Protecting Access to Medicare Act of 2014

Floor Speech

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Mr. President, as the new chairman of the Senate Finance Committee--16 working days on the job--it is humbling to be parachuted late into the issue of reimbursing doctors for Medicare services, and I intend to be brief here at the outset of this debate.

All sides agree that the current system for paying doctors, known as the SGR, does not work well for seniors, the many gifted physicians who serve them, or taxpayers. Devised in 1997, the SGR sets an annual cost target for Medicare physician payments, and it is honored more in the breach than in the observance. When the SGR is not met, the Congress says that is OK, we will just apply a patch and we will punt. Patch it up and let that SGR limp along, just as it has year after year after year.

Mr. President and colleagues, there have now been 16 of these patches--16--and every Senator who I talk to says that just defies common sense and it seems bizarre even by Beltway standards. The cost of the patches now resembles the cost of the full repeal.

To his great credit, the majority leader, Senator Reid, has repeatedly said his first choice for dealing with this issue is to finally repeal the SGR. Now is the ideal time for repealing SGR. The cost of full repeal is far less than anticipated. Thoughtful, bipartisan work has been done in the House and the Senate on repeal and replace, and leading advocates for seniors and their doctors want to replace the status quo with real reform.

So as an alternative to the flawed status quo--an SGR patch No. 17--this afternoon I will make two unanimous consent requests so that the Senate is allowed to have a choice; specifically, a vote on a proposal to permanently repeal and replace the SGR and also to fund the health care extenders.

I will wrap up by briefly describing this proposal. Its essence is to close two chapters of Federal budget fiction. Since the SGR is just pretending that Congress will hold the line on Medicare spending, I believe it is time to end this fiction and wipe SGR off the books. And for balance, I am going to propose ending another piece of budget fiction, specifically the Overseas Contingency Operations, known as OCO, and the spending on wars that are winding down. This too is fiction.

As former Republican Senator Jon Kyl said--a conservative by anybody's calculation--during a previous SGR debate, let's use war savings for one last time to wipe out the debt Congress has built up by overriding reductions in payments to doctors, and from that point on war savings would only be used for defense.

So there you have my proposal: truth in budgeting all around. Wipe the slate clean on Medicare so you can support seniors and their doctors and move forward with real reforms along the bipartisan lines the House and Senate have already agreed to.

I would add that if Congress took the action I just proposed, it could go farther and address the health extenders. Unlike the SGR, these are real programs helping, for example, vulnerable low-income seniors, rural communities, and seniors who need a variety of therapies. Each one of those has strong bipartisan support.

This, too, could be addressed in a fiscally responsible manner. A big chunk of the cost of 10 years' worth of these extenders could be addressed with the savings of the 1-year patch.

So here is my closing: A lot of good work has gone into a bipartisan, bicameral reform plan that finally repeals and replaces the SGR. I would just say to my colleagues, doesn't that deserve a vote? If my unanimous consent request is accepted, we would have that vote.

At this time, Mr. President, I ask unanimous consent that notwithstanding the previous order with respect to H.R. 4302, following disposition of the Owens nomination, when the Senate resumes legislative session, the Senate proceed to the consideration of Calendar No. 336, S. 2157; that following the reporting of the bill, the bill be read a third time and the Senate proceed to vote on passage of the bill with no intervening action or debate; and that upon disposition of the bill, the Senate resume consideration of H.R. 4302, as provided under the previous order.

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Mr. President, before my friend from Alabama leaves the floor--just to highlight where we are--I think he knows how strongly I feel about always trying to tackle these issues in a bipartisan fashion. I would just assure the Senator from Alabama, the reason we took as our underlying repeal-and-replace bill the good work that was done by Senator Hatch and Chairman Camp and Chairman Upton is I felt that extended the olive branch in trying to bring the parties together. I intend to do that consistently on the Finance Committee--pretty much justvthe way I did when I supported George W. Bush on Part D of Medicare.

The challenge, of course, here is that this would be the 51st attempt to essentially try to make changes in the ACA that would end up particularly shifting costs to so many vulnerable people.

It seems to me, particularly today as we have thousands and thousands of people still trying to sign up--I noticed the Wall Street Journal, Saturday, stated that the CBO said the original target for the Affordable Care Act had been met. I think it would be particularly unfortunate to go forward with what would be the 51st effort to try the same kind of approach that particularly would cause so much cost shifting in American health care onto the books of a lot of folks who are already walking an economic tightrope.

I know a number of my colleagues want to speak. As the manager of the time, it is my intention to try to alternate with colleagues of various points of view with respect to this issue. I am sure that will be done as well on the other side.

