Floor Speech: Murkowski Says Democrats' Health Care Bill Doesn't Solve Medicare Access Problem in Alaska

Mr. President, I appreciate the good Senator from Pennsylvania and his discussion and his clear and constant focus on children and children's health. I wish to commend him for his good work and for always reminding us of the importance of our children in so many aspects of our policies. So I thank him for that.

I, too, rise this afternoon to talk about the debate on health care and the debate we seem to have ongoing with the numbers. Whether it is numbers that are coming out from the Congressional Budget Office, the CBO, or from our States or from other noteworthy entities, there is a great deal of back and forth as to whose numbers are right, whose numbers are wrong.

There has been a great deal of discussion in the past day or so about the numbers we have received and the analysis we received from the Office of the Actuary, from CMS, the Centers for Medicare and Medicaid Services. The Chief Actuary is Mr. Richard Foster. A good deal of discussion has been had as to these numbers, and the question that needs to be asked is: Why would the numbers from the CMS Actuary be any more significant than, say, what we have seen coming out of the Congressional Budget Office?

The Chief Actuary of CMS is kind of the independent arbiter, if you will. They look at both the private and public health care expenditures. The Chief Actuary provides actuarial details that I think we recognize can be critically important for certainly my State and for any of our States' economists to develop individual State estimates of the financial impacts, the effects of the health care reform proposal.

As important as discussion on the broader scale is, the people back in my State want to know: Well, what does it mean for us in Alaska? What does it mean for increased access? What does it mean for us in terms of our premiums? Are they going up? Are they going down? How do we as a State that is very unique in its markets--geographically dislocated, smaller population--how does this health care reform proposal impact us? So the numbers and the assessment we have received from the Office of the Actuary are very important.

I have mentioned we all want to know what this Democratic health care proposal will mean to us as individuals in terms of the increase to premiums, the impact on the long-term sustainability of Medicare, whether it is going to restrict access to care in a State such as Alaska or throughout rural America. And ultimately, will this $2.5 trillion bill bend this cost curve down on health care expenses that are pricing so many Americans out of the market on health insurance.

I think it is so important that we be focused on the cost side and on the spending side. That is a bipartisan thing. We haven't done a lot that is bipartisan of late, but it is clear we all want to know we are doing all we can effectively to reduce those costs.


I will note a letter that came from six colleagues on the Democratic side. This was sent when the Finance Committee bill was being considered. A letter went out to Chairman Baucus that provided that:

There are many wide-ranging options to address the broad and complicated issues of runaway health care costs, and we pledge our support to you in making the necessary and tough decisions.

 ``This is our No. 1 priority,'' the letter states. ``If we pass health care reform without addressing the issue of health care spending, we have failed.''

 I couldn't agree more with my Democratic colleagues who signed that letter. We will have failed if we have not addressed the issue of cost, the issue of spending.

Again, this takes me back to the report from CMS, the Actuary's report. I want to highlight some of the very important points that were raised by the Chief Actuary.

First, the Reid bill reduces payment updates to health care providers, which are unlikely to be sustainable on a permanent basis. If you go through the report, on page 9 is a statement that:

As a result, providers could find it difficult to remain profitable, and absent legislative intervention might end their participation in the Medicare Program. The Reid bill is especially likely to result in providers who are unwilling to treat Medicare or Medicaid patients.

On page 18, the statement is:

Providers might tend to accept more patients who have private insurance and fewer Medicare and Medicaid patients, exacerbating existing access problems for the latter group. Either outcome, or a combination of both, should be considered plausible and even probable.

I can tell you for a fact this is not just some maybe or if, in fact, these things happen; this is happening.

I received a call 1 week ago from a practitioner in Alaska, in Anchorage, a family care practitioner. I was told that this practitioner, who has been practicing for many years in the family care practice--that the decision had been made to opt out of Medicare. In the e-mail we received and the followup conversation that was had with this practitioner, it was specifically cited that it is due to what is--I am reading from the e-mail we received--``due to what is in the Reid bill, as it will collapse my practice.''

