Thomas Coburn

Mr. COBURN

Mr. COBURN. In this bill, what we are debating are three terrible things for care but great things for cost: the U.S. Preventive Task Force on Prevention Services, the Medicare Advisory Commission, and the references to the Cost Comparative Effectiveness Panel. When the U.S. Preventive Services Task Force came out with their recommendation, as far as costs--I am talking about breast cancer screening for 40- to 49-year-olds--as far as costs, they were absolutely right, as far as cost-effectiveness. But as far as clinical effectiveness, they were absolutely wrong. What did we do? We accepted a Vitter amendment to hold off, so that recommendation, that mandate from that panel will not apply to women in this country under these programs--except the women in California on Medi-Cal because, you see, this week California embraced the U.S. Preventive Services Task Force. So if you are a Medicaid patient--which we are going to put 15 million more people into--you cannot have a mammogram in California if you are under 50. You cannot have it because, from a cost standpoint, they are right. From a clinical standpoint, they are wrong. What we have done is, every time one of these three organizations creates a ruling, that the American people rise up and say: That is wrong, we are going to come in here and correct it? But throughout this bill, strung throughout are multiple references to what these three panels are going to ration--I did not miss that word--ration the care to American people in this country. If you are a senior, you have two real reasons to be worried. One is, we are cutting Medicare. And if we are not, then vote for the Gregg amendment and you will make sure we don't. It is an insurance policy. But more important, within that, we are going to see the care to seniors rationed based not on what is in their own best interests or their health's best interests but what is in the cost's best interests. There is no question about it. We are going to do that. It would be different if we created a comparative effectiveness panel, a clinical comparative panel. But they are already out there. We knew that. When I study to take my recertification exams, I have to know what the clinical comparative effectiveness guidelines are or I will not pass as a practicing physician. But we didn't do that. We said: Cost is most important. So how are we going to cut? We are going to say where something is cost-effective though not clinically effective, we are going to cut that care. So if you are a senior, especially if you are on Medicare Advantage, you don't have to just worry about the fact that we are going to decrease the revenue stream that will supply those benefits that cause you not to have to buy a supplemental policy, and we are going to decrease some of the things that are available to you as a Medicare Advantage patient, but you also have to worry about the next ruling that is going to come from the U.S. Preventative Health Services Task Force. You have to worry about what is going to come from the Medicare Payment Advisory Commission because it is going to be looking at costs too. Then you have to worry about what is going to come from the cost comparative effectiveness panel. I could spend up to 8 hours talking about tragedies from England and Canada on care denied based on things Americans have today that that very panel is going to deny to Americans in the future because they are not cost-effective. That is one of the reasons our result in terms of cancer treatments is one-third better than anywhere else in the world. It is because we don't have mother nanny bureaucracy saying what you can and cannot have. It would be totally different if we created incentives for lowering the cost, but we don't. We create mandates. We drive down the cost of health care in specific areas through these three separate panels. There is one thing that is even worse than the two things I just talked about for Medicare patients. Here is what it is. When you have these three panels, you have just taken away the loyalty of your physician to you. You have just decided, with these three panels, that the physicians have to keep their eyes on the government. They have to do what the government says is in your best health interest rather than what that provider knows is in your best interest. Remember, the Medicare Payment Advisory Commission, the cost comparative effectiveness panel, and the Preventative Services Task Force doesn't know your family history, doesn't know your clinical history, has never done an exam on you, do not know the idiosyncrasies of your health care. But we are going to apply that all to you; we are going to depersonalize health care. I readily admit, for 80 percent of the people, it is going to be just fine. They will not see any untoward result. But I will predict, as a practicing physician for over 25 years, for that remaining 20 percent it is going to be a disaster as far as their personal health is concerned. It will destroy the patient-doctor relationship. It will give us worse outcomes, and it will not save us any money because the consequences of those decisions will create a complication which will require more dollars expended. When we think the government can practice medicine--and that is what this bill does; this bill sets up the government to practice medicine-- we might as well hang it up and just be ready because 20 percent are going to get substandard care compared to what a Medicare patient receives today. We are going to get sicker. The life expectancy of people under this health care bill will decline. The quality of care will decline. The innovation of new advancements in health care will decline because we have chosen the government to decide what everybody will get. It is a disaster as far as the individual patient is concerned. That is not the motivation of my colleagues on the other side. I know that. I am not accusing them of that. But what they don't see, sitting in Washington, is what I see in a clinic office practice in medicine. Medicine is intensely personal. It ought to be about your choice, about what is best for you and your family and your children, not what the government says makes the best economic sense to the budget picture in Washington any particular year. When we lose that quality in American medicine, we are going to lose the best of what we have in the name of fixing what is wrong. I agree with my colleagues the insurance industry has a lot of stink to it. But there are a lot of ways to fix it other than the way we have done. I agree with my colleagues that my profession is not pure at every turn of the corner. I agree with my colleagues we can do better. But when we write a bill that is absent any absolute clinical judgment left to the practice of medicine by those who know the patients best, who have 100 percent of that patient's best interests at heart, we are going to hurt the quality of care. We are going to hurt it significantly. Your motivations are good. The answers are wrong on a clinical basis. Now to the Gregg amendment. The Gregg