be sold, no more than 750,000 would be available during those early years of medical savings accounts, and I was very concerned that I would be even able to get one. I thought that they would be so popular that that 750,000 limit would be very quickly subscribed and I might be left out of the process. It turns out I didn't need to worry, because there were so many restrictions placed on those old medical savings accounts that if you didn't have that M.D. degree, perhaps you weren't going to be capable of dealing with all of the things that you would have to deal with. In my home State of Texas, the restrictions were such that there were only two insurers that provided the medical savings account products. Still, I found it to be a very useful type insurance. First and foremost, it left me completely in charge of any medical decisions to be made for myself and my family. I didn't have to talk to an HMO director, I didn't have to dial 1-800-California and get permission for a particular treatment. I could spend my own money and reimburse myself out of that medical savings account. The downside was you couldn't put very much money away each year in the medical savings account and the deductibles were significant, and that was seen to be a significant barrier to a lot of people with getting a medical savings account. In 2003, the compromise that ended up being the Medicare Modernization Act did significantly expand what are now called health savings accounts. The amount of money that can be put away for a family greatly increased from, I believe, $3,200 to up to $5,000 for family coverage. The deductible itself was essentially maintained, though there were several tiered products made available so that that deductible didn't have to be as high as the highest number. You could in fact purchase an HSA product with a deductible that wasn't at the maximum. One of the most significant things, and the reason I know this is having tried to purchase a health care policy for an adult child back before even medical savings accounts came along in 1994 and 1995, there was almost no one out there willing to sell in the individual market an individual insurance policy. Whether it be a high deductible or a nominal deductible, it just wasn't available for any price. Fast forward to the time after the health savings account legislation passed in 2003. Come to 2004, 2005, 10 years later, and a young person who needs health insurance just out of college, say, wants to go into business for themselves, doesn't want to have to work for a big corporation to get that employer-sponsored health insurance but wants to carry their own insurance, they can go to Google or the search engine of their choice, type in ``health savings accounts,'' and with a few clicks and a quick search they can find high deductible PPO policies sold by reputable names that we would all recognize. And of course I won't mention any of those names, but they are sold by reputable companies that we would all recognize as longstanding established insurers in this country, and the premium would be in the range of $60 to $65 a month for a high deductible policy, imminently within reach of that 25-year-old nonsmoking male just out of college in my home State of Texas. Again, that type of policy was absolutely unavailable in 1994 for any price, and now it is available at a price that arguably would be affordable by a lot of people who are just getting out of college and have their earnings at the beginning of their earning cycle. And why is this important? Yes, it is a high deductible policy. That means, if you need a flu shot, you are probably not going to be able to show your insurance card and get a flu shot; you are going to go down to the place that gives flu shots and pay the $20 or $25, whatever is required to get the flu shot. If you have money accumulated in your health savings account, yes, you can make a draw on that money to reimburse yourself for that flu shot. But if you are even to the point where you haven't gotten enough of a savings into that account yet to go and tap into that money, you are going to have to pay that money out of pocket, the important thing is, is that after your flu shot you get on your motorcycle and ride home and have an accident and spend a day in the emergency room and 3 or 4 days in the intensive care unit and face a bill that may be as much as $10,000 or $15,000 or $20,000, you do have coverage for those catastrophic amounts. And, let's face it, for young people today, trauma or accidents are going to be one of the principle causes of hospitalization. Association health plans, again, a concept that we have dealt with in this Congress the last two Congresses. It has not come up this year and the reality is it may not. But this gives small businesses the ability to band together to get that purchasing power of a large corporation. One of the hard things is you go out to buy group coverage for your small business, and they say, you know what, you have got so few employees that it is really not worth our time and the cost for that coverage is, consequently, going to be astronomical. But if you are able to combine with, say, your chamber of commerce and you can combine with a chamber of commerce across in the next county, you can combine with a couple more chambers of commerce in other cities and perhaps even across State lines, suddenly you are accumulating enough covered lives to really get that insurance company's attention and perhaps drive a better bargain, perhaps get a better deal. Right now, we won't let that happen. But the fact is that Congress should get out of the way and allow those things to occur, because it is not so much that association health plans are going to bring down the number of the uninsured, but it sure will help the rate of rise of the uninsured we see in this country, because that rate of rise is in a large part fueled by the cost of purchasing health care by that small business person; and anything we can do to keep that cost of coverage down is going to ultimately increase the amount of coverage that is available. Transparency, I mentioned before, is critically important if we are going to have so-called consumer directed health care in this country. We have got to put that information in the consumer's hands so that they can make decisions about cost price and quality in the health care system. And I understand that there is an inherent danger in transparency. Opacity is there for a reason, and that reason is generally it is financially