Health Care for All


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Our Sick Health Care System

Health care in America is sick, and we must heal it to improve the lives and “promote the general welfare” of our people, as the United States Constitution promises. Americans pay more than anyone in the world for a system that delivers some of the worst care at the highest costs. This kind of outcome differential doesn’t add up.

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As a proud veteran, my family and I are covered under Tricare. The vast majority of others in this country are not so lucky and, before the passage of the Affordable Care Act (ACA), faced insurmountable financial obstacles to lifesaving routine checkups and preventative screenings. A doctor’s visit was a luxury for far too many hard-working Americans. For the millions who couldn’t afford it, this could mean prolonged illness or preventable death.

After that landmark legislation, however, many Texas families were able to gain access to health insurance purchased in the marketplace with premium subsidies. However, the ACA and many other positive facets of the health care system remain jeopardized by Washington leadership looking to “save money” from the budget by sacrificing the health and lives of millions of Americans—knowing we will still pay even more for it on the back end. Let’s end the false polarization of this subject, and let’s work together to find a pragmatic solution to fix health care in America.

I believe that the to way to solve America’s health care quagmire is to ensure all Americans are covered, regardless of employment status or income level. I’ll fight for health care coverage for all, and I’ll work to close the disparities in both the system’s costs relative to the quality of care Americans receive and the vast gulf in coverage that separates the wealthiest Americans from everyday, hard-working middle-class citizens.

Health care offers freedom, and if we truly want to be the land of the free, Congress needs to be home to those of us who are brave enough to take drastic action to fix our broken system.

Moving from “Sick Care” to “Health Care”

As stated in the United States Constitution, a fundamental goal of our country is to “promote the general welfare” of our people. As such, it is time to invest in “health care” rather than continually propping up a “sick-care” system that has left America paying more than anyone else in the world with outcomes that don’t exactly match our costs.

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I fully support and will co-sponsor HR 676 and fight for universal health care. The reality is, however, that we simply don’t have 218 Votes in the House and the 60 votes in the Senate, and it unlikely we will even after the 2018 elections. That doesn’t mean we can’t improve the system incrementally until we do. Here are my values and goals as we continue the fight for universal health care.

Any health care solution, whether interim or a final goal, must help us reduce cost, increase access, and improve outcomes.

Health care expenditures in the US represented 17.9% of the gross domestic product in 2016. This is higher than any other developed country and exceeds most other countries by 200%, and the second-ranked country (Switzerland) by 37%. The U.S. also ranks top in the world for pharmaceutical costs per capita. Despite these extraordinary and accelerating figures, the US ranks in the bottom third (or lower) of world countries for numerous disease outcomes; life expectancy; infant and maternal mortality; low birth weight; and cancer incidence.

The US now has one of the highest rates of health care disparity between low and high-income earners of the OECD nations. As many as 19 percent of non-elderly Americans report being unable to afford to fill their prescriptions, even after the ACA. As a result of this inequality, the life expectancy gap between the richest and poorest Americans is now more than ten years apart.

It is time for health care to be equitably accessible and affordable to all Americans. The system must be designed to improve the health of American families and our economy.

America’s health care system is fraught with challenges, but with those challenges lies an opportunity and an obligation to improve it. I am committed to pushing for immediate and viable solutions to repair the broken system. Health care for all means freedom from worry, from disease and from unnecessary death or suffering due to lack of health care. When all Americans enjoy the freedom of health care for their families, it will allow them to leave jobs they don’t enjoy, start companies they might otherwise could not, and participate in the economy untethered to only certain jobs that provide health care. Health care for all Americans means freedom for all Americans.

My Health Insurance Experience

As a veteran who proudly served my country, I have been grateful for the ability to receive coverage under Tricare. While Tricare is an example of a program our country established to meet its social contract with those who served in the military, our country’s social contract to ensure its citizens are healthy should not end with military members and veterans or the aged, disabled, or poor—it should extend to every single American.

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The fact that I can keep my own children on a Tricare health insurance policy until they are 26 has allowed my daughters to focus on their educations and careers without worry about whether they’ll have employer-sponsored insurance.

Tricare allowed me the freedom to take entrepreneurial risks and help create jobs, opportunity, and wealth that I otherwise would have been unable to after I left the Army. It is simply wrong that in the richest country in the world, we won’t allow everyone the same security, opportunity, and freedom in their own lives.