amendment does what you all say you want to do. I remind my colleagues the Medicare trustees are highly suspicious of the Medicare cuts in this bill. What they say is, they highly doubt it will ever happen because it has never happened before because there is not the political will to decrease the dollars in Medicare. More importantly, the dollars are going to come out of care instead of out of fraud. There is only $2 billion, say, out of at least $100 billion a year, in fraud. Only 2 percent of it per year is coming out. That is the problem. We could have had a Medicare bill and we could have cut $60 or $70 billion of fraud together out of this bill. We can come together on that. We could have cut $720 billion out of Medicare just based on fraud alone without ever touching Medicare Advantage, without ever giving sweetheart deals to the people in Florida because their Senator wanted it, without ever touching FMAP adjustments in other States. We could have done that, but we chose not to. We chose what we know up here rather than what we know in the hinterland, those of us who are practicing medicine. What do we know? We know there are some rip-offs in home health care. We know there are significant rip-offs in durable medical equipment. We know there are some rip-offs in hospice. We know there are drug company rip-offs. We could agree to some of those. We actually even know in large hospitals that there are some problems there as well. But there are very few problems in our rural hospitals because they are struggling just to keep the doors open. We could have done that, but we chose not to. So we have this divide, and we are going to fix it one way. The biggest pot of honey in Medicare is fraud. Everybody knows that. But we are not going to fix it. If, in fact, what my colleagues claim is true, that these are Medicare cuts that nobody will ever feel any consequence from, in spite of my own years of practice and knowing the difference, that that isn't true, but let's give you that, why would we not put it all back in Medicare so we don't steal from our children and our grandchildren? Why would we not do that? We have chosen not to do that. We have chosen to mix it. And it is honorable to try to create a system to get more people insured. Yet we will still have 24 million people not insured. Out of this bill, we will still have 24 million people not insured, when it is all said and done, if everything goes as planned. Yesterday I introduced into the Record the analysis by the State insurance commission in the State of Oklahoma. Kim Holland is of your party, the majority party. But she sees what is getting ready to happen with this bill. What does she say? What she says is, insurance premiums are going to significantly rise in Oklahoma. More people will be uninsured than there are today. The State Medicaid fund is going to be tremendously stressed with at least $67 million a year having to go into that, again, based on the mandates in this bill that we don't have money to do; that, in fact, it is not the way to solve what Oklahoma is facing in terms of health care. I didn't call her and say: Give me something bad to say about this bill. She volunteered this information out of her legitimate concern for the consequences, of what is going to happen with this bill. Why would she do that? Because she knows one heck-of-a-lot more about insurance than I do and anybody else in this body. She knows it in our State. And the other insurance commissioners around here, some through their association, have endorsed this bill. Most, when they look at their State, especially the poorer States, especially West Virginia, it is going to hurt. How are we going to cover that? We are going to shift 15 million people to Medicaid. What do we know about Medicaid? I have delivered thousands of babies and over half of them have been Medicaid. I have cared for thousands of Medicaid children, thousands of Medicaid adults and thousands of Medicaid patients. What do we know? Medicaid is a substandard program. Compared to everybody else, it is substandard, except when compared to the Indian Health Service, and that is a disaster. So our answer is to put a mandate on the States that they cannot afford and shove another 15 million people into a system that has poorer outcomes, higher complication rates, higher infant mortality rates, later presentation, and a system that has 11 million people eligible for it today who are not signed up. We have the system out there, but they are not signed up. So they are not getting any preventative care. They are not interacting with a primary care physician. And that is our answer? Move 15 million more Americans into Medicaid. By the way, keep a discriminatory stamp on their forehead, rather than give them an insurance program; put a stamp on their forehead that says 40 percent of the doctors can't see you, 65 percent of the specialists will not see you because your reimbursement rate is so low they can't afford to have you walk into their office and cover the cost of seeing you. That is what we are going to do. That is not reform to health care. That is banishing people to a substandard system as compared to what the rest of the system is and then feeling good about it. That is not reform. That is discrimination because here is what really happens to a Medicaid mom and her children. If she has a sick kid, she can't get in. She has this 6-year-old with a fever, not eating, dehydrated, and she can't get in to see a primary care physician, which could keep that child out of the hospital. So what happens? She keeps trying to get in. What does she do? She accesses the emergency room, the most expensive place. She accesses it late--not early, late. So we have a sicker child, with higher costs, because we have a system that will not reimburse its costs. And you all have actually talked about the cost shift on that, from Medicare and Medicaid, to the private sector. We would be much better off paying the same rates in Medicaid so we do not get that cost shift, so we do not discriminate against people on Medicaid for access to care. But we have chosen not to do that because it fits with the numbers. It fits with the Washington, government-centered management of health care. I will tell you as a physician, we would be better off--single-payer rationing and all--than what you are doing to so many of these patients in this bill. We would be better off with the government just running it all, rationing it, and saying: Tough, you get to 75 years of age, you can't get your hip fixed; you get cancer, we are not going to give you the latest drugs. We would be better off because now we are going to get the worst of both worlds. We are going to get the rationing through these three panels I talked about. They are going to tell doctors what they can and cannot do. They are going to practice medicine--the very people who have never touched, never had an encounter, never visited with that patient and do not know anything about them--they are going to make a decision. Mr. President, I would inquire, I think I have 5 minutes.

