Health Care

Floor Speech

HEALTH CARE -- (Senate - July 17, 2008)

Mr. WHITEHOUSE. Madam President, I am very pleased to have a chance to speak today about the problem of health care in our country.

We are coming into a potentially very exciting time, when a new President and new administration will open up new opportunities to reform our ailing and broken health care system. It is a matter of urgency that we do so. It is also a matter of urgency that we get it right.

I have spoken on this issue on a number of occasions on the floor and elsewhere, and I often describe the marks of failure of our health care system, which are many. For example, the number of uninsured Americans is now climbing toward 50 million people. The fact is that despite the best doctors, the best nurses, the best medical equipment and procedures, the best medical education in the world, as many as 100,000 Americans are killed every year by avoidable medical errors. In the United States, our life expectancy, our obesity, and our infant mortality rates are an embarrassment compared to other nations.

The health care system cost is over $2 trillion. The last report I saw was at $2.3 trillion, and it is anticipated shortly to reach $4 trillion. At this point, we are spending 16 percent of our gross domestic product on health care, which is far more than any other nation; the closest nation comes to 11 percent. The average of the European Union countries is only 8 percent. So we are putting twice as much of our national product into our health care system as our European competitors are.

Within our own system, the insurance companies' overhead eats up 31 percent of private insurance health care expenditures. In the battle between insurers and providers over getting paid--which is becoming increasingly an arms race--$20 billion per year gets burned up and lost.

More American families are bankrupted by health care emergencies and health care expenses than any other cause. It is not just uninsured families who are being bankrupted. It is the insured as well because of the thinness of so much of our coverage. There is more health care than coffee beans in Starbucks coffee. There is more health care than steel in Ford automobiles.

So when you look at it from that perspective, you truly see a troubled system.

The Commonwealth Fund has recently put forward a report that drills into the problems of our system even further. I would like to take some time to share with my colleagues the findings from the Commonwealth Fund study. They are quite impressive, but not in a positive way.

They found that Americans spend more on health care expenses than any other of the countries they tracked. This axis of the graph shows total health care spending. This axis of the graph shows the out-of-pocket spending in addition to the insured health care spending. You can see that the United States stands as an extreme outlier to all of these other nations, including France, Germany, Canada, Netherlands, Australia, New Zealand, and Japan, and the average of the OECD countries--a group of 30 market economy countries that are very competitive with ours.

It is astonishing. We cannot remain competitive when total health care spending is this much above those countries, plus out-of-pocket demands on individual Americans, in addition to that national health care spending, is so much greater than those other countries.

People who spent more than $1,000 out of pocket for medical care in 2004 when the study was done: In the United States, nearly a third of the above-average income people; a quarter of below-average income people, compared to the United Kingdom, 2 percent and 5 percent; New Zealand, 4 percent and 6 percent; Canada, 10 percent and 12 percent; Australia, 8 percent and 21 percent. We are not even close.

Spending on physician services: In the United States, we pay $1,362 every year per capita on physician services. In the Nations with which we compete: Japan $563; OECD, the average is $482; Australia, $436; France, $371; Canada, $319; Germany, $307. That is a quarter of what we spend. And they are not receiving bad health care in those countries.

Pharmaceutical spending is a little bit more even but, once again, who has to spend the most? Good old USA, more than twice what the OECD average is or The Netherlands; about twice what Australia is. Over and over, we see persons punished by the cost of the health care system.

Here is what I mentioned earlier, the percentage of the gross domestic product spent on health care: America, 16 percent; the next highest is just under 11; OECD, the average is 8.7 percent. This is not a sustainable situation.

Health care spending per capita, $6,102 for Americans, compared to the competing systems: Canada, $3,165; France, $3,159; The Netherlands, Germany, Australia, OECD, UK, Japan, New Zealand, down to $2,083, about a third of what we spend in the United States of America. And they have very decent health care systems and, in many cases, better health care outcomes.

This is similar to the other graph showing that $6,102 goes per capita per year to support our health care system. This shows that if you break it up into public spending in the yellow, out-of-pocket spending in the white, and private insurance spending in the blue, if you take the private and out-of-pocket spending, it is more than every other country with which we compete. That entire $2,572 per person in private insurance spending is all above what everybody else has to pay for health care in their countries. No wonder facts such as these emerge.

Physicians perceive that patients often have difficulty paying for medications: 51 percent of American doctors have observed in their professions that we Americans have difficulty paying for our prescriptions--51 percent. In New Zealand, the next highest, it is 27 percent; Canada, 24 percent; Germany, 23 percent; Australia, 15 percent; UK, 13 percent; down to Netherlands, 7 percent. Wouldn't we be better off as a country if only 7 percent of physicians reported that their patients often had trouble paying for medications?

