Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2024

Floor Speech

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Mr. SANDERS. Mr. President, let me begin by thanking Senator Marshall of Kansas for his very hard work on the bill that we have introduced today after being on the floor with me this afternoon to briefly discuss it. And I also want to thank his staff and my staff for putting in an enormous amount of time on this bill over the last several months.

Most Americans understand that our healthcare system is broken. We are spending nearly $13,000 a year per capita on healthcare. That is an astronomical sum of money, almost twice as much as most other countries. And yet despite all of that spending, some 85 million Americans are uninsured or underinsured. And there are estimates out there, believe it or not, that some 60,000 Americans die each year because they do not receive the healthcare they need when they need it. And our life expectancy as a nation is actually in decline, despite all of that spending.

Frankly, as broken as our general healthcare system is, our primary healthcare system is in even worse shape. As everyone knows, I don't think there is any debate on this, we face a major shortage of doctors, nurses, mental health professionals, and dentists. And those shortages will only grow as a result of the COVID burnout that many providers experience and the aging of our healthcare workforce.

According to the most recent estimates that I have seen, over the next decade, our country faces a shortage of over 120,000 doctors, including a huge number of primary care physicians. The nursing shortage may be worse. Over the next 2 years alone, it is estimated that we will need more than 200,000 nurses. And despite the very serious mental health crisis we face, we are facing a massive shortage of mental health providers--psychiatrists, psychologists, social workers, et cetera.

Now, that is not the point that Bernie Sanders is making or Senator Marshall has made. This is a point of view of virtually every major medical organization in the country.

And on this matter, let me quote from a recent Washington Post op-ed by Elizabeth Rosenthal, a contributing editor at Kaiser Family Foundation Health News. This is what she writes--and I hope our colleagues hear this:

American physicians have been abandoning traditional primary care practice--internal and family medicine--in large numbers. Those who remain are working fewer hours. And fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients. The percentage of US doctors in adult primary care has been declining for years and is now about 25%--a tipping point beyond which many Americans won't able to find a family doctor at all.

She writes:

Already, more than 100 million Americans don't have usual access to a primary care doctor--a number that has nearly doubled since 2014.

They said they couldn't find another primary-care doctor who could take them on or who offered a new-patient appointment sooner than months away.

Their individual stories reflect a larger reality: American physicians have been abandoning traditional primary-care practice--internal and family medicine--in large numbers. Those who remain are working fewer hours. And fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.

The percentage of U.S. doctors in adult primary care has been declining for years and is now about 25 percent--a tipping point beyond which many Americans won't be able to find a family doctor at all.

Already, more than 100 million Americans don't have usual access to primary care, a number that has nearly doubled since 2014. The fact that so many of us no longer regularly see a familiar doctor we trust is likely one reason our coronavirus vaccination rates were low compared with those in other countries.

Another telling statistic: In 1980, 62 percent of doctor's visits for adults over 65 were for primary care and 38 percent were for specialists, according to Michael L. Barnett, a health systems researcher and primary-care doctor in the Harvard Medical School system. By 2013, that ratio had exactly flipped and has likely ``only gotten worse,'' he said, noting sadly, ``We have a specialty-driven system. Primary care is seen as a thankless, undesirable backwater.'' That's ``tragic,'' in his word--studies show that a strong foundation of primary care yields better health outcomes overall, greater equity in health-care access and lower per capita health costs.

One explanation for the disappearing primary-care doctor is financial. The payment structure in the U.S. health system has long rewarded surgeries and procedures while shortchanging the diagnostic, prescriptive and preventive work that is the province of primary care. Furthermore, the traditionally independent doctors in this field have almost no power to negotiate sustainable payments with the mammoth insurers in the U.S. market.

Faced with this situation, many independent primary-care doctors have sold their practices to health systems or commercial management chains (some private-equity-owned) so that, today, three-quarters of doctors are now employees of those outfits.

One of them was Bob Morrow, who practiced for decades in the Bronx. For a typical visit, he was most recently paid about $80 if the patient had Medicare, with its fixed-fee schedule. Commercial insurers paid significantly less. He just wasn't making enough to pay the bills, which included salaries of three employees, including a nurse practitioner. ``I tried not to pay too much attention to money for four or five years--to keep my eye on my patients and not the bottom line,'' he said by phone from his former office, as workers carted away old charts for shredding.

He finally gave up and sold his practice last year to a company that took over scheduling, billing and negotiations with insurers. It agreed to pay him a salary and to provide support staff as well as supplies and equipment.