This is incredibly important to us not only in a State such as Alaska, where we are in a crisis situation when it comes to providers who are willing to take new Medicare individuals. Right now, in our State's largest city, we have 13 providers who will take new Medicare individuals--13. Well, if this individual whom we have communicated with a week ago is making the decision to opt out of Medicare because of the low reimbursement rates, because of what is seen developing here on the floor of the Senate, and the impact that will have on that family care practice--talk about not being able to sustain things--it is not acceptable.

When I read the language in the Actuary report that says that providers might tend to accept more patients or might find it more difficult to remain profitable and might end their participation in the Medicare Program--to me, I am saying it is not ``might,'' it is happening, it is now, and it is impacting Alaskans' access to care in my State.

This is something we should all be concerned about. It is not just this one practitioner. We have heard this has caused a great deal of anxiety within Alaska, primarily because that is where I am checking in with folks. But the anxiety about their ability to sustain a practice, again, with Medicare reimbursement rates as low as they are--in our State, we don't have a medical school, so it is not as if we are growing more practitioners to come in. It is very costly to have a practice in Alaska. We have a lot of strikes against us.

We have to figure out a way we can continue to receive care from these fine professionals. But right now, from a policy perspective, it seems as if we are doing everything possible to drive them out.

I am talking a lot about the situation in Alaska, but don't think for a minute that it is isolated to my State. The statement that is made by the Actuary is devastating news for States that are also facing problems of access, in terms of finding a general care doctor to see them, such as Oregon, Nevada, Colorado, and New Mexico.

There was a GAO report--granted, this is a 2006 GAO report, but it did an assessment of what is happening in locations across the country, and those areas where access is compromised. You look at the statistics coming out of GAO, and their wording is:

This suggests the distinct possibility of a deepening problem in many of our Western States.

 So it is not just in a few isolated communities. We have States that are looking at this and calling the crisis for what it is. What we are doing in this health care bill currently before us is we are using Medicare as kind of this guinea pig, if you will, cutting from the Medicare--from the health program, even though we all recognize Medicare is slated to go broke by 2017--and using the Medicare money to expand Medicaid and, if the Medicare reports are true, expanding Medicare as well. So the end result is to harm Medicare patients as we expand Medicaid.

Alaska is a little bit unique. We are one of two States where Medicaid is actually a better payer, or better in terms of the reimbursements, than Medicare. But even still, the economists we have at the University of Alaska's Institute for Social and Economic Research have said that Medicare patients will lose access and, as they have suggested, kind of go to the back of the bus, if we expand Medicare.

I want to use their language specifically. This is from the analyst at ISER. He has stated that:

We can continue to be concerned that the newly enrolled through the Medicaid expansion and the new exchange will create a big surge in demand that could easily create a traffic jam in the health care system and send the Medicare beneficiaries to the back of the line in Alaska due to Medicare's low reimbursement rate. Expanding Medicaid is bad for Alaska.

The Chief Actuary at CMS is saying Medicare and Medicaid patients will both face limited access to care under this bill. While in Alaska Medicaid patients may fare better, what is happening is at the cost, or expense, if you will, of Medicare patients. So you are robbing Peter to pay Paul.

Keep in mind that, as we look at the CMS letter--the Chief Actuary's letter--it doesn't even address the Democratic leader's desire to bring to the floor the provision that would expand Medicare to those 10 years younger than the current threshold age for Medicare. So what we are seeing within this analysis is probably just the floor in terms of what the impact will be if we allow for this expanded Medicare provision, this buy-in, if you will.

Again, my State's seniors are absolutely suffering on Medicare, with virtually no primary doctors who will see them in our State's largest city. Now we have experts saying Medicare's patient access to care is going to suffer.

We simply cannot expand broken health care systems. We have to fix the systems. You don't expand a broken thing and hope it will fix itself.

Yesterday, in our State's largest newspaper, the headline at the bottom of the fold was:  ``Health Bills May Hurt Some Alaskans,'' consultant says. And it says:  Older residents could have more trouble seeing doctors.