And for all of that, look at some of the results we get. Deaths due to surgical or medical mishaps per 100,000 population: America leads the nations with .7 mishaps per 100,000; .6 for Germany; .5 for Canada and France, all the way down to .2 for Japan and The Netherlands. We pay more, but we don't get better results.

This one makes me cringe to look at. Infant mortality rate for our country: 7 deaths per 1,000 live births. Look at the countries that beat us in infant mortality: New Zealand, Canada, United Kingdom, Greece, Ireland, Portugal, Australia, Netherlands, Switzerland, Italy, Denmark, Belgium, Germany, the Czech Republic, Austria, France, Spain, Norway, Sweden, Finland, Japan, and Iceland, with many countries with an infant mortality rate half our country's, despite the fact we are spending twice as much on health care.

If we look at potential years of life lost to circulatory illness, which means dying younger than you should have, America leads: 825 potential years of life lost per 100,000 population; Australia, 419; France, 411, half as much. It is embarrassing.

Potential years of life lost due to diabetes: In the U.S., again, 101, down to Japan, 25, four times better. Look at how we are outliers against the rest of our competitors and against these other developed nations.

Diseases of the respiratory system: Here we go again. Who is the worst? The USA.

Obesity: This is a huge indicator of future illness and future health care expense. Again, who is the worst? Madam President, 30.6 percent in the U.S., down to 9.5 percent in France; 10.9 percent in The Netherlands; 12.9 percent for Germany; the OECD average, 13 percent. We are twice as bad as the OECD average.

Look at the system that is backing it up. Patients reporting any error based on the number of doctors they have seen: If they have 4 or more doctors, 48 percent of American patients reported errors; with 1 doctor, it is 22 percent. We are worse than all the other countries again and again.

It is similar for medical, medication, and lab errors. Who is the worst? The United States, with 34 percent compared to 22 percent in the UK; 23 percent for Germany; 25 percent for New Zealand; 27 percent for Australia; 30 percent for Canada.

Incorrect lab and diagnostic test or delay in receiving abnormal test results: Again, who has the worst record? The U.S., 23 percent. The Germans managed to get that down to 9 percent. We are more than twice as bad as they are.

Coordination of care, vitally important for people who have multiple illnesses and multiple treatments, reporting of coordination problems: The U.S., 43 percent for those with 4 or more doctors; 22 percent for those with 1 doctor. That is again, worse than all of our competitors that were in the study.

Difficulty getting care on nights, weekends, and holidays without going to the ER: It has become standard in America that the place you get care on nights, weekends, and holidays is the emergency room, and that is why 61 percent of adults who sought care reported it was very or somewhat difficult to get care without going to the emergency room. In Germany and New Zealand, they managed to get that to 25 percent and 28 percent respectively, another measure that the system is not serving the American people.

Test results or medical records not available at the time of appointment: 23 percent compared to 11 in Germany. Again, we are the worst on the table.

Doctors who report they routinely receive alerts about potential problems with drug dosage or drug interactions: In the United Kingdom, 91 percent report they receive alerts about a potential problem with a drug dosage or interaction; 97 if you include those who use a manual system; 93 percent total in New Zealand; 95 percent in The Netherlands; 90 percent in Australia; 51 percent in the United States. We are not even close by a lot of these measures.

Here is our public investment per capita in health information technology, which is probably the platform to the solution of our health care dilemma: United Kingdom, 192 bucks per person in 2005; Canada, $31; Germany, $21; Australia, $4.93. Here is what we invest in the U.S.: 43 cents--43 cents--to develop health information technology. No wonder we are getting those results we saw.

And here they are, primary care doctors' use of electronic patient medical records: 98 percent of primary care doctors use electronic patient medical records in The Netherlands; 92 percent in New Zealand; 89 percent in the UK; 79 percent in Australia; 42 percent in Germany; and look at us, 28 percent. It is pathetic.

And where are the financial incentives to encourage doctors to do it? Why is it at 28 percent? Look who reports they have financial incentives for quality of care improvements: 95 percent do in the UK; 79 percent in New Zealand; 72 percent in Australia. Who, again, is the worst? Who again is trailing the civilized, developed world? The United States of America. Again, it is embarrassing.

If you are managing patients with chronic disease, which is where the big money is and where the biggest health risks are, how many primary care doctors get financial incentives for quality of care improvement: 79 percent do in the United Kingdom; 68 percent do in New Zealand; 62 percent in Australia; in The Netherlands, 47 percent; in Canada, 37 percent; in Germany, 24 percent. Look at us, 8 percent. And we wonder why there is a problem.

We are not even happy about the system and our interactions dealing with it. Does your doctor always listen carefully? Who comes in last? The U.S.

Does your doctor always explain things so you can understand them? Who comes in last? The U.S.

Does your doctor always spend enough time with you? Who comes in last? The U.S.