The outcome: Calls to his office were routed to a call center overseas, and patients with questions or complaining of symptoms were often directed to a nearby urgent care center owned by the company--which is typically more expensive than an office visit. His office staff was replaced by a skeleton crew that didn't include a nurse or skilled worker to take blood pressure or handle requests for prescription refills. He was booked with patients every eight to 10 minutes.

He discovered that the company was calling some patients and recommending expensive tests--such as vascular studies or an abdominal ultrasound--that he did not believe they needed.

He retired in January. ``I couldn't stand it,'' he said. ``It wasn't how I was taught to practice.''

Of course, not every practice sale ends with such unhappy results, and some work out well.

But the dispirited feeling that drives doctors away from primary care has to do with far more than money. It's the lack of respect for non-specialists. It's the rising pressure to see and bill more patients: Employed doctors often coordinate the care of as many as 2,000 people, many of whom have multiple problems.

And it's the lack of assistance. Profitable centers such as orthopedic and gastroenterology clinics usually have a phalanx of support staff. Primary-care clinics run close to the bone.

``You are squeezed from all sides,'' said Barnett.

Many ventures are rushing in to fill the primary-care gap. There had been hope that nurse practitioners and physician assistants might help fill some holes, but data shows that they, too, increasingly favor specialty practice. Meanwhile, urgent care clinics are popping up like mushrooms. So are primary care chains such as One Medical, now owned by Amazon. (Jeff Bezos, Amazon's founder, owns The Post.) Dollar General, Walmart, Target, CVS and Walgreens have opened ``retail clinics'' in their stores.

Rapid-fire visits with a rotating cast of doctors, nurses or physician assistants might be fine for a sprained ankle or strep throat. But they will not replace a physician who tells you to get preventive tests and keeps tabs on your blood pressure and cholesterol. The doctor who knows your health history--and has the time to figure out whether the pain in your shoulder is from your basketball game, an aneurysm or a clogged artery in your heart.

Some relatively simple solutions are available, if we care enough about supporting this foundational part of a good medical system. Hospitals and commercial groups could invest some of the money they earn by replacing hips and knees to support primary-care staffing; giving these doctors and patients more face time with each other will be good for their customers' health and loyalty if not (always) the bottom line.

Reimbursement for primary-care visits could be increased to reflect their value--perhaps by enacting a national primary- care fee schedule, so these doctors won't have to butt heads with insurers. And policymakers could consider forgiving the medical school debt of doctors who chose primary care as a profession.

They deserve support that allows them to do what they were trained to do: diagnosing, treating and getting to know their patients.

The United States already ranks last among wealthy countries in health outcomes. The average life span in America is decreasing, even as it increases in many other countries. If we fail to address the primary-care shortage, our country's health will be even worse for it.

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Mr. SANDERS. Mr. President, now, what this article points out is certainly not news to the people in America. In Vermont and all over this country, our people often have to wait months in order to get an appointment with a doctor; and in some cases, they have to travel very long distances to get the healthcare they need.

And let us be clear: There is no debate upon this. Some people think we don't have to act on it now; let's do it next year, next year, following year. Wrong. The crisis is only going to get worse, and every day we delay it, it becomes even worse.

Now, why is this happening? Well, there are a lot of reasons why. One of the reasons is that it turns out that the United States--despite all of our spending on healthcare--spends about half of what other nations do on primary healthcare. We spend approximately 7 percent; most of the country spends at least twice as much.

And the absurdity of that situation is that everybody knows that ``an ounce of prevention is worth more than a pound of cure.'' And if there is anything that Senator Marshall and I are talking about, that is exactly what we are talking about. You spend money--we are spending money to save money. Keeping people healthy saves money. In other words, common sense tells us that if we can prevent disease, do a better job keeping our young people healthy, if people can access the medical care when they need it not when they are just very, very sick-- if we can do those things, we can keep them out of the hospital. And hospital costs are just extremely, extremely high.

Common sense also tells us that it is literally insane that millions of Americans with nonemergency healthcare needs get their primary care in a hospital emergency room, which, in some cases, is 10 times more than the care provided them in a community health center.

Let me just give one other example of the irrationalities of our current system. In my own small State of Vermont, last year, our major hospitals spent $125 million in 1 year on traveling nurses because we don't have enough local nurses to support the needs of the hospital and many other facilities in Vermont. Meanwhile, young people want to become nurses. They are applying to nursing school, but the nursing schools don't have the faculty to educate them.

I recently talked to a Senator who told me that, in her State, some 1,100 young people were applying for a space in nursing school; the school could only provide 80 openings.

So we have a nursing crisis. We are not addressing it. Hospitals are spending three, four times as much money on traveling nurses as they are on homegrown nurses because we are not educating our young people at nursing school. This may make sense to somebody; it does not make great sense to me.