Mr. COBURN. I think I will finish up in seconds.

Mr. COBURN. The Senator would not yield. I will continue my talk. For Medicare Advantage patients--there is no question, I have agreed with the chairman of the Finance Committee--the competitive bidding needs to happen. But there is one little thing that happened on the way to the bank. It is that there is going to be a decrease in benefits-- not only a decrease in what we pay for, but there is going to be a decrease in benefits. Where will that impact be most importantly felt? Not in the urban areas. It is not going to be felt in the urban areas. It is going to be felt in rural areas throughout this country. That is where it is going to be felt. It is going to be felt out there where there is a marginal rural hospital that is using the other benefits to help maintain the flow to that hospital. So there is no question that, if you are one of the 11 million--with the exception of those who got deals cut in this bill--that, for sure, the 90,000 Oklahomans are going to feel an impact from this cut. Nobody says Medicare Advantage is perfect. It is not. It is far from it. But there is another aspect of Medicare Advantage that really helps those on the lower rung of the economic ladder. It is that with Medicare Advantage, they did not have to buy a supplemental policy because all the things they need are covered. Ninety-four percent of Americans on Medicare who are not on Medicare Advantage purchase a supplemental policy. Why do they do that? Why do they spend $300 or $400 a month to buy a supplemental policy? Because basic Medicare that we have proudly said will not be cut does not cover the basic needs of a senior and their health care. Consequently, they pay into Medicare Part A, HI trust fund their whole life, they buy Medicare Part B, and then they buy a supplemental policy. It just so happens that one of the largest sellers of those policies happens to be somebody who is endorsing this bill. If that is not a conflict of interest, I don't know what is. I heard the Senator talk about Massachusetts. I refer to an article from the Chicago Tribune--they have broadened care. I am proud of them for doing that. But at what cost? At a 10-percent increase in cost of premiums for the people in the middle. When we go back to what the President said about what his goals are, there is no question that this bill does not keep those promises. I now ask unanimous consent to turn to another area which we have discussed and ask unanimous consent to have printed in the Record an article from the North County Times/The Californian, dated December 5, 2009, at 9:35 p.m.

Mr. COBURN. I thank the Presiding Officer for the accommodation of the time, and I yield the floor.

Mr. COBURN. What is the request of my ranking member?