I know I have taken everybody through a lot of graphs. There are a lot more in the overall study by the Commonwealth Fund. This is the wrap-up of the ranks for 2004, 2006, and 2007 of the six nations. Who is last every year? Sixth place for six; sixth place for six; sixth place for six; and for $6,102 per person compared to about $3,000 or less for almost every other one of our competitors.

This is what it leads to. This is spending on health per capita. Back in 1980, all the nations were grouped fairly closely together. The other nations have remained fairly closely grouped. But look at what has happened to our cost profile, and it is going to continue to go up and up and up and up, and we are going to come to a breaking point.

David Walker, the former Comptroller General, has said the cost of the unfunded liability we bear for the future costs of entitlement programs is $53 trillion. I come from Rhode Island. We don't deal in trillions of dollars. Our whole State budget is a little over $5 billion.

What is $53 trillion? If a penny is $1 billion and 5 pennies is a stack about this high, which will be the entire State of Rhode Island budget, $53 trillion is a stack of pennies more than 250 feet high, through the roof of this building and hundreds of feet into the air.

What we are going to have is a health care calamity. We have two choices as to how we deal with it. We can wait around. We can wait until the wolf is at the door and then we can decide we cannot afford $53 trillion. We can make fiscal adjustments to that. We know what fiscal adjustments we can make. We have done some already. You pay providers less. You throw more people off health care. You make insurance coverage thinner. You raise taxes to pay for it. But we have gone down all those roads already. We have gone too far down those roads already.

And if we are left with only those tools in the toolbox to solve this health care problem, we will be doing one of the gravest disservices this Congress has ever done to the country we are here to serve. Instead, we have to go and look at the health care delivery system and repair it so it provides better results.

The good news from all the bad news on those charts is that there is enormous room for improvement. We can substantially reduce the cost. There are three important ways I think we can go about doing this. The first is to improve our health information technology. We need to have a national health information technology infrastructure. The RAND Corporation values having a national health information technology infrastructure at somewhere between $81 billion and $346 billion per year. That type of savings is worth spending some serious money to achieve--not the 43 cents per person we saw on the graph. We have to engage in a national urgent construction project of a health information technology infrastructure.

The second thing we have to address significantly is the problem of quality and the underinvestment in prevention in our system right now. There are enormous savings to be reached there. In a project we are doing in Rhode Island, copying the Keystone project in Michigan, we are seeing significant savings in our intensive care units and improving quality of care. In Michigan, in 15 months, they saved about 1,500 lives, and they saved about $150 million. And it wasn't even in all the intensive care units in Michigan. There are huge savings from quality improvement if you can set up the incentives so people will do it.

When we set this up in Rhode Island, the hospitals came to me--I was attorney general then--and they said: we will do this, but it is going to cost $400,000 a year. And I said: Yes, but it saves money. Keystone showed that. We think it will save $8 million. That is a 20-to-1 return. Go. And they said: No, no, no, you don't understand how it works in the health care system. That $400,000 comes out of our expenditures. That is a negative on our bottom line. That $8 million savings comes out of our revenues. We get reimbursed for that care. So we will lose $8 million in revenues if you ask us to spend this $400,000. That is a big hit.

They agreed to do it, but I have taken aboard in my mind and my heart the lesson of how badly our health care system supports providers when they try to improve the quality of care in this very tough financial environment they are in.

That brings us to the third piece. Health information technology was first, quality prevention investment in ways that will save costs is second, and the third is to reform the reimbursement system so the price signal that gets sent into the market by our health care system directs people in ways we want.

We can't do this on a piecemeal basis any longer. These three ideas can dramatically reform our health care system. They have one problem. They will take some time. You can't turn the switch and make them go. We have some work to do to develop the strategy, to implement it, and to build what new infrastructure has to be constructed to make it work. I would guess, based on an experience I had in Rhode Island with a similar reform, that it is a 10-to-15-year lead time to have the full effect begin to show itself.

And you know what, if you dial back from the time when that $53 trillion fiscal tsunami is going to hit this country, that 10 to 15 years is probably right now. So not only is a new administration with a new President and new energy and new opportunities a great chance in the coming year to begin to
get this work done and to open a substantial reform of our health care system, but it is also, in many respects, a deadline.

You can go by a highway exit and it is too late to come back to it, and I am afraid that is where we are right now. So as I prepare to conclude my remarks and yield the floor, I want to say to my colleagues: we are going to have to work very hard together to fix our health care system in the coming year. I know the financing problems and the access problems are real, but I urge and implore you to consider that it is not enough to repair the finance and the access problems of our health care system. We need to get into the delivery system and fix it so it provides better, less expensive, more efficient health care for Americans.

I believe we can do it, and I believe it is not a partisan issue. It is a question of right versus wrong, smart versus stupid, wasteful versus efficient, and not right versus left or Republican versus Democrat. So I challenge my colleagues to join me in this fight, and I look forward to the important results from it that America needs.

I thank the Presiding Officer for recognizing me, and I yield the floor.

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