The legislation that Senator Marshall and I have introduced today does not solve, by any means, all of the healthcare crises we face. But if this legislation is passed, it will not only save us substantial sums of money, not only provide a medical home for millions more Americans, not only significantly increase the number of doctors and nurses that we desperately need, but it will go a long way toward transforming primary healthcare in America--something that is so long overdue.

With that, I want to turn the floor over to Senator Marshall.

And I would say this, that Senator Marshall has a unique perspective on this. Not only is he a Senator from a rural State, he is also a practicing physician and has interesting insight into the crises in healthcare that many of us don't.

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Mr. SANDERS. Mr. President, this is an issue I have worked on since I have been in Congress. And one of the results of that--working with others--is that, in my State of Vermont, I think--I think--we are leading the Nation in terms of the number of people per capita who participate in the community health center program.

Senator Marshall, my understanding is that in Vermont, one out of three Vermonters get their primary healthcare or dental care at a community health center. And one of the things that I love about community health centers is that they really are community health centers. In Vermont, they are not just for low-income people, as important as that is. They are for everybody in the community. We used to have a Supreme Court Justice of the United States of America who vacationed in Vermont. Guess where he went? To a community health center.

My understanding is, the Governor of the State of Vermont gets his primary healthcare at a community health center, and that is what I love about them.

And as you well know and as you mentioned, what they do is not only provide primary healthcare, many of them provide dental care, which is a huge issue. Many of them provide mental health counseling, which, as you indicated, we have a major crisis in. And they also provide lower cost prescription drugs.

What they say is that, regardless of your income, if you have Medicare, come on in; if you have Medicaid, come on in; if you have private insurance, fine; if you have no health insurance, we will work on a sliding scale.

By expanding these community health centers all over America, we are going to provide millions of people the opportunity to get the healthcare they need. That is what exists in Vermont right now, and we want to see that expanded all over the country.

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Mr. SANDERS. Thank you very much for raising the issue of dental crisis in America. I can tell you that in Vermont, we have a crisis. We made progress, but we have a serious problem. The cost of dental care is very, very high. In the southern part of my State, Bennington County, if you are a poor child, you are probably on Medicaid. You probably can't find a dentist.

What we have done in this bill is put $3 billion one time--just one time--into capital improvements for community health centers. That is long overdue because if you want to expand community health centers, they need money for their own expansion and infrastructure.

Building a dental operatory--and that is the dental chairs and the good equipment that dentists need--is a very expensive proposition. So by putting $3 billion into capital improvements, much of which I suspect will be going to those dental operatories, we are going to be able to provide communities all over this country with the ability to access dental care in a way they are not doing it today.

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Mr. SANDERS. Senator Marshall raised this issue from almost the first time we sat down and seriously discussed it. If we are going to talk about prevention, we have to talk about obesity, among other things, because we are looking at a major--you tell me if I am wrong, Doctor-- we are looking at a major diabetic epidemic in this country that will not only cost massive amounts of suffering, but it is also going to be a very expensive healthcare bill. Certainly, one of many of the contributing factors is obesity. What Senator Marshall has talked about from the very beginning is we have to do a better job in nutrition education. Community health centers are very well-situated to be able to do that.

At Senator Marshall's insistence--and I was delighted to work with him--we have language in here that will make it easier for community health centers to work on nutrition programs in a variety of ways with their clients.

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Mr. SANDERS. Let me thank Senator Marshall and his staff so much for their hard work and say, as he just said, we think there are other ideas that can improve it. We are open to new ideas. We hope to be marking up and intend to be marking up this bill next Thursday. We look forward to talking to all of the members on the Health, Education, Labor, and Pension Committee for doing what is really important.

Senator Marshall started his remarks off by saying, I think, exactly the right thing. We can come here and all give great speeches. We can all talk about how next year, we are going to get to something or, 5 years from now, we will get to something.

Everybody in America--in Vermont, Kansas, and all over this country-- understands we have a primary healthcare crisis. This is the greatest country on Earth. We spend more money on healthcare than any other country. It is not asking too much that when you get sick, you are able to find a doctor, that you are able to find a dentist. It is not asking too much that when you are in a hospital, there are enough nurses there, that our young people who want to become nurses are able to get that education so they go out and get really good jobs. That is not too much. That is all we are doing in this legislation. We are looking at the real world as it exists.

Senator Marshall is a physician and understands that world quite well. We are looking at that world saying: You know what, let's not wait 5 years from now. We have a crisis today. Let's deal with it. I yield the floor.

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