Health Care Reform

Floor Speech

HEALTH CARE REFORM -- (Senate - August 03, 2009)

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Mr. WHITEHOUSE. I ask my distinguished colleague from Iowa a question about prevention because it strikes me, if you are a community health center and you want to invest in a health prevention strategy that will help the community you serve have healthier lives and therefore lower the costs to the system for everyone--you put out the money for that program if you are the community health center, you have to staff it, you take all the risks, you do all the work, and yet the benefit of what you have done doesn't come back to you. It goes to private insurers, it goes to the Federal Government, it goes to patients and better health. But it makes it a very unfortunate business proposition for anybody who is doing this on their own, which suggests this is an important place for the Federal Government to invest because the market, by itself, will not take care of this because you invest and you don't get it back. You invest and it goes to the insurance company. You invest and it goes to Medicare.

I know Senator Brown wishes to make some statement. I wish to make that point because Senator Harkin's work has been so important on this, and I think that is an important thread.

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Mr. DODD. I thank my colleague and thank him for making that contribution on so many points, particularly on the public option. As our colleague from Ohio has pointed out, and some may find it somewhat alarming--but the whole idea of competition is about as basic in America as any I can think of. The idea that people can have choices out there is something we cherish in this country.

In fact, what exists today in so many case is the lack of choice. I listened to my colleague from Iowa talk about western Iowa, rural Iowa, where you only get one or two choices. In the State of Virginia, almost 70 percent of all insurance is written by two companies in the entire State--two companies in the entire State of Virginia. That is not untrue in most places. I cannot speak specifically State by State, but it is not uncommon that in many areas the choices are very limited. So today, for most Americans, the ability to shop for the best health care plan that serves their needs and the needs of their families is very limited.

What is being discussed here is not a subsidized plan, not taxpayer subsidized in any way, but a plan that would offer an option, a safety net in many cases, probably for some kind of illness that can afflict someone, which most people worry most about that could ruin them financially. It is a pretty straightforward kind of a plan that would provide some basic coverage, at a competitive price, a nonprofit operation that would take the element of profit out. I know that may be intimidating to people, to have someone out there competing with an idea. If it is not a good plan and people don't like it, they will not go to it, in which case it will not work very well. If it is a well-drafted plan that does what many would like it to do, it might just have the effect of bringing down the cost in a competitive environment.

I mean, under a capitalistic system, competition is what contributes to price fairness. If one company controls the whole game, or two do, you get a predictable result--price fixing--and you pay an awful price as a consumer, whether you are buying shoes or automobiles or any other product or service.

So the idea of injecting a level of competition--I find it somewhat ironic that our Republican friends are frightened of this idea. I traditionally think that all of us embrace the free enterprise system as providing the best results for our country throughout 200 years of history. Why in the 21st century should that be any different from the 20th or the 19th century, where competition helped produce the greatness of this country?

I appreciate the Senator from Ohio today raising the point about the value of injecting some competition. We all know ultimately that could have the desired effect of bringing down those costs and making insurance or health care coverage more affordable. At some point, I hope someone might explain to me why competition is a bad idea. I though quite the contrary, and it is almost un-American to suggest that we ought to make this a noncompetitive environment, that everything else ought to be competitive but not health care. It seems to me that quite the opposite ought to be the case.

I see my colleague from Rhode Island here, who made a significant contribution in crafting the public option and the very public option that was praised by the so-called Blue Dogs in the House, the more conservative Democrats in the House who were reluctant to be supportive of that specific health care package. But to their great credit, they took a good look at what we had created in our bill on the public option, and they were so impressed by the work done by our committee--specifically, our colleagues from North Carolina, Senator Hagan, Senator Brown from Ohio, and Senator Whitehouse from Rhode Island, who were the principal authors of this provision in our bill--that the House Blue Dogs insisted that this language be incorporated in part of their health care effort in the House. I thank my colleagues from Rhode Island and Ohio and Senator KAY HAGAN from North Carolina for their work in this regard.

Possibly my colleague from Rhode Island would like to talk about that or some other aspect of this bill.

Mr. WHITEHOUSE. I would be delighted to talk about that. But the first thing I would like to do is react to a point the distinguished chairman has just made regarding how ironic it is that some of our friends on the other side are so opposed to increasing competition in the insurance industry. One of the things that is particularly ironic is that a great number of our colleagues on the other side go home to their home States to a health insurance system that already is a public option for their business community, their workers' compensation system.

The two places you get health care are from the general health insurance marketplace and from the workers' compensation marketplace. You can get workers' compensation coverage, and it will cover small workplace injuries, it will cover catastrophic workplace injuries, it will cover temporary conditions, and it will cover lifetime chronic conditions. It has all of the elements of health insurance coverage and the need for it.

Well, when our colleague from Wyoming, the distinguished ranking member of the HELP Committee, goes home to Wyoming, he goes home to a single-payer public option for workers' compensation health insurance. So it can hardly by anathema to have a choice public option.

The distinguished gentleman, Senator McCain, who was the Republican candidate for President, goes home to Arizona to a competitive public plan providing workers' compensation health insurance in his home State.

The Republican leader himself, Senator McConnell, goes home to Kentucky, to a State where there is a public plan that delivers health insurance, a competitive public plan. And I suspect his employers like it and the people are comfortable with it.

Our colleague, KAY BAILEY HUTCHISON, is shortly to go home to Texas to run for Governor. When she does, she will go home to a State that has a competitive public plan that delivers health care through the worker's compensation system.

Our distinguished friends in Utah, Senator Bennett and Senator Hatch, who have done so much work on health insurance issues over the years, go home to Utah, where their business community has a competitive public plan for delivering health insurance.

So, in addition to the irony of being against competition, their business communities, I believe, are highly favorable to a public plan that competes in the market to deliver health insurance that the business community funds, the workers' compensation health insurance market. So I guess ironies abound here.

I would also like to compliment Senator Brown for keeping it real here on the Senate floor and reading those letters and reminding us that when push comes to shove around here, it is not the nametags and the labels that matter, it is not ``socialized medicine,'' it is not ``government takeover,'' it is people who have real problems.

I was struck by a letter that was brought to my attention today. I do not know exactly what day it came in, but I saw it today. A working couple with a son, sort of the ideal American family, doing nothing wrong, doing everything right, playing by the rules, working hard. The son becomes grievously ill, has a very grave illness. Over the years, his condition worsens, and ultimately his disease takes his life. They were insured through this whole period, but the insurance was not enough. There were copays, there were limits, there was cost sharing. As a result of all of this, they are deeply in debt. They had to take time off work and spend time caring for him, and so they have had employment issues.

Now, this is, again, sort of the ideal American family. They are both working hard. They have a son whom they love. They are doing everything right, and they are playing by the rules. And because he got sick and because our health insurance system is such a nightmare for a family in that situation, they have lost their son, they have lost their savings, and they are about to lose their home. They are about to be put out of the house that has all of the memories of their son.

You know, there are people for whom this is very real, and we have to keep our eye on that ball and not on all of the smoke and all of the fear mongering that is happening around here. A lot of that smoke and fear mongering is happening around our public plan.

Well, it is not that complicated. It is competitive. It is fair. It has no special subsidies for people who are in that plan versus in competing private plans. It has no special advantage. And it honors President Obama's programs and the promise of all of the Presidential candidates that if you like the plan you have, you get to keep it. You are not forced out of anything.

So if it has no special advantages, if it has no special subsidies, why do we support a public option? Why is it better? Well, I would say that there are three reasons we can have some confidence that a public option will make a difference for the kind of people Senator Brown was talking about, the family I was talking about, people who suffer through our existing health care system.

The first is, a public plan does not need to take profit out of the system.

In 2007, in Rhode Island, one of our insurers, United Health Care, asked permission to remove $37 million as its profit in that year from Rhode Island back to its home headquarters. My State isn't as big as Ohio. It is not as big as Iowa or Connecticut. It is a small State. It has a million people. In one year to take $37 million out of that State, when they only had a 16-percent market share, think of that. A 16-percent market share in a State of a million people is about 160,000 folks they cover, assuming that everybody had coverage; $37 million out of those 160,000 people in 1 year gone for profits.

Stop doing that. Stop paying exorbitant salaries such as United Health Care's chief executive who got $124 million in salary. That is a lot of money that could go back into other things in health care. That could help families either get better coverage or pay lower premiums. So there is one thing--no profit, no excess cost.

The second is, you could have better dealings between insurers and providers and hospitals than we have right now. Fifteen percent of our health care costs from the insurance side goes to overhead and administration. Most of that goes to denying claims and making life difficult for providers, doctors, and hospitals, when they submit their bills. There is a war, a claims war going on right now between the insurance industry and doctors and hospitals. And 15 percent of what we pay for health care gets burned up on the insurance company side of that war. The insurance companies are bigger and smarter, and they set the rules. So you can bet that the doctors' side of responding to that costs more than 15 percent.