Moral and Financial Consequences of our Current System

Unfortunately, many others do not have the same security that Tricare has afforded me. There are countless examples of Texans whose health and economic well being has suffered at the hands of our health care system.

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Before the ACA, working families simply could not prioritize the out-of-pocket expense of routine checkups at the onset of health issues. After the passage of the ACA, many Texas families were afforded the opportunity to gain access to health insurance purchased in the Marketplace with premium subsidies. This gave them access to preventative care without the burden of considering the heavy costs of care or being forced to wait until emergency situation, where care is much more expensive.

However, many Americans remain uninsured. When people do not have health insurance, most are not able to seek preventive care or have their minor medical concerns addressed before they become major ones. Instead of getting regular preventive care that can catch cancer in an early stage or another illness before it becomes devastating, most uninsured Americans end up in the emergency room seeking treatment for a disease at advanced stages. This is not only morally devastating to the Americans and their families who face this face, but it is economically devastating to our country as well.

In Boerne, an emergency room doctor told me the heartbreaking story of countless families without health care walking into his facility at 2 am when the lines are short to seek care for coughs, colds, and flu-like symptoms – they are waking their children in late at night to come in for care that otherwise was out of reach.

These emergency room visits and sometimes subsequent long-term hospital stays lead to uncompensated care for our hospitals, most frequently our safety net hospitals that treat a disproportionate amount of low-income and uninsured patients.

These safety-net hospitals, especially in rural areas, have been hardest hit in states like Texas that have declined to expand Medicaid to cover more of their state’s uninsured population. The amount of uncompensated care resulting from Texas’ lack of Medicaid expansion, combined with a federal funding match that is slated to decrease and eventually end from 2018 to 2025, has left safety-net hospitals in dire situations. Many have already closed their doors, and many others are slated to do so in the future, or to pass along the cost of this care to local taxpayers.

Even if the federal government can save some money in the short-term by callously ignoring these impacts on the health and safety of millions of Americans, taxpayers will still have to pay for it on the back end. The best way forward to ensure equitable, affordable, quality care for all of our citizens is to ensure all Americans are covered, regardless of their employment or socioeconomic status.

Interim Solutions Along the Path to Universal Health Care

This country’s health care system is failing tens of millions of Americans. The status quo we have costs too much, results in poor outcomes, and results in millions of Americans who go without access to health care, many of whom suffer and needlessly die after they wind up in the emergency room, where we collectively pay for the worst outcomes at the highest cost.

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The good news is that in the decades since Medicare and Medicaid were created, there are examples of policies that states and the federal government have created that work to benefit individuals and the country as a whole. The health policy solutions I am proposing will leverage what has been shown to lower costs, improve access, improve quality, and, if fully implemented, extend coverage to all Americans. These reforms are regarded by health policy experts as key ways to begin immediately improving our health care system.

Medicaid Expansion and Buy-In

Medicaid expansion is the provision of the ACA that allows states to expand Medicaid coverage to anyone under 65 who earns 138% or less of the federal poverty level. (For 2017, that is about $34,900 per year for a family of four.)

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Since 2014, 31 states and the District of Columbia have expanded Medicaid, and it is impossible to deny that Medicaid expansion works! The states participating in the Medicaid expansion have seen their uninsured rates decline dramatically. The program primarily helps children and uninsured adults access the health care they need so they can continue unencumbered in their jobs, education, and/or in day-to-day life with their families. For these people, Medicaid is not a safety net; it is a foundation for building healthy productive lives without having to choose between health care and other basic necessitates. It is not surprising, then, that states that have expanded Medicaid coverage have seen saved money and improved overall economic growth as a result.

However, some states, including Texas, have to date not expanded Medicaid. Texas has the highest uninsured rate in the nation and the simple decision to expand Medicaid would cover almost an additional 1.5 million Texans and add over 303,000 jobs to the economy. In the counties that comprise Texas’ 21st Congressional District (Bandera, Bexar, Blanco, Comal, Gillespie, Hays, Kendall, Kerr, Real, and Travis), that would mean more than 150,000 additional people with health insurance and growing the economy in the district by more than $2 billion.