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

Mr. COBURN. Every person in this country should be able to have access. I agree. Nobody should lose their home. Nobody should have to file for bankruptcy because of health care. I agree. That premise we agree on. How we get there is in two totally different ways. The No. 1 impediment to access is cost. Costs are not going to go down. We know that by all the studies. The health care costs are not going to go down. They are not going to go down per individual and they are not going to go down in total. So we will not have fixed the big problem with health care, which is cost. We will have worked on access through a government program, but we will not have fixed the real problems. What are the real problems? Fraud is at least 6 percent of the cost of health care. Tort extortion by the trial bar is at least 6 percent of the cost of health care when you count defensive medicine. There is 12 percent where you could lower it tomorrow--12 percent where you could lower the cost of health care tomorrow if, in fact, we would fix the real problems. No. 3, transparency with insurance companies and transparency with doctors so you know what the cost is, you know what the outcomes are, you know what their track record is, so you can truly make a decision about your care. There is no incentive for that, the incentivization for prevention and management of chronic disease. I have said this on the floor before, but it bears repeating: The reason we have a primary care doctor shortage in this country today is because of Medicare. The Centers for Medicare & Medicaid Services sets the rates of reimbursement for primary care encounters in Medicare, and everybody else follows it. So you have a disruption, a differential of 300 percent from a family practice doctor and an obstetrician like me to a super-subspecialist. And what do you think the doctors in medical schools are doing? Last year, only 1 in 50 went into primary care. Only 1 in 50 went into primary care. So let's say we get everybody covered. Who are they going to see? Oh, I know what the answer is. We are going to use physician extenders. So not only are we going to say you are covered, now we are not going to give you an experienced, gray-haired, reasoned, long-term educated physician with 25 or 30 years of experience; we are going to hand you off to somebody who is a nurse or a PA who is good at limited things but does not practice the art of medicine. So I will wind up with this. I so want to fix health care. I am so sick of the way it is. But I am not near as sick of the way it is as the way it is getting ready to be under this bill. I know my patients are going to get hurt under this bill. My Medicaid patients are going to get hurt under this bill. My Medicare patients are going to get hurt under this bill. And those who are in between--whether it is with insurance with their employer or insurance they are buying on their own or they are paying cash--are going to pay more for their health care because of this bill. That is what I believe is going to be the outcome of this bill. And all you have to do is go look at the history. Talk to Alice Rivlin, the first CBO Director, about the accuracy of CBO in estimating anything when it comes to health care. They have missed it every way. They have only gotten one ``wrong,'' by saying it was going to cost more. For every other one, they said it was going to cost less than it did. So every patient--every patient--in some way or another is going to suffer under this bill. That is what we should be worried about. We should not worry about whether the President wins or we win.

Mr. COBURN. Mr. President, the question I was going to ask the distinguished Senator from Massachusetts is, how many Medicare Advantage patients has he ever cared for? How many Medicare Advantage-- how many Medicare patients has he ever cared for? How many times has he been in the trough, experiencing the heavy hand of government as we try to care for people on Medicare? The answer to that question is zero because he is not a physician. He relies on the American Medical Association--the American Medical Association that today represents less than 10 percent of the active practicing doctors in this country. He relies on AARP, which has 40 million in membership but is the fifth largest revenue receiver from supplemental policies. That is whom he relies on. The fact is, he does not have the experience of being in the trough, caring for patients. Let me tell you what is going to happen to Medicare Advantage patients.

Mr. COBURN

Mr. COBURN. Mr. President, I yield the floor.

Mr. COBURN. Mr. President, I am going to ask to have printed in the Record a letter dated December 1, 2009, from the insurance commissioner of the State of Oklahoma--she happens to be of your party, the majority's party--outlining the significant problems that she sees for our State if this bill becomes law. This is not a partisan document. This is a document that relates to what is going to happen to Oklahoma. If I might summarize, very shortly: It will increase premium costs and increase the number of uninsured people in Oklahoma. That is according to our State insurance commissioner, who is of your party. It will decrease the amount of availability of insurance to people who do not have insurance today. The letter states it will not rein in the cost. In fact, it will increase costs for everybody else in the State of Oklahoma. It will drive up costs and increase the number of uninsured. It will increase the costs for the private plans, negatively impacting medical providers and the health delivery system in Oklahoma, and it will encourage fewer businesses in Oklahoma to offer benefits. That is a fairly strong indictment from somebody who cares about the people of Oklahoma and what is going to happen in health care. Mr. President, I ask unanimous consent to have printed in the Record this letter from the State insurance commissioner of Oklahoma.

Mr. COBURN

Mr. COBURN. What is going to happen is the spread--the people who have insurance, if you are over 40, because these young people drop out, your premium is going to go up. So what is available today because of the mix of people who are in the broad group of pools who are insured--we are going to drop out young, healthy people, so that small younger group insurance is going to go up. But because there are going to be 6 million to 11 million fewer of them and the insurance company keeps them in the pot to lower the cost for the older ones, the 65 and above, their premiums are going to go up. So we are going to have exactly the opposite effect because when you mandate coverage and you force people to buy it with a big government program, people are going to make an economic decision--and the first year of this is $250 is all you have to pay, and it goes up to $750-- they are going to say: Why would I do that? I will buy the insurance when I get sick. So what we are going to do is totally disrupt--and it may be planned to be that way so we can come back and say: Well, look at the private insurance industry. It is not working. The government needs to take it all over. I don't know that is the case, but the consequences of what this bill is going to do----

Mr. COBURN. Mr. President, I thank the chairman for allowing me to respond.

Mr. COBURN. Mr. President, I thank you. I appreciate it. I sat here and listened to my colleagues to hear their input. I find it extremely peculiar that the only industry for which you would limit their taxes is one that has not struck a deal with the committee. The only one. Pharmacists are going to spend $70 million advertising for this bill. The other industries are putting up additional moneys to advertise for this bill. The only industry that we are going to restrict is the industry that is in opposition to what we are doing. It is interesting. Senator Cornyn made the point with me a moment ago that we are going to take $450 billion, and we are going to give it to the very industry you are talking about. We are going to take $463 billion from Medicare and give it to the same industry you are now criticizing. Senator Baucus said--and let me quote--he said: As we tried to work this, it was ``rough justice'' to put this agreement together. This is democracy. It was done behind closed doors. That is not democracy. It was done behind closed doors. The Senator from Arkansas asked why we have not brought forward something. The Senator from Massachusetts asked. The first bill introduced was the Patients' Choice Act. I commend to my colleagues a white paper by Thomson Reuters, a very well respected firm, talking about the $600 to $850 billion worth of waste in the health care system today, entitled ``Where Can $700 Billion in Waste Be Cut Annually From the U.S. Healthcare System.'' The reason we are concerned about $465 billion coming out of Medicare, to be paid to the very insurance companies you are going after right now, is because we are not going where the real waste is. The promise of the President was to cut the cost of health care. Right here is where it is. This bill does not touch it. There is $175 billion a year in fraud in the health insurance industry. You all go after $2 billion of it--$2 billion. There is $175 billion a year in fraud. What is in it? Nothing. We are going to manage to pay a private industry, but only the private industry that will not play along behind the closed door, rough justice of democracy in this country. When Senator Corker asked the chairman of the Finance Committee, Why are you taking the money from Medicare and using it somewhere else, rather than extending the life of Medicare, he did not answer the question. The fact is, there is a $44 trillion--according to the latest calculation, if you go to the Medicare trustees: $44 trillion--counting what has been borrowed--unfunded liability over the next 75 years for Medicare. We are going to take $\1/2\ trillion out of that program that we all know is going wrong. And I do not doubt the motives of anybody here. I just think we are misdirected. And we are going to take that and spend it on another program. That is where people ought to be concerned. It is interesting--I will submit another document for the Record. This is a report from the Congressional Research Service, released December 1, 2009, at my request. I ask unanimous consent that document be printed in the Record.

Mr. COBURN. Oh, yes, it does. We will have at least 20,000 new Federal Government employees. It will benefit them. It will benefit the bureaucracies. It will give them power to control. It is not a soft control or a light control; it is a heavy control. We will mandate on States bankruptcy through Medicaid--mandate to the States--the mother of all mandates to the States. So it will benefit the Federal Government and the bureaucracy but will have minimal benefit for the patients in this country.

Mr. COBURN. If I might, I ask unanimous consent to have printed in the Record the consolidated audited financial statements of AARP. They are the fifth largest insurance sales company in America.

Mr. COBURN. The reimbursements, where you can invest 1 additional year in residency and double the income you can make from being a physician. How did the payment rates get where they are? Who set the payment rates? The Federal Government set the payment rates because 60 percent of the payments to private physicians come from Medicare, Medicaid, TRICARE.

Mr. COBURN. If they could afford it--and that is where a large number of Medicare Advantage people will be hurt; most of those people cannot afford to buy a supplemental policy. The fifth largest seller of insurance policies in the country happens to be AARP.

Mr. COBURN. Supposedly.

Mr. COBURN. I don't think there is any question that is going to happen. Actually, it is even going to be worse than that because we have shrunk the differential for young people. If you are a young person, listen to me. The cost of your insurance is going to double under this bill. If you are a young couple or a young individual--and I am talking 40 and under, 24 to 40--your insurance is going to double under this bill. What you are going to do, you are going to do this: You are going to say, I am going to pay the tax rather than coverage for insurance because it is financially much more important for me to do that. And what we know is that between 6 million and 11 million young people are going to cancel their insurance under this bill, according to a report put out by--and I will reference it here--Oliver Wyman and Associates.

Mr. COBURN. It puts the consumer--i.e, the patient--in charge of their health care rather than the government in charge of their health care.

Mr. COBURN. I am happy to.

Mr. COBURN. Absolutely right.

Mr. COBURN. I yield the floor, and I suggest the absence of a quorum.

Mr. COBURN. For AARP.

Mr. COBURN. And it doesn't reform. I have wondered that.