In fact, the Lewin Group has estimated that 36 percent of a provider's overhead cost goes to fighting with the insurance industry. Everybody in this place has had the experience or somebody they know or love has had the experience of trying to get a claim paid, having it be denied, submitting a bill, having it be denied, having to wait for treatment that you need while your doctor tries to get prior authorization from the insurance company that says: No, we need more papers. All of that is expensive. None of it provides any health care value, zero. It is all administrative overhead and nonsense.

In some cases it is big. I was at the Cranston, RI community health center. It is not a big organization. Rhode Island is not a big State. Cranston is not our capital city, not our biggest town. Its community health center does not have an enormous budget. They spend $300,000 every year on the consultants who help them try to negotiate this payment claims war they are stuck in--$300,000 a year. On top of that, 50 percent of their personnel time, half of their personnel time, goes to fighting with insurance companies. So you take a little place such as the Cranston community health center and you can tell them: Half of your personnel costs can go away or can be devoted to prevention, as the Senator from Iowa has suggested, instead of fighting with the insurance industry. That is an improved model. That is something the public option can pursue.

You don't have to fight the providers that way, and the amount of waste that is burned up on all of that warfare for no health care value whatsoever is an opportunity for this public option to achieve.

The third area is to more broadly change the busines model. There is a failed private insurance business model right now. It is pretty simple to summarize. No. 1, if they think you are going to get sick, they deny you insurance. You don't even get in the door. No. 2, if they make a terrible mistake and let you in the door and then you have the temerity to get sick, they look for a way to deny coverage. They go through the form and look for a mistake you might have made so they can throw it out. They find something that might have been a preexisting condition. They look for a loophole. If they are stuck, if they can't find a loophole, then they deny payment. They tell you that the coverage you need isn't what you need or they refuse to honor the doctor's bill when it comes through the door. But a business model for an entire industry of denying insurance to the people who they think will get sick and then denying coverage to the people who actually do get sick and, when they can't dodge their coverage responsibilities, denying payment to doctors or hospitals or trying to have some person who is not even a doctor second-guess the coverage that your doctor tells you you need, that is a terrible business model. It has caused immense pain across the country, and it has been a disaster. There is a better business model. A public option can pursue it.

Mr. DODD. If my colleague will yield on that point, those very fact situations the Senator describes would be totally prohibited under the bill we marked up in our committee nearly 3 weeks ago. Every one of those fact situations would be prohibited under the legislation we sent to the body for its consideration.

Mr. WHITEHOUSE. Yes, it would. And it is an important piece of this legislation that has received far too little attention so far in the debate. It has caused an immense amount of personal pain, human anguish, and suffering that our health care system causes.

The distinguished Senator from Ohio, Senator Brown, and I wrote an article about this. We wrote: Your health insurer should be your advocate, not your adversary. The community health insurance option will invest in prevention so that when you are healthy, you stay that way. It will invest in care management coordination, if you have a chronic condition, and it will fight for you, not with you, to get you the best possible care with the least possible hassle.

That is what this is all about. The new business model can look in these areas: Quality improvement. We know that improvement in the quality of care in this country can save dollars. But as we were saying earlier in our colloquy, it doesn't save money for the person investing in the quality. It saves it for the system. A public option will have the public purpose necessary to pursue those quality improvements that will drive down cost.

Health information infrastructure. We have the worst health information infrastructure in this country of any industry. The only industry that has worse information infrastructure is the mining industry. It is pathetic. But the same principle applies. The doctor investing in that equipment on their desk puts out all the money, takes all the risk, absorbs all the hassle, and the savings go to the insurance companies. So we are underinvested. A public option can make those investments in our electronic health record infrastructure.

Prevention strategies. I won't dwell on that because the Senator from Iowa has done such a good job already. Same principle: A public option can pursue the public purpose of protecting public health through prevention in a way that insurers never will because they don't have the financial interest at stake. Finally, you can develop new models of payment to make all those happen, because the way we pay for it now is piecework. Procedure by procedure, the more you do, the more you get paid. Not the healthier your patients are, the more you get paid; the more you do, the more you get paid.

There is enormous hope for the whole system. In fact, it may be the only hope for our whole system is to change that business model to a model that works on quality improvement, prevention, investment, payment reform, and electronic health record infrastructure for everybody. A public option will lead us in that way.