I note my friend from Virginia on the floor. He is going to be the new chairman of the Senate Finance Subcommittee on Fiscal Responsibility. I think he brings extraordinarily important credentials to this job. His support of the kind of approach I have advocated this afternoon highlights that this will have support in both political parties from Members who have strong credentials in terms of promoting fiscal responsibility.

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Mr. President, before he yields the floor, through the Chair, I would pose a question to the distinguished Senator from Virginia.

The Senator from Virginia has, as usual, gotten right to the heart of the long-term challenge with respect to entitlements. I have always tried to describe it as the challenge of protecting the Medicare guarantee because what seniors have is a guarantee. It is not something that is up for grabs. It is a guarantee. It is inviolate. Protecting their guarantee means that in the days ahead we are going to have to figure out new ways to hold down costs.

What I have heard the Senator from Virginia talk about very eloquently is one of the key ways to do that is what the Senator from Virginia and I have sought to do, which is to start having Medicare--start having Medicare pay for value rather than just staying with this volume-driven fee-for-service system, which largely rewards inefficiency. I think it is my sense that the Senator from Virginia believes it is very hard to start the kind of real entitlement reform we need, where we protect the Medicare guarantee and hold down costs, unless we make the kind of approach we are advocating in this repeal-and-replace strategy with SGR.

We better get to it, because until we have those changes, we cannot begin to get on with another area that the Senator from Virginia feels very strongly about; that is, chronic diseases--diabetes, cancer, heart disease, and stroke--which consume more than 80 percent of the Medicare budget. By my calculation we cannot get on that or any of the structural entitlement challenges until we do what the Senator from Virginia is talking about: Is that pretty much the way the Senator from Virginia sees it?

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Before he leaves the floor, I want to say to the Senator from Oklahoma, who says--and always with a smile--that he and I certainly don't agree on everything in this debate, that the concept of what he is talking about--that physicians spend time with their patients--is certainly a concept that ought to be incorporated into how we proceed in the days ahead.

The other aspect of this that people ought to focus on, with respect to what the Senator from Oklahoma is talking about, is that time that the physician spends with the patient in the office presents a pretty good chance that some of those discussions they have there in the office are going to help keep that patient out of the hospital, and all sides ought to see that as a constructive goal.

So I want my colleague from Oklahoma to know that in the discussions he and I have had--and I appreciated the way my colleague said with a smile we don't agree on everything--the concept he is talking about with respect to doctors and time in the office--is something that ought to be incorporated into this, and it is my intention to work with my colleague on that.

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Mr. President, I want to pick up on another aspect of what both the Senator from Virginia and the Senator from Oklahoma have talked about, and that is that at this rate we have to be concerned that after patch 17 there will be patch 18, and after 18 there will be patch 19. I am sure there are some young people up in the galleries who are light years away from Medicare. In fact, the distinguished Presiding Officer of the Senate is a number of years away from the program, and I don't want to see him looking at patch 30 or 31 or 32. But the reality is if all we do is to take what we have and extend it, we are not going to turn this situation around.

My colleague from Virginia and I started talking about one of the key concepts in our repeal and replace strategy, and that is making sure we have a hard date--really, for the first time--to start paying for value in health care. Repeal and replace has that hard date. This is long, long overdo. Until then, in much of our country, we will still have volume-driven, fee-for-service medicine still driving health care in those communities from one end of the country to another.

I heard one observer say what they hoped for is that somebody in Washington would take a machete to fee-for-service. At a minimum, we ought to do what repeal and replace does, which is to reward for the first time quality, and ensure the message goes out to every corner of the country. I have heard the distinguished Presiding Officer of the Senate say with respect to his important health care reform efforts that instead of just paying for volume, we should actually pay for results, and results mean patients have a higher quality of life. What we know, in many instances, is that kind of care also costs less because we don't have people sicker and needing more expensive services and possibly institutional care.

So now, while I wait for additional colleagues to come and speak, I want to take a few minutes to describe some of the other opportunities we are missing out on by not going forward with full repeal and replace, as I and Senator Warner and others would like to see.

In particular, it is very clear that Medicare in 2014 is remarkably different than Medicare back when it began in 1965. Medicare in 2014 is now dominated by chronic disease. Cancer, diabetes, heart disease, and stroke is more than 80 percent of the Medicare spent. I believe we have some opportunities for some very important breakthroughs.

The Senator from Georgia, Mr. Isakson, has joined me in a bipartisan bill here--the Better Care, Lower Cost Act. It is bipartisan in the other body with Congressman Peter Welch and Congressman Erik Paulsen. That would give both parties an opportunity for the first time to provide the real financial incentives for the long term to reward the kind of coordinated care we are not getting in this country for seniors.