While many Texans would be assisted by a Medicaid expansion, over a million people would remain uninsured. There are a lot of Americans who, despite the subsidies, still do not find the options on the health insurance exchanges affordable. We need to develop a bridge for this population between the Medicaid expansion and the Marketplace. Fortunately, Medicaid has modeled a program for us that could work.

Bipartisan majorities have supported Medicaid buy-ins in various programs for decades. In Texas, these programs have helped children on CHIP, children with disabilities from middle-income families, and adults receiving Social Security disability insurance purchase Medicaid coverage.

I propose that Congress allow states to offer a Medicaid buy-in for people who qualify for health insurance subsidies. This would allow a family of four that collectively earns $85,000 or less in income to use the federal subsidies to purchase state Medicaid plans. The existing subsidies will go further in Medicaid for families who are still struggling with the cost of insurance and it won’t cost states or the federal government an extra cent. For states that choose not to expand, Congress should also allow states to authorize their Medicaid Managed Care plans to participate in the Marketplace to make all options known to families at the time of enrollment in a streamlined, accessible manner. The inclusion of Medicaid plans in the Marketplace can also help stabilize markets with too few options.

Public Option

As discussed in the debate leading up to the passage of the ACA, a public option is a pathway that Congress should consider to create a health insurance plan that can compete with those offered by private insurers on the Marketplace. While that option was dismissed for political reasons, bringing in a competitive plan to ensure that private insurance companies do not overcharge consumers is one way to address existing issues within the Marketplace related to cost.

All-Payer Rate Setting

Congress should also reform facility and provider payments from the vastly unregulated and unfair field it is today to one that allows facilities and providers to be paid fairly, but not at the expense of consumers who have one insurance company versus another.

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Current service rates set are in negotiations between individual insurers and individual facilities for each health care service. This results in patients with different private insurance providers, public insurance, or without insurance altogether, paying dramatically different amounts for the same service.

While we pave the way toward universal health care, ensuring that all payers within the current system operate by the same rules can make immediate improvements to the financial affordability of health care for Americans.

Prescription Drug Prices

Drug makers have spent more than $2.3 billion lobbying Congress over the last decade – more than any other industry, which explains why no legislative proposal to rein in rising prescription prices has gone anywhere.

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Price gouging by prescription drug companies in the United States is rampant. For example, Gilead Sciences sells a Hepatitis C drug in the U.S. as Sovaldi at a retail price of $1,000 a pill. However, in India, they contracted with pharmaceutical companies to create generic versions of the drug which are available for $4 per pill. Meanwhile, Gilead’s CEO received over $43 million in total compensation. This is just one example of an epidemic of pharmaceutical companies abusing our health care system to extract extortive profits from millions, and deny access to millions of other people who simply cannot afford life-saving medication.

It’s not just Gilead; executive compensation for pharmaceutical CEOs is reaching staggering heights across the board. As reported by USA Today in 2016, the fourteen biotech and pharmaceutical companies in the Standard & Poor’s 500 pulled down median compensation packages valued at $18.5 million in 2015, which was 71% greater than the median for executives across all industries for the year.

This status quo reeks of favoritism at the expense of the health and well-being of Americans. Luckily, there are some solutions that Congress can take to begin to fix this problem.

Patent Litigation Reform

Large pharmaceutical companies routinely abuse the patent system, continually tweaking old formulas superficially to abusively extend monopoly rights so that consumers pay increasingly high amounts for their necessary prescriptions.

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The status quo isn’t promoting innovation; it is enriching pharmaceutical executives like Martin Shkreli by allowing them to extract larger profits for a longer period than was ever intended. This occurs while people who need these drugs to survive are forced to make impossible choices to pay for their medication over other bills or go without the treatment to afford other necessities.

Reform of this abusive loophole is long overdue. Pharmaceutical companies should be required to demonstrate that a change to a medication has significant, new therapeutic advantage to extend or renew a patent.

Ban Gag Clauses/Pharmacy Benefit Manager Clawbacks

Gag clauses are commonly used by pharmacy benefit manager (PBM) companies to ensure consumers pay unnecessarily high prices for prescription drugs. These clauses ban pharmacists from telling consumers that they could save money by paying out of pocket for prescriptions, under the threat that the pharmacy will be kicked out of the insurer’s network if they fail to comply. This is simply immoral, and Congress should act immediately to prohibit these agreements. Some state legislatures, including Texas, have recently done so.

Research Investment Return Reform

American taxpayