1. How serious is the number of Americans without health insurance, and what measures would you support to enable more Americans to have health insurance coverage?

The most significant issues facing health care and medicine today are quality and access – everything else that is discussed in health care comes back to these issues. America is blessed with many of the world’s greatest medical researchers and amazing innovation that saves lives and improves quality of life. However, not all Americans have access to quality and affordable health care. The most significant threats to quality and access are the medical liability crisis, access to affordable health insurance, and broken reimbursement systems.

The Census Bureau reports that nearly 46 million Americans, including eight million children, were uninsured in 2004. I have strongly advocated for policies that expand access to affordable health insurance, with patients and their physicians deciding what care patients receive. I am adamantly opposed to government-controlled health care. Policies advocated by my opponent are unacceptable because they are enormous and prohibitively costly expansions of the federal government controlling health care, resulting in over $1 trillion added to the federal deficit and crippling tax increases. We should be enacting policies that increase competition and choice in health care, not eliminate it. Patients and physicians should make health care decisions, not government bureaucrats.

I have used my leadership position in the U.S. Senate to encourage an honest debate about health care coverage. Individuals and families are uninsured for a variety of different reasons; therefore there is no single solution to the problem. Policies that I support are patient-centered proposals to expand access to quality and affordable health care, rather than increasing dependency on government programs. However, the federal government can be an important partner in facilitating affordable coverage. This is why I have supported legislation to increase outreach and enrollment in the State Children’s Health Insurance Program (SCHIP). Approximately 20 to 30 percent of the children eligible for SCHIP are currently not enrolled.

I have also authored numerous bills to expand affordability of heath care coverage. One recent example is my Tax Relief for the Uninsured bill, which would provide refundable tax credits for low and moderate income individuals to purchase private health insurance, would allow an above-the-line tax deduction for high-deductible health plans, and would provide incentives for small businesses to contribute to an employee’s coverage.

2. For several years, Medicare Part B spending has risen more than the average rate of economic growth in the U.S., while physicians and other Part B providers under current law have to absorb these costs in the form of reimbursement cuts calculated by a Sustainable Growth Rate (SGR) formula. Congress has intervened and temporarily suspended the mandated reimbursement cuts for 2003 through 2006, which has been followed by continued growth in utilization and intensity of health care services, in Medicare Part B spending, and in beneficiary premiums for Part B services – a dynamic which CMS Administrator Mark B. McClellan, M.D., Ph.D. has called a "vicious circle of rapid growth in utilization and spending." There are currently two legislative proposals [HR 5866 and HR 5916] to replace the SGR formula. What do you think should be done to address this problem?

Ensuring that physicians are reimbursed adequately and fairly for the valued care that they provide is one on my top priorities and will continue to be so. Access to needed medical care is currently being harmed in Pennsylvania by the critical status of the medical liability crisis; we cannot also expect physicians to take drastic cuts in Medicare reimbursements. The medical liability crisis is significantly driving up medical practice costs in Pennsylvania, which is why we must address both issues. The issues of medical liability and reimbursement are intertwined, creating a snowball effect – dramatic increases in medical liability expenses and the defensive medicine that it fuels drive the variables in the SGR that punish physicians.

This is one of my top priorities because of the dire impact on my constituents in Pennsylvania. Last spring the Pennsylvania Medical Society released its 2005 "State of Medicine in Pennsylvania" report, which concluded that the health care system in the state is "stressed and access questionable." There is strong evidence that Medicare reimbursement is inadequate. Pennsylvania has one of the largest senior populations in the country, yet from 1999 to 2005, when the top 20 most populous states saw a 15 to 35 percent increase in the number of physicians permitted to bill for Medicare services and refer Medicare patients, Pennsylvania witnessed a 10 percent decline. Congress needs to replace the SGR with a truly sustainable payment policy.

A permanent solution is necessary to preserve and strengthen access to care. As a member of the Senate Finance Committee, I worked with my colleagues to secure the $7.2 billion in the Deficit Reduction Act that was necessary to prevent a 4.4 percent cut in Medicare physician reimbursements for 2006. I have repeatedly urged the Center for Medicare and Medicaid Services and the Office of Management and Budget to take the necessary actions to address this issue. Yearly stopgap measures will not address the continued threat to access. I am committed to working with my Senate colleagues, and ask that physicians and patients join us with their valuable insight to find a permanent solution.