rewarding for whoever is providing the opacity. They don't want everybody to know what goes on behind the curtain. Again, I will reference my home State of Texas. The very beginning of a transparency project has now gone up on line. Mr. Speaker, if anyone at home were interested, it is tx.pricepoint.org, and someone can go to that, Mr. Speaker, on their Web site and look at that and get information about hospital charges in their area and how they compare with the rest of the State. Granted, there is going to need to be more information available, but it is a good start, and I certainly support the folks at the State level who provided that degree of price transparency for the citizens of Texas. In talking about the uninsured, one of the things that will come up, and I think we heard the President mention it here in this House during the State of the Union address, is what about the concept of that private ownership of insurance that is paid for with after-tax dollars? The President talked about giving people a tax deduction if they purchased their own insurance, not through their employer, but just went out and purchased it themselves. Certainly a valid argument that can be made about that is, well, there are a lot of people out there who don't pay income tax. So what about the concept of providing a tax credit? Some people would call it a voucher; I prefer the term premium support. If someone is working and their employer is providing the option for having the insurance but they say, you know with what, I still can't afford the $200, $300, or $400 a month I would have to pay individually in order to get that insurance; what if we provided them some help with that premium? And might that not be a better way to approach or to tackle some of the problems of the uninsured rather than just simply ever expanding the Medicaid system or some of the other systems that are out there to cover the uninsured? If someone is earning a living but does not have health insurance available at their place of employment, even providing them that premium support so that they can go out and purchase insurance in the private market. If we would help create and sustain that market, I believe that the private insurers would look at 42 million, 45 million people as a segment of market share that they would compete for, and we ought to give them the tools to do that. Now, currently the United States Census Bureau says there are 46.6 million uninsured. I think it's important to stress, once again, that uninsured does not always mean no access to health care. It may mean that the access to health care does not occur at the point where the health care can be rendered for a lower total dollar figure, or you may not receive the best health care outcome because care has been delayed. But having access to coverage will increase access to care. One of the things that this Congress did 10 years ago, long before I got here, was a program called the State Children's Health Insurance Program. It's 10 years old. It's going to be required to be reauthorized this year. But this did provide States some flexibility and some options for providing coverage for uninsured children that resided within their State. This was primarily to be directed to children who were not eligible for Medicaid, whose parents earned a little bit too much money to have them covered under the Medicaid system and therefore couldn't, but they, themselves, did not earn enough money to truly afford health insurance. So this was a good thing. Coverage of children is relatively cheap coverage. You pay $0.60 for what would be $1 of health care for an adult. You can pay $0.60, buy $0.60 worth of health insurance for a child and get the equivalent of $1 worth of insurance for an adult because children, as a general rule, are young and healthy. They tend to recover from their illnesses quicker than do adults, and money invested in the children's program is, indeed, money well spent and money wisely invested. Some of the things that I think we ought to keep in mind as we reauthorize this bill this year, and we will be doing that through my committee, Health Subcommittee on Energy and Commerce, but some of the things I think we ought to keep in mind is that it is primarily a children's health insurance program. The decision was made to cover pregnant adults, and I think that that was a good thing, and that should be continued. But covering non pregnant adults in the Children's Health Insurance Program is perhaps not the best use of those dollars. If there needs to be a program for providing additional coverage to those adults, then let's look at doing so, but let's not divert those dollars that should be going into coverage for health care for children; let's not divert those to some other purpose. And unfortunately, we have the situation in this country today where four States actually cover more adults than they do children. Again, we need to get back to the original principle that this program was enacted, and make sure, once we're covering all the children, once we're covering all the uninsured children in this country, then perhaps we can talk about expanding it to include adults. But until that time, we do need to focus and make certain that we are covering the uninsured children. You know, a letter to the editor back home in Dallas this weekend I was reading made the comment that, of course, SCHIP, and they were talking about it primarily at the State level. And the State, my State Legislature is in session right now, and they are grappling with the questions of funding for SCHIP. But the comment was made in the letter that the SCHIP program was there for some parents who cannot afford insurance; and sure enough, that's what it's there for. And the second line went on to say that also there are some parents who are working and covered under their parents' insurance, but they can't afford that additional premium for the dependent coverage on their insurance. This is some of the cheapest coverage out there that we should take advantage of. And certainly, it is available within the SCHIP program currently for some degree of premium support. But I certainly think we need to expand that, certainly, make states aware that this is available for them to use, that they can leverage those children's health insurance dollars to buy more health insurance. And the other thing that we do that's extremely important, if the Federal Government simply takes over the function of providing all of the insurance for all of the children, the private sector is completely crowded out. And is that fundamentally a good thing or a bad thing? I would argue that it is not in the best interest of our country to let that happen, that the private sector does belong in the children's health insurance market. And we should, while we may not be required to do anything to particularly subsidize that, we certainly should not do anything that makes that an untenable business model because, ultimately, I think we are going to be less satisfied with the result. Federally qualified health centers. We are going to have to, we didn't finish the work on reauthorization of the federally qualified health center statute last session of Congress. It is going to be important to try to do that again. Once again, that's an issue that will come through my committee on Energy and Commerce. We had some very good hearings on that last year, leading up to the introduction of the bill by Mr. Bilirakis, who is no longer with us. And that bill will come up again this year. I think that when you look at the federally qualified health center, one of the things that is really encouraging to me is that a Congress, and I grant you it was 35 or 40 years ago, sat down and agreed amongst themselves, the Members on both sides of the aisle, agreed what procedures, what items would be covered under that federally qualified health center statute. And to me, that's a beacon of hope, that perhaps we can work, this body can work together and decide on what are the things that should be covered; if we wanted to have an insurance policy, for example, that was generally available for individuals who were currently uninsured. What are the parameters that should be covered? What should we encourage? If we are going to go talk to the private sector about insurance policies that may be affordable by the Nation's working poor, what should those things cover, and can we ever come to an agreement that will allow those types of policies to be sold in one State or another, and what could we do about getting those policies up and on the Internet to take advantage of the competitive influences that are present on the Internet? You know, one of the things, again, I reference Texas a lot because I spend a lot of time there. But one of the Nation's largest automobile insurers has really made a big push in the Texas market. They're famous because they have a little green lizard who's kind of their spokesman, the little green lizard with an English accent, in fact, who's kind of their spokesman. But the message is that if you can go online and spend 15 minutes with them, they can save you some money. Wouldn't it be great to provide that same tool, that same device in the health insurance market as well and get the advantage of that, that very strong competitive market out there that has been provided by the new technology of the information superhighway? It's certainly had a very significant beneficial effect on bringing down the costs of term life insurance. And we saw this back in the late 1990s, the early part of this century. Why not take that same competitive power and unleash it for health insurance and allow more people to be covered? I referenced health savings accounts before. Again, you can go on the Internet and buy a health savings account now that's available because some of the state-by-state restrictions do not apply because of the way that legislation was written. And this is an extremely powerful tool to put into people's hands. One of the disadvantages, one of the ways we disadvantage our citizens when it comes to purchasing a policy like a health savings account is that it is paid for with after tax dollars. You don't get that pre-tax expenditure. We could, in fact, further leverage the health insurance, how far a health insurance dollar could go in a family's budget by tapping into that concept of a pre-tax expense. But some of the things we have done with health savings accounts, and again, I would stress that since we passed the Medicare Modernization Act a scant 4 years ago, between 4 and 7 million people have now purchased health savings accounts. I referenced early on that first off, back in the early 1990s or, I'm sorry, the middle 1990s, it was going to be capped at 750,000 total policies. That cap was removed with the Medicare Modernization Act, and as a consequence now, at least 4 million people have purchased health savings accounts. Forty percent of those people were previously uninsured. That means that number of the uninsured would be higher by a factor of a million or a million and a half had we not passed that legislation that expanded health savings accounts. Making those premiums tax deductible, that is something that, an idea whose time has come, has long since come. We weren't able to do it during the last Congress. I know there are a number of competing influences out there, and we heard references to things like PAYGO before, so it is going to be a tough battle. But I do believe that we need to do that. The low income tax credit, or the premium support for an HSA like product for someone whose low income, again, an idea, certainly whose time has come. Maybe we should allow employers to make larger contributions to an HSA for a chronically ill employee, an employee who has diabetes or rheumatoid arthritis or any of other of a number of chronic diseases where, yeah, their health expenditures are going to be higher because they were unlucky enough to have this chronic disease, so their health insurance may cost a little bit more. But let's allow the employer the flexibility of perhaps contributing a little bit more to that plan. What about allowing the flexibility for health savings accounts to coordinate with other type of things that employers do to make the health care insurance burden for their employees easier to bear? Things like flexible spending accounts. A flexible spending account where an employer contributes a certain amount of money each year so that their employee can go out and have some of the first dollar coverage that they otherwise might not have, because even if they don't have a health savings account, just the regular deductible on regular commercial insurance, anyone who works and has employer-derived insurance will tell you that number has increased over the past 5 or 10 years. So flexible spending accounts are moneys that the employer puts away for the employee to help to use to offset some of these expenses that may be incurred. If we allowed someone with a health savings account to participate in a flexible spending account and even went further; for a flexible spending account, at the end of the calendar year, it is a use it or lose it phenomenon. If the employer has contributed that money or the employee has said, I want to put away a tax-deferred amount of money into this account so that I can spend it for health care needs and try to capture a little bit of that pretax leveragability there, they lose that money at the end of the year if they haven't spent it on their health care. Why don't we let that roll over into their health savings account and let that health care nest egg accumulate at a little bit faster rate so that those citizens who do wish to utilize the power of a health savings account can perhaps make it work even more to their advantage? And what if someone wants to retire early and they have got that health care nest egg built up in their health savings account but now they are going into early retirement, and doggone it, that insurance premium is going to be an additional burden to bear? What about allowing them to draw on the health savings account to pay their premium to continue their health savings account in those years from their early retirement prior to the time that they are covered by Medicare? It is an interesting concept and one I think this Congress would do well to spend some time thinking about doing. I will come back again to the pretax treatment of health care expenditures incurred under an HSA. Again, we can leverage a citizen's dollars so much more by allowing that type of treatment of those dollars. Again, association health plans for employers who want to provide their employees insurance but find they are being increasingly priced out of the market. Give them the flexibility to go out there and group together and say, We are a group of realtors and we want to be able to go out and buy health insurance in the market like we had a whole bunch of employees rather than an office that employs five or six people because we are not getting a good deal when we just go out and try to buy insurance in the market to cover five or six employees at a time. All of these things are critical for us to think about. All of these things are ways that we can improve the system that we have before us today. But we do have to ask ourselves if we are perhaps putting the cart before the horse. Alan Greenspan, the gentleman's name who is not unknown in this town, the prior Chairman of the Federal Reserve Board, about 1\1/2\ years ago came and talked to a group of us one morning, talking about just things in general, and the question inevitably came up about Medicare: How in the world are we ever going to pay for Medicare? How in the world are we ever going to tackle this unfunded obligation that we have? And Chairman Greenspan felt confident that at some point some Congress would be able to deal with this problem in a satisfactory way. And he paused and he got quite reflective, and he said, You know, what concerns me more is, is there going to be anyone there to provide the services when you need them? Of course he was talking about our physicians. Of course he was talking about our nurses. Those are words that certainly I have taken to heart. And I think we do need to spend considerable effort on thinking about this problem and considerable effort towards rectifying some of the difficulties that are out there so that we do, indeed, preserve the health care workforce that is present today and the health care workforce that we are going to want for the future. Last year, in order to deal with this problem, I introduced a bill, H.R. 5866, the Medicare Physician Payment Reform and Quality Improvement Act of 2006. I introduced that bill in July. Of course, with the August recess and then the recess before the election, there wasn't a lot of time left in the year to work on it. The reason it was so important is because the system we have developed in our Medicare system, parts A, B, C, and D are not paid for equally. The fact is that part B, the part that is handled by physicians, is dealt with in a different fashion. Part A, the hospital; part C, the HMO; part D, the prescription drug benefit, all of those each year receive essentially a cost-of-living adjustment, an update, because the cost of inputs is going to go up. The physician payment, this is an important concept. I realize it may sound arcane, but the physician payment is handled differently. There Congress, in its wisdom many, many years ago, said if we can control the volume and intensity of these payments, we are going to be able to save money over the long term. So a system was put in place called the Sustainable Growth Rate formula. You will hear it referred to as the SGR. The problem with the SGR is that every year physicians, instead of getting a cost-of-living update based on the fact that their electricity costs more, it costs more to put gas in their car to drive to work, it costs more to pay their help, all of those things go up, but the physician reimbursements go down. An estimated 5 percent a year, and this is projected to go up for years in the future so that the accumulative effect will be a 30 to 35 percent reduction in physician reimbursement in the Medicare system. And anyone just looking at this understands that that is untenable. You can't keep doing that. Every year Congress has to come in at the last minute and do something to keep that from happening for that year. Sometimes we get it done; sometimes we don't. But the problem is every year that we put that fix in place, we increase the price tag for eventually getting out of that system. A case in point: I first came to Congress in 2003. In fact, the Congress before my first term here had not passed any appropriations bills. So the first thing we were faced with was a huge omnibus bill, spending hundreds of billions of dollars. That omnibus bill contained within it a fix for the doctors. And I remember the then chairman of the Ways and Means Committee coming to our conference and saying, I have put a fix in there so that the doctors won't see that pay cut that they got last year, and it is going to cost $52 billion to do that. At that time the cost of buying our way out of the SGR formula and switching over to a cost-of-living formula, a cost-of-living adjustment formula, known as the Medicare economic index, was pegged at about $118 billion, a significant sum of money. But $52 billion as a down payment on a $118 billion problem, that seemed reasonable. It seemed