For many seniors, after the free physical they now get under Medicare, their care is so fragmented, so poorly coordinated that until they land in a hospital emergency room, perhaps with a $1,100 deductible and can't figure out all the doctors they have seen during their odyssey through chronic care treatment, we have virtually no system that responsibly manages and is accountable for that senior's care.

In repeal and replace, we take the first steps toward building a chronic care policy for our country. We take the chronic special needs plans--what are called the CSNPs--that haven't worked out as hoped and initiate reforms for those particular plans to ensure that all of the individuals who are part of that program would, for the first time, have an individual care plan. That is something many seniors--certainly a majority of seniors--lack, particularly if they are part of traditional fee-for-service medicine. They don't have an individual care plan. They might have two or more kinds of chronic conditions.

A senior might think they can manage their own medicines and manage their own nutrition, but there would be an alternative. That would be what Senator Isakson and I have talked about for the long term and what we would begin with in a true repeal and replace program for SGR. With SGR, we would start finally looking at those chronic care patients in a way that ensured they got coordinated care from the first time they saw a physician, who, under our approach for the long term, would have a pharmacist and a physician assistant and maybe a nurse. They would be able to have one person accountable for their care.

The irony is that all over the country there are programs that are now doing this and reaping dramatic savings. For example, in rural Pennsylvania there is a particularly promising program where the savings have exceeded more than 20 percent on some of the sickest patients with the kind of approach that Senator Isakson and I are advocating for the long term, and which we would at least begin with these chronic special needs patients under full repeal and replace of the SGR.

Now, I want to close with one other point before I yield the floor to colleagues. The full repeal and replace of Medicare would also contain an idea that Senator Grassley and I have worked on for over 3 years, which is to open the Medicare database. The Medicare database is really a treasure trove of the most useful information about Medicare claims and payments around this country. It holds the record of all payments from taxpayers to physicians and other providers for seniors' health care.

Right now, access to this Medicare database is very limited. If the public or seniors or others want to get access to this information, they have to wade through the bureaucracy, and there are simply very substantial obstacles. We know this kind of information can often produce better quality for lower prices because providers who do well when that information gets out will see they are rewarded for their work, and those that are not measuring up to those standards will either have to change their practices or simply find it hard to keep their doors open. The markets work best when information is transparent for all parties.

Today, most patients lack any comparative information and usually don't find out the cost of their care until after the fact, if at all. So Senator Grassley and I have proposed there be a free and searchable database, one that would allow seniors to find and choose doctors and other health care professionals enrolled in the Medicare program, adding the actual services that are performed and what price Medicare pays for those services.

Americans would finally be able to compare what Medicare pays for particular services in different parts of the country. Opening the Medicare claims database in this way would help us hold down health care costs, would also improve the quality of Medicare services, be a tool in fighting fraud, and would be useful in helping individuals with private health plans--private plans, HSAs and employer-based insurance.

What is going to happen there is, if you have an employer plan in Hartford, CT, or an HSA in Connecticut, the first thing you are going to say is, this is what Medicare pays for a particular service; why can't I, with my employer plan or my HSA have the same price? If I am not getting it, that probably means I am getting less pay, and I would rather see health care costs held down so I could get more in my paycheck.

So opening the record--from a quality standpoint--of Medicare-paid services would be a very powerful tool for measuring hospital and doctor performance. The claims data, with full protection of patient privacy, would open how doctors and hospitals are treating patients.

It would also provide a full accounting of areas which lack access to doctors, specialists, treatment, and procedures. Making this information readily available would also allow doctors to collaborate on improved care management, and make sure the highest quality services are delivered to patients at lower costs.

Finally, the transparency we would get from the efforts Senator Grassley and I have teamed up on, which was part of the full repeal-and-replace strategy, would help us have a powerful new tool against fraud and waste.

We look at the Medicare Program. The Wall Street Journal and the Center for Public Integrity have been able to, even with limited access to Medicare claims data, look at that information and expose through a series of articles how doctors and medical practitioners game Medicare to increase their profits. If we made the system more transparent, as Senator Grassley and I have sought to do and is in the full repeal-and-replace proposal, we would have a significant new tool to root out those--and they are a relatively small number, fortunately--who truly fleece seniors and taxpayers and allow us to get more value for the Medicare dollars.

In 2012 the Medicare Program cost about $580 billion. In a few years, given the demographics and technology, this bill is going to go over $1 trillion.

Often when I go to a high school and meet with young people--as I am sure does the distinguished Presiding Officer--16-, 17-, and 18-year-olds, we talk about matters which concern them, student scholarships, parks, transportation. Toward the end of the meeting I often say: So you all are 16, 17, and 18. My guess is, given your age, you probably tweet your friends when you get up in the morning about Medicare.

These students smile: Well, there is another person from Washington, DC, who doesn't get it.

I kid with them a little bit. Finally, I say: I just want you to know I am kidding, but not really. Because if we don't figure out how to protect the Medicare guarantee and hold down the costs for all you students who care about scholarships and parks and roads and the like, guess what. There is not going to be any money for the concerns which are first and foremost to you.

At this point, of course, the students jump right in, and they want to know about preventive medicine and how to root out waste and some of the things we are talking about. But we can't get to a lot of those important Medicare reform issues which Senator Warner articulated so well when he began his remarks if we can't get full repeal-and-replace of the badly flawed Medicare SGR Program.

I have spent a few minutes talking about how Senator Isakson has an approach which is bipartisan in both the Senate and the House on how to deal with chronic disease; I have talked about opening the Medicare database which is in full Medicare repeal and replace; I have talked about some broad reforms. Of course, at the center is paying for value, which is in full repeal and replace starting in 2018, and we may not get for a while if the Congress just keeps reupping from the 17th patch to 18th patch to the 19th patch.

So what we are going to have to do here in this body--and I know the distinguished Presiding Officer has a great interest in the question and the budget and the future particularly of entitlement costs, which I would say puts the Medicare guarantee and holding down costs front and center--we are going to have to speed up, we are going to have to accelerate the drive to actually get full repeal and replace, rather than patch 17, patch 18, patch 19, patch 20, and up. My view is we ought to be doing it now.

I recognize the objection from the other side. But I have talked to a lot of Senators over the last 3 days of both political parties, and I think there is a growing awareness that simply extending what we already have and punting on the need to fix the urgent structural problems with what we have--which is what some Senators and House Members sought to do--can't be ducked much longer.

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Mr. President, I would like to respond to the Senator from Kentucky by again making it clear that it is my interest to work very closely with colleagues on the other side of the aisle on these health care issues, and that is why we took the proposal Senator Hatch had for repeal and replace on Medicare as the base bill. It is why I spent a lot of time working with colleagues on the other side of the aisle on Medicare Part D and trying to make sure it could be implemented well.

What was striking was that a lot of the stories about Medicare Part D in the first couple of months resembled the stories we are now seeing about the Affordable Care Act. The Congressional Budget Office has made the comment that Part D has come in more than 25 percent less in terms of projected costs than what CBO saw years ago.

We are going to work in a constructive way. I hope we will not see a push, for example, to repeal the Affordable Care Act because if you do that, you will go back to the days when health care in America was for the healthy and the wealthy because you would again allow discrimination against those with a preexisting condition. The Affordable Care Act has air-tight protection for those who have a preexisting condition, and if you repeal the Affordable Care Act, you would simply go back to those days.

Working with colleagues in a bipartisan way on strengthening the health care system and our economy--absolutely. But turning back the clock on vital consumer protections, such as protecting our people from discrimination against preexisting conditions, is something that I think would be a huge mistake.

Mr. President, I ask unanimous consent to have printed in the Record an article that appeared in the Wall Street Journal last weekend. It is entitled ``Health Insurers Make Late Push to Enroll Young People'' with respect to the Affordable Care Act. The signups topped the Congressional Budget Office's target ahead of the March 31 deadline.

I was particularly pleased by the comments from insurance executives in Pennsylvania, Rhode Island, and Florida. They all talked about how more younger people are signing up, which, of course, is key to what we all want to do in terms of bipartisan approaches that strengthen the role of private health care in America.

I would like to have this article printed in the Record so my colleagues can read the remarks of Highmark, Inc., a major health plan based in Pittsburgh. Blue Cross & Blue Shield of Rhode Island said their fastest rising segment in March was people ages 22 to 40. Florida Blue senior vice president Jon Urbanek said, ``Younger people are signing up.''

I think all of this indicates--as far as private sector health care is concerned, which we all sought to promote in connection with this--that more younger people are signing up for these plans.

Also, in response to my friend from Kentucky who asked about the jobs agenda, Senator Hatch and I have been working very constructively together on efforts to go forward in the Finance Committee--which could even begin this week--to deal with the tax extenders. Tax extenders are particularly important for the jobs Senator McConnell seeks--as he mentioned in his remarks--to get some traction. We will be talking about an extension for the research and development tax credit, which is key for innovation. We will be talking about jobs and renewable energy and jobs for veterans. This is the kind of jobs agenda we are pursuing in the Finance Committee.

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