Perhaps you can trust the private insurance industry to do this, although they never have so far. But perhaps now suddenly something will change and you can trust them to start doing this for the first time, when they never did before. But I don't think it is a wise bet to put all of our eggs in that one basket. Give us a public option and let them compete. I think they can help transform this world.

The last thing I will say it is cost control. We have heard a lot about cost control on this subject. There is no better way to have cost control than to get a public option out there doing all these things--stripping the excess profit out of the system, lowering the administrative costs, ending the warfare with providers that provides no value, and working to a business model founded on quality, prevention, electronic infrastructure, and clearer payment signals. That is where we need to go. The public option takes us there.

Nobody cares more about this than the distinguished chairman and particularly the people he has heard from in Connecticut. I would revert back to the chairman to discuss the personal aspects of this on the part of the people he serves.

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Mr. WHITEHOUSE. I wanted to follow up on Senator Merkley's discussion of the different ways in which somebody who is watching this, and who is insured, can look forward to some benefit from all of this. A simple one would be to think, in your own experience, how often you have gone into your doctor's office and maybe been referred to a specialist or you brought a family member in and you had to take a clipboard and fill out on paper for the umpteenth time your personal health insurance, your billing information, your Social Security information, and whatever it is they want. You have to fill it out over and over again. That is the experience many people have with our health care system.

Compare that to going online at--pick one--say, Amazon. You log into Amazon and they say: Welcome, Sheldon Whitehouse. Good to have you back. Here are all the books you bought in the last year or so. Based on that, we think here are more books you might like. Choose something you would like, and your billing information is here.

Put those experiences side by side and show where our bill can take the American health care consumer, and what that means for quality of care, and not just for the convenience of not filling out the form, but when you are a pharmacy, it is connected to your laboratory, it is connected to your doctor, it is connected to the hospital, and you are the center of it, and all of it is private and secure. That is a new and better world for everybody, including those who have insurance.

Who has not had somebody they know go into a hospital and come out with a hospital-acquired infection? It has happened over and over. I have had a friend who went in for a simple knee surgery, arthroscopic surgery. He was a big athlete in college, and he needed a simple surgery on his knee. He got a hospital-acquired infection--a strong, big guy--and it nearly killed him. It took him out of work for weeks. Mercifully, he recovered and everything is fine.

It was touch and go for a while, and the cost of all of that was tremendous from that hospital-acquired infection. He required weeks of medical care. Everybody has had that experience. About 100,000 people every year--Americans we represent--die every year because of hospital-acquired infections.

Senator Harkin tells me that it is the fourth leading cause of death--hospital-acquired infections. They don't care if you are insured when it comes to hospital-acquired infections. The insured will get one just as quickly as the uninsured. The quality provisions of this bill will prevent that and diminish that. That number should be under 5,000. It should be a rarity. Instead, it is a commonality. The system has to change for that to happen.

If you have an illness, try to find a prevention program. Ask anybody you know where they can go to find somebody who will support them in getting an appropriate, sensible, supported prevention program for themselves. It is rare to find. It is almost impossible. As I said earlier, when I was talking about the person who had a leg removed for $30,000 because there was nobody there to prevent them from letting that disease get to that stage, there are big savings there. It is a human consequence. You can have all the insurance in the world, but if it doesn't have a prevention option, you are not helped.

The last thing I will say is that so many of us who feel comfortable right now with our insurance only feel that way because we have had the good luck not to have the experience of having some loved one or ourselves get very sick. People's viewpoints change when they have had that experience. They find the limits of their policy. They see how fast the copays add up. They see the fine print in what they thought was a great policy when times were good and they were healthy, with just a little injury here and there, and everything was taken care of fine; but when they got really sick they found that policy they thought they could count on wasn't there for them.

Now the leading cause of families going into bankruptcy and losing everything in this country is somebody in the family having a health care disaster that wiped them out. That should not be. It happens over and over and over. It happens to the insured. That is not the uninsured. If you are uninsured and you have medical bills, you know you will have problems, but it is the insured who are caught by surprise. They have their homes, their stock portfolios, perhaps, on the side; they have a nest egg, and maybe they help support their children a little bit. And, boom, comes the illness and suddenly they have all these costs and these bills and it is piling up and they cannot keep up and they start to get behind. Before you know it, they have lost it all, and they are in bankruptcy.

Americans have that experience every day and every one of us have heard from somebody in our State who is right there. So I think the point the chairman has been making, and Senator Merkley made, about how important it is for people who have insurance, in terms of improving their lives, their quality, and their care and prospects is very poor. I applaud the Senator for having made that point.

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