If you don't think that sends chills up and down the seniors in my State, knowing that the difficulty they are facing now could be made worse--a point that I think is important to add to the conversation here. You might think, well, Alaska, you don't typically have a lot of seniors, you are a younger population. We are that, but it should be noted that we are, per capita, the State with the fastest growing senior population in the Nation. We have a situation where, as we have our baby boomers aging in, the numbers are increasing dramatically, as far as those who will require the care. The number of patients who are 65 and older at the health care facilities, Anchorage Neighborhood Health Center, has jumped on the order of 50 percent within a few years. The neighborhood health center saw twice as many Medicare patients in 2007 as in 2001.

The report also found that older Alaskans have been visiting the emergency room in growing numbers. What we are seeing is an expansion of those who will be our Medicare consumers. In 2008, there were 49,455 Alaskans 65 and older; but by 2015, 5 years from now, the number is expected to increase 50 percent. By 2020, 10 years from now, the number is projected to increase to over 86,000 individuals in Anchorage. Yet, we have fewer and fewer primary care doctors who are willing to accept these Medicare patients.

The proposal out there is that we are going to cut $ 1/2 trillion from Medicare to pay for a new government entitlement. That doesn't add up.

Back to the Actuary's report. It goes on to state that:

 We estimate that total national health expenditures under this bill would increase by an estimated total of $234 billion during calendar years 2010 to 2019.

We know that bending down the cost curve, which has been so essential to the health care reform bill, according to our own government's expert, is not going to be achieved in the Democratic leader's health care proposal.

Contrary to what Senator Baucus said last week, that Senator McConnell's statement that this bill raises costs was ``a false statement,'' this bill does, in fact, raise health care expenditures, and all you need to do is go to the Actuary's statement to determine that.

The Actuary's report goes on to provide:

The new fees for drugs, devices, and insurance plans in the Reid bill will increase prices and health insurance premium costs for consumer. This will increase national health expenditures by approximately $11 billion per year.

We know this bill is going to raise money on the backs of patient consumers. This is going to happen in my State. It is going to happen in every other State. And it is going to be done by taxing the industries that provide us with the prescription drugs, the medical devices, such as tongue depressors, medical thermometers, blood sugar meters, x-ray machines, and the like.

Whether or not you agree on taxing these industries, what the CMS Actuary is telling us is that these additional taxes are going to be passed on to the patient consumer to the tune of $11 billion every year. Again, the American people should know that their costs on drugs, thermometers, diabetes test strips, labs, and x rays are all going to go up because new penalties imposed by the Federal Government will be passed on to the patients.

I appreciate the work Mr. Foster, the Chief Actuary, has done in getting us this report. I wrote him a letter on Monday asking if we could get the report so the folks in our respective States could look through it and better assess and understand. They want to know that they are relying on a good, sound assessment. But I will tell you, after reviewing the Actuary's report, I do not know how anyone could come to a different conclusion other than that these proposals, these bills, do not look good for my State, they do not look good for the medically underserved areas of the country, such as urban areas with limited access to care because of their high Medicaid populations or for rural America where general-care doctors just simply are not taking Medicare patients.

This is just a bad bill. It is a bad bill. It hurts our seniors, it does not bend down the cost curve, it spends $2.5 trillion, and it raises health care costs. We have to figure out a path forward that is reform that does not increase the cost to our constituents around this country, that truly does make a difference when it comes to the delivery of health care costs in this Nation, and that really does provide for expanded access.

I have said numerous times that just by giving an individual a card that says: OK, now you are part of a health care plan but you don't have access to a provider, we really haven't done what we have promised to do to help you receive good health care.

There is a great deal that is floating out there in terms of ``he said, she said'' type of conversation on the numbers. It is incumbent on us in the Senate to give thorough vetting, thorough assessment. We have to rely on the experts. We hope we rely on those experts who have been able to look at the proposals fairly and evenly and give their best assessment. I have a great deal of confidence in our independent entity in the State of Alaska, the Institute for Social Economic Research at the University of Alaska. I appreciate what they have done to provide more focus on what this national proposal will do to access to care in my State and costs that will be borne by my constituents.

I think the more time we spend understanding what we have in front of us, the more we realize this is a bad deal for America.

Mr. President, I yield the floor.