In addition to addressing the overall SGR formula, I have fought for Medicare payment policies that benefit patients and providers. For example, recently I was able to successfully enact a provision from my Colon Cancer Screen for Life legislation that will save lives by greatly increasing Medicare access to colonoscopies. I have also championed ESRD legislation, and have successfully secured payment updates for dialysis treatment.

3. Consumer-driven health care – in the form of high deductible health plans and price and quality transparency initiatives – is being touted as a movement to hold down health care costs, provide more choice and autonomy to health care consumers, and lead to more competition on price and quality. What is your view on consumer-directed health care, and what role do you think the federal government should play in supporting it?

Health care decisions should be made for clinical reasons, by patients and clinicians, not by government bureaucrats, nor by insurers. One of the important reasons that I support Health Savings Accounts (HSAs) is that patients and their physicians decide how health care dollars are spent, not health insurers. Over 3 million Americans are now covered by these policies, and contrary to critics’ charges, they are making a difference. Over one-third of the policies sold last year were sold to those previously uninsured, and some argue that the other two-thirds were at great risk of losing coverage. Also, one-third of HSAs were purchased by small-business employers that previously offered no health care coverage to their workers. Critics claim that these policies are only for the wealthy and young – much to the contrary, 62 percent of HSAs have been purchased by individuals over the age of 40, and nearly 45 percent of HSAs cover those with annual incomes less than $50,000, and 20 percent have annual incomes less than $40,000.

Recent trends in the cost of health insurance are deeply concerning. An important study by the AMA on competition in the health insurance market found a "remarkable reduction in the number of competing health plans." The same study also found that a single insurer has at least 30 percent of the market and in 56 percent of the areas a single insurer has a share of 50 percent or more. More must be done to increase competition, and consumer-driven health care is an important part of that effort.

The federal government’s role in supporting consumer-driven health care is one of providing financial incentives and reducing barriers. We must be careful that we do not create overreaching regulations and administrative burdens that take valuable physician time away from patient care. Government funded and controlled health care would significantly expand the amount of regulatory burdens placed on health care providers. This is one of the many reasons that I am strongly against health care policies that further expand the government’s role in health care delivery, and why I have worked to include market-based reforms whenever possible in health care legislation.

4. Many in government and the private sector have talked about the importance of interoperable health information technology products – such as electronic health records and electronic prescribing systems that can communicate and share data with each other – in fostering networks so that consumers and health care organizations have secure and widespread access to that information. Studies have shown that it is not cost-effective for most physician practices to purchase those systems on their own. What role do you think the federal government should play in facilitating the adoption of this technology?

The widespread use of HIT holds enormous potential to reduce costs, enhance efficiency, and improve the overall quality of patient care. The federal government’s role in facilitating adoption of health information technology should be, as in all aspects of health care, to provide financial incentives where and when appropriate, and reduce barriers such as overreaching regulations and administrative burdens.

Most importantly Congress needs to provide clear exceptions on physician self-referral, and anti-kickback – current rules and regulations are significant roadblocks to the adoption of HIT. I have consistently supported efforts to fund HIT projects, including Regional Health Information Organizations in Pennsylvania.

5. A 1999 report by the Institute of Medicine, "To Err is Human: Building a Safer Health System," put the subject of medical errors on the map and made patient safety a public issue. What do you think is the best approach to reducing medical errors and compensating victims of medical errors, while reducing the strain of skyrocketing medical malpractice insurance premiums on the health care system?

The best approach to reducing medical errors is adoption of HIT and reforming the medical liability system. I don’t think anyone believes that these dedicated medical professionals are intentionally or maliciously harming patients, so we must look at the root cause of this issue. Most, if not nearly all of what is labeled "medical malpractice" is actually a breakdown in process due to incomplete information or human error. This is one of the most important reasons that we need better HIT, so that we can identify when there is a breakdown in process (i.e., why did patient get wrong dose of medication?), and give providers robust information when they are making health care decisions. However, the current medical liability crisis creates an environment that does not encourage open discussion of medical errors, in fact quite the opposite. In a survey of Pennsylvania physicians, 93 percent reported practicing defensive medicine in order to avoid a lawsuit, and 92 percent reported ordering unneeded tests and referrals. Worse, the current situation does not compensate most individuals that are harmed from adverse outcomes of medical errors, but acts as a litigation lottery for a very small number of individuals, with most of the money going to the lawyers.

6. On the subject of medical malpractice reform, the American Medical Association and many physician groups support a cap on noneconomic damage awards (e.g., pain and suffering jury awards in malpractice trials) as a key ingredient to controlling skyrocketing medical malpractice insurance premiums, while also preserving patient access to high-risk medical procedures performed by physicians who are saddled with the highest insurance premiums (e.g., obstetricians, neurosurgeons, orthopedic surgeons, and general surgeons). The U.S. House of Representatives has passed such a bill several times, while it has repeatedly been defeated in the Senate. What is your position on the issue?

I have strongly advocated for medical liability reform because of the current crisis that is significantly affecting both the cost of health care and access to critical services. Medical liability reform is one of the planks of the Legal Reform Agenda of the Senate Republican Conference that I chair. Last year the Senate considered the successful California MICRA model as the basis for reform, and I supported that bill.

This year, the Senate modeled legislation based on the successful Texas Model. Both models have a $250,000 cap on non-economic damages for physicians. Senator Ensign authored the broad medical liability reform bill (S. 22) and I authored the bill targeting obstetricians and gynecologists (S. 23). Both bills were endorsed by the American Medical Association, the American Osteopathic Association, Doctors for Medical Liability Reform, the American College of Obstetricians and Gynecologists, the Health Coalition on Liability and Access, and many others.

Like the Pennsylvania Medical Society, I believe that "permanently addressing the medical liability dilemma in Pennsylvania is critical for the future of health care delivery and economic development." I was disappointed that my colleagues yet again decided not to address this issue, but I remain committed to continue to push this issue forward and press for the urgent solution that is needed – including caps on non-economic damages.

7. Medicare has several demonstration projects looking at paying providers more for measurably higher quality care. What role do you think pay-for-performance reimbursement has in improving the quality of health care, and what role do you see the federal government having on the matter in the future?

The current Medicare payment policies are volume based, without regard to quality or outcomes. Medicare should do a better job of compensating for chronic disease management, wellness and health outcomes. However, policy development should be driven by physicians. Clinicians, not government bureaucrats or politicians, should be defining quality, and developing the tools by which to measure and compensate for quality.

8. Pennsylvania and many other states are struggling to fund burgeoning Medicaid expenses, in part because of shrinking federal dollars. What can, and should, the federal government do to help states meet their Medicaid obligations?

I am very concerned about the health care needs of Pennsylvanians, and I am diligently working to strengthen the Medicaid program. I have been particularly frustrated and angered by reports of extensive fraud, waste, and abuse within the Medicaid program. The Government Accountability Office continuously rates Medicaid as a "high risk program" for fraud, waste, abuse and mismanagement. Last year an audit of the New York state Medicaid program determined that approximately 40 percent of the billings were fraud, waste and abuse, totaling $18 billion. If Pennsylvania has a similar rate of fraud, waste and abuse, addressing the problem could save the program an estimated $6 billion a year, more than addressing financial shortfalls, and strengthening the safety-net for those in need.

The Deficit Reduction Act (P.L. 109-171) takes action to combat fraud, waste, and abuse in the Medicaid program by providing states tools and incentives to combat fraud and abuse. One example is incentives to states that pass False Claims Acts, which has been successful at the federal level in combating fraud and abuse in the Medicare program. The DRA also invested more federal resources into fighting fraud and abuse. I was shocked and upset to learn that in 2004 the Centers for Medicare and Medicaid Services allocated only $26,000 and eight staff members to address fraud and abuse in a $295 billion program.

Last year all 50 governors agreed that Medicaid was unsustainable, and unanimously asked for tools to contain explosive cost growth. States have been forced to limit benefits and eligibility – for example, Tennessee dropped 171,000 Medicaid beneficiaries because they did not have the flexibility to control cost and waste. The DRA will provide needed relief to states by directing resources where they are needed and improve access to health care for our most vulnerable citizens – tools that all 50 governors agreed were necessary to save Medicaid.

Prior Medicaid law created an "all or nothing" situation because the law was inflexible, regardless of a beneficiary’s need or income. The DRA gives states the option to tailor benefit packages to better meet the needs of their populations and target resources to those most in need. States will have the option of asking a very limited group of Medicaid beneficiaries to share in the cost of their care. Under current law, all beneficiaries have the same cost sharing, regardless of income. The cost-sharing policy in DRA excludes anyone under the federal poverty level, as well as any pregnancy-related services and many services offered to children. Only those individuals not in poverty will have this cost sharing, and to protect beneficiaries, Congress also put in protections so that beneficiaries will never have to spend more than five percent of their income.