like we were going in the right direction. But fast forward 4 years, and every year, of course, we have done something similar, never quite as much as the $52 billion that was passed that first month that I was in Congress, but every year that at the end of the year where we have had to add that money to keep physicians from seeing a pay reduction, we have increased the cost of eventually repealing the SGR so that it now totals $280 billion. But wait. There is more. If you do not protect seniors, because by law in part B of Medicare, seniors pay 25 percent of the cost of the part B program, which 75 percent is borne by the Federal Treasury; 25 percent is recovered in premiums, and every time we increase that amount, the premiums necessarily increase. No one likes to do that because those premium increases by law hit in the month of October and that is very close to an every 2-year election that occurs in the month of November. So everyone wants to deal with that problem of the premiums going up every year. If you were to deal with the entire problem, the SGR and premium protection for senior citizens, the costs suddenly goes up to $340 billion. It is clear to see in a PAYGO environment that that is almost an impossible hill to climb. Last year in the Physician Payment Reform and Quality Improvement Act of 2006, in attempting to deal with that, I looked for help within the health care community, people to find places where there could be efficiencies to help offset that SGR price tag that at that time was $218 billion. Suffice it to say that those cost savings were never identified. People were reluctant to come forth with areas in their particular part of Medicare where they might save money. And as a consequence, the pay- fors did not materialize, and the bill was something we didn't take up. This year, it's not even just about fixing that part of the formula. It is important to do that because one of the pernicious effects of that formula is you have doctors who are looking toward their retirement and perhaps thinking about accelerating it for a few years. So we have physicians in the workforce who may be leaving early because they look down the road and say, 5 percent reduction in the rate of Medicare reimbursement every year for the next 10 years for a cumulative total of 30 or 35 percent, I don't think so. Maybe I do need to get on with my retirement plans. And then on the other end of the spectrum you have the young physician who is just getting out of medical school, who is meeting the residency in those primary care high need specialties, they may need some additional help. And finally, the student who's finishing college and looking to go to medical school; how am I going to deal with those significant loans I'm going to face when I get out of school? All three areas are going to require this Congress to think very carefully and work very hard on trying to craft solutions. And I would just stress that it is important not to craft a solution that is only going to fix the short term. We've really had this kicking-the-can phenomenon or postponing-the-pain phenomenon has worked only up to a point. And you have to believe that this type of trajectory does have a shelf life, and ultimately we're going to reach a point where we are in fact no longer able to afford even those relatively modest, and I use the term modest advisedly because we are talking about a Washington expenditure here, will be unable to afford even those modest payments that are required to offset the reductions that happen year over year. And you might say, well, that's not so bad, it's just the Medicare system. That's just half of health care, how could that be that big a problem? The unstated aspect of this is that every private health insurance company out there who writes insurance policies, I shouldn't say every, but a lot, will peg their reimbursement rates to what Medicare pays. They pay 80 percent of Medicare, they pay 120 percent of Medicare, but they pay some percentage of what Medicare pays. And when we as a Congress say to the physicians of America, guess what? You get a 5.4 reduction this year. Those companies that peg their reimbursement rates to the Medicare 2007 reimbursement schedule are in fact also given a bit of a break. And they were never intended to be the recipients of the largess of the Federal Government, but that's what happens when you have Federal price controls on a system like health care. Well, improvements in the bill from last year I think are in progress. And the fact that the entire concept is split into three parts to deal with the overall affordability of educating and providing the incentives for people to go into medicine in the first place, providing the tools for their educational process, providing some flexibility with loan forgiveness, tax credits for the young physician, and then finally, providing some stability for the physician who is mature and in practice, that they are going to face a stable pricing environment going forward, not a continuously shrinking price environment going forward. It is going to be difficult. There again, I will reference the Medicare Trustees Report. Again, 680,000 hospital beds that were not filled in 2005 because of improvements in the practice of medicine. We've come a long way from the days of Benjamin Rush, when they used leeches to treat their patients. Those 680,000 hospital beds that weren't filled in the Medicare system, that is money that is saved in the part A part of Medicare, but the savings actually occur because of the work being done in the part B part of Medicare. And there has got to be somewhere, some way within the Federal statutes that the savings that occur in part A or part C or part D because of continued work and vigilance by the folks who are practicing in part B, there has got to be a way that those savings will accrue to part B, and use those savings as the offset for lowering that total price tag on the SGR formula. Further, there are some places, unfortunately, where people do attempt to abuse the system and take money that perhaps they are not entirely entitled to. The Inspector General's Office at HHS and the Department of Justice held a lengthy hearing with our Energy and Commerce Subcommittee a few weeks ago; it was a terribly enlightening process. But the money that's recovered in those audits is not money that should go to the Department of Justice, though don't tell them I said that, but it's money that should go back to the part B of Medicare to offset the eventual repeal and replacement of the SGR formula with the Medicare Economic Index. And I quite simply don't know any other way how to say that. If we are not able to get that done this year or next year or the year after, we do need to put some programs in place that will protect physicians from those cuts that are programmed to occur in 2008 and 2009. And again, that is part of the legislation that I will be working on to not only capture those monies that rightfully belong to part B to offset the eventual cost of repealing the SGR, but additional things in place to protect the earnings of the physicians who care for our Medicare patients during those years before the SGR can be repealed. Well, I mentioned earlier that some of the States have done some things within their health plans that have been innovative and really quite exciting; Massachusetts is probably the leader in that regard. It's significant because the Governor of Massachusetts is offering himself as a Presidential candidate and is certainly one of the individuals who can say ``check the box, I've done that.'' And working with a legislature and a State senate who was of the opposite party and not always aligned with his vision of where things were and where they ought to be, was able to craft a plan. Just like so many things, we can always say it's God's plans, but the devil is in the details, and sure enough in this situation the devil is in the details. The months starting in July of this year will tell the tale as to whether or not that plan will actually work. But some very clever ideas were incorporated. Now I will be the first to admit that as a Texan there are a lot of things that you can apply to Massachusetts that you could never apply in Texas. But one of the concepts that I thought was, you have heard me reference several occasions that wouldn't it be great to get the leverage of getting a pretax expense for someone who wanted to buy their health insurance? Well, they found a way to do that in Massachusetts, it's called the Massachusetts Connecter. And indeed, even back in my home State of Texas I know they are looking at this concept. There is apparently a chapter in the IRS code, we heard the last speaker say how complicated the IRS code can be, but buried within the IRS code is section 125, which will allow for Federal tax deductibility of insurance premiums where the State acts not so much as the broker, but the middle man, if the State acts as the person who is going to bring the buyer and seller in the insurance market together, there is apparently a way in the IRS code where there is a tax deductible treatment then of that expenditure. And think about that for persons who are in the 20 or 25 percent tax bracket. If they can buy their health insurance premiums with 80 cent dollars, suddenly we've gone a long way towards allowing them some additional flexibility within the plan. The thing I like the best about the Massachusetts plan is it does stress the concept of personal responsibility. That is to say that if you are a resident in the State of Massachusetts and you can afford health insurance, then you've got no good reason not to have health insurance and we are going to require you to have it. Again, a concept that may not work in other States. And Governor Schwarzenegger is looking at doing something in California. I know in my home State of Texas, Governor Perry is looking at some options. Governor Jeb Bush in Florida and now Governor Crist, who replaced him, all have the ability to look at the State programs because of flexibility that was put in the system when the Deficit Reduction Act passed in December of 2005. Again, the much maligned Deficit Reduction Act gave the tools to these State leaders so that they can look at doing these innovative plans in their States to provide coverage for their populations who are uninsured. And after all, again, one of the great things about the United States is the States can serve as laboratories. We don't necessarily have to change everything for the whole country, we can see how it works in a given State, and to the extent that it is helpful, we can expand the program. If we find it wasn't helpful, we won't expand the program. But it is one of those great things that our Founding Fathers envisioned, that the States would be great laboratories for needed social change to occur in this country. One of the other things that I didn't cover earlier because I wasn't sure if time would permit it, I do obviously need to say a word about the medical liability system in this country. My home State of Texas, again, did tackle this issue in 2003 and did pass a State law that capped non-economic damages, much along the lines of the Medical Injury Compensation Reform Act of 1975 that was passed in California. Our State of Texas picked up that concept, modernized it for the 21st century, and those caps on non-economic damages, instead of just being one realm of non-economic damages, the cap is trifurcated, $250,000 thousand cap on the doctor, $250,000 thousand cap on the hospital, $250,000 thousand cap on the on a nursing home or second hospital, if one is involved. The critical thing about this is it has brought insurance costs for medical liability insurance down by 20 percent in my home State of Texas, and, remember, medical liability costs were going up by 25 to 30 percent a year prior to the passage of that law. So it has had an immediate and beneficial effect on physicians in Texas. And one of the unintended beneficiaries was the mid-sized, community-based, not-for-profit hospital who self-insured. Those hospitals have seen a significant reduction in the amount of moneys that they had to put toward medical liability, and, as a consequence, those are dollars that they are investing in capital improvements, nurses' salaries, the very things you would want your medium-sized, not-for-profit community hospital to do if they had the flexibility to do so. I have legislation that I have drafted that bases off the Texas plan. I think it is reasonable legislation. In our budget resolution that the Republicans had, the savings, and this was scored by CBO as a savings, at a time we are looking for ways to save money in the healthcare system to pay for other things, it is almost unconscionable to walk away from that $8 to $10 billion in savings that CBO scored this particular legislation. Mr. Speaker, I see that the hour, it goes so quickly when you get down here to talk about these things. I will wrap up. I do want to point out that Americans, for all of the criticism that we have, there was an article in The New York Times published October 2006, Tyler Cowan, who writes, ``When it comes to medical innovation, the United States is the world leader. In the past 10 years, 12 Nobel Prizes in medicine have gone to American-born scientists working in the United States, three to foreign-born scientists working in the United States, and just seven have gone to researchers outside of the country.'' That is what we need to preserve, protect and defend. That is why these issues are so important for us to face in this Congress.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to recognize Lawrence Green for being named ``Driver of the Year'' by the Environment Industry Associations. Mr. Green is an employee of IESI waste service and an exemplary citizen of Forest Hill, Texas. The award is presented annually by the Environment Industry Associations. EIA recognizes the best drivers from the U.S. and Canada involved in solid waste hauling and recycling services who have demonstrated their commitment to their profession, shown a commitment to service and quality, and operated their vehicles in a safe and responsible manner. Mr. Green is an employee of IESI, an environmental services company founded in 1995. The company has since expanded across the southern and northeastern United States. During his 24 years of service, he has collected an estimated 87,000 tons of waste in the Colleyville and Haltom City area. Over the course of 1.5 million miles, he has not had a single accident or complaint. Lawrence Green's services have extended beyond his job description. On one occasion, he followed and apprehended some children whom he had seen breaking into a car. Another time, he carried home a girl who had fallen off of her bicycle. Although he has proven himself worthy of being promoted, he has turned down the offer on different occasions. I would like to commend Mr. Green for his outstanding service and congratulate him for being named ``Driver of the Year.'' It is terrific to see someone who both enjoys his job and excels at it. I wish him success in the future, and I am very proud to represent him in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to congratulate Mr. Bill Mullican of Lubbock, Texas on his recent appointment to the National Advisory Council for Environmental Policy and Technology (NACEPT). Mr. Mullican was appointed to the NACEPT by the U.S. Environmental Protection Agency Administrator, Stephen Johnson, on April 23, 2007. The Council is comprised of outside experts representing diverse interests from academia, industry, non-governmental organizations, and state, local and tribal governments. The U.S. Environmental Protection Agency (EPA) established the NACEPT for the purpose of providing expert advice to the EPA Administrator on a wide array of environmental policy, technology, and management issues. Due to his vast knowledge of water development policies and issues, Mr. Mullican will prove to be a valuable asset to the NACEPT. A native of Lubbock, Texas, Mr. Mullican graduated from Texas Tech University with a B.S. degree in Broadfield Science Education, and later an M.S. in Geology. From 1983 to 1997 he was Research Associate at the Bureau of Economic Geology at the University of Texas at Austin. Later that year, Mr. Mullican began his career at the Texas Water Development Board, first serving as Director for Water Resources Planning, then as Deputy Executive Administrator for the Office of Planning. While serving as Deputy Executive Administrator, his areas of responsibility included water data collection, environmental programs, and research and planning fund management. As a leading authoritative figure for state water planning, Mr. Mullican assists other States such as California, Illinois, Indiana, Oklahoma and Pennsylvania in establishing statewide water planning initiatives. It is with great honor that I recognize Mr. Bill Mullican for years of hard work and dedication. As a citizen of Texas, I am truly grateful that he has continuously taken a proactive role in our water development. I am pleased to join his friends, family and colleagues in congratulating him on this prestigious milestone.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to commend Alyssa N. Nabors for being selected as a 2007 National Merit Scholarship Awards winner. Alyssa is a student at L.D. Bell High School in Hurst, Texas. The National Merit Scholarship Program is an academic competition held annually. Students are initially evaluated by their performance on the Preliminary SAT/National Merit Scholarship Qualifying Test. Of the approximately 1.4 million entrants, only about 8200 students are selected as finalists. In this first announcement of 2007 winners, about 1000 high school seniors are awarded scholarships from various companies, foundations, and businesses. These organizations fund the scholarships to help some of our nation's most capable students reach their potential. I wish to offer my congratulations to Alyssa. I would also like to recognize her parents and the faculty of L.D. Bell High School for their outstanding commitment to Alyssa's education. I wish her even greater success as she continues her education, and I am proud to represent her in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to commend Gabriel J. Diaz for being selected as a 2007 National Merit Scholarship Awards winner. Gabriel is a student at Ryan High School in Denton, TX. The National Merit Scholarship Program is an academic competition held annually. Students are initially evaluated by their performance on the Preliminary SAT/National Merit Scholarship Qualifying Test. Of the approximately 1.4 million entrants, only about 8,200 students are selected as finalists. In this first announcement of 2007 winners, about 1,000 high school seniors are awarded scholarships from various companies, foundations, and businesses. These organizations fund the scholarships to help some of our Nation's most capable students reach their potential. I wish to offer my congratulations to Gabriel. I would also like to recognize his parents and the faculty of Ryan High School for their outstanding commitment to Gabriel's education. I wish him even greater success as he continues his education, and I am proud to represent him in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to commend Vatsala Goyal for being selected as a 2007 National Merit Scholarship Awards winner. Vatsala is a student at Dunbar High School in Fort Worth, Texas. The National Merit Scholarship Program is an academic competition held annually. Students are initially evaluated by their performance on the Preliminary SAT/National Merit Scholarship Qualifying Test. Of the approximately 1.4 million entrants, only about 8200 students are selected as finalists. In this first announcement of 2007 winners, about 1000 high school seniors are awarded scholarships from various companies, foundations, and businesses. These organizations fund the scholarships to help some of our Nation's most capable students reach their potential. I wish to offer my congratulations to Vatsala. I would also like to recognize her parents and the faculty of Dunbar High School for their outstanding commitment to Vatsala's education. I wish her even greater success as she continues her education, and I am proud to represent her in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to commend Brendan A. Jones for being selected as a 2007 National Merit Scholarship Awards winner. Brendan is a student at the Texas Academy of Math and Science in Denton, TX. The National Merit Scholarship Program is an academic competition held annually. Students are initially evaluated by their performance on the Preliminary SAT/National Merit Scholarship Qualifying Test. Of the approximately 1.4 million entrants, only about 8,200 students are selected as finalists. In this first announcement of 2007 winners, about 1,000 high school seniors are awarded scholarships from various companies, foundations, and businesses. These organizations fund the scholarships to help some of our Nation's most capable students reach their potential. I wish to offer my congratulations to Brendan. I would also like to recognize his parents and the faculty of TAMS for their outstanding commitment to Brendan's education. I wish him even greater success as he continues his education, and I am proud to represent him in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to commend Kim Tran for being selected as a 2007 National Merit Scholarship Awards winner. Kim is a student at Birdville High School in North Richland Hills, TX. The National Merit Scholarship Program is an academic competition held annually. Students are initially evaluated by their performance on the Preliminary SAT/National Merit Scholarship Qualifying Test. Of the approximately 1.4 million entrants, only about 8,200 students are selected as finalists. In this first announcement of 2007 winners, about 1,000 high school seniors are awarded scholarships from various companies, foundations, and businesses. These organizations fund the scholarships to help some of our Nation's most capable students reach their potential. Kim is ranked first in her class at Birdville High School. Aside from academics, Kim holds leadership positions in numerous clubs and organizations. She has led the school's math and science teams to victory while attaining some personal awards. Recently, Kim was accepted to Stanford University. I wish to offer my congratulations to Kim. I would also like to recognize her parents and the faculty of Birdville High School for their outstanding commitment to Kim's education. I wish her even greater success as she continues her education, and I am proud to represent her in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to commend Nathan S. Abell for being selected as a 2007 National Merit Scholarship Awards winner. Nathan is a student at Marcus High School in Flower Mound, TX. The National Merit Scholarship Program is an academic competition held annually. Students are initially evaluated by their performance on the Preliminary SAT/National Merit Scholarship Qualifying Test. Of the approximately 1.4 million entrants, only about 8,200 students are selected as finalists. In this first announcement of 2007 winners, about 1,000 high school seniors are awarded scholarships from various companies, foundations, and businesses. These organizations fund the scholarships to help some of our Nation's most capable students reach their potential. I wish to offer my congratulations to Nathan. I would also like to recognize his parents and the faculty of Marcus High School for their outstanding commitment to Nathan's education. I wish him even greater success as he continues his education, and I am proud to represent him in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to commend Sarah H. Drew for being selected as a 2007 National Merit Scholarship Awards winner. Sarah is a student at Flower Mound High School in Flower Mound, Texas. The National Merit Scholarship Program is an academic competition held annually. Students are initially evaluated by their performance on the Preliminary SAT/National Merit Scholarship Qualifying Test. Of the approximately 1.4 million entrants, only about 8,200 students are selected as finalists. In this first announcement of 2007 winners, about 1,000 high school seniors are awarded scholarships from various companies, foundations, and businesses. These organizations fund the scholarships to help some of our Nation's most capable students reach their potential. I wish to offer my congratulations to Sarah. I would also like to recognize her parents and the faculty of Flower Mound High School for their outstanding commitment to Sarah's education. I wish her even greater success as she continues her education, and I am proud to represent her in the 26th District of Texas.

Mr. BURGESS

Mr. BURGESS. Madam Speaker, I rise today to commend Kristofer K. Bjerga for being selected as a 2007 National Merit Scholarship Awards winner. Kristofer is a student at Keller High School in Keller, Texas. The National Merit Scholarship Program is an academic competition held annually. Students are initially evaluated by their performance on the Preliminary SAT/National Merit Scholarship Qualifying Test. Of the approximately 1.4 million entrants, only about 8,200 students are selected as finalists. In this first announcement of 2007 winners, about 1,000 high school seniors are awarded scholarships from various companies, foundations, and businesses. These organizations fund the scholarships to help some of our nation's most capable students reach their potential. I wish to offer my congratulations to Kristofer. I would also like to recognize his parents and the faculty of Keller High School for their outstanding commitment to Kristofer's education. I wish him even greater success as he continues his education, and I am proud to represent him in the 26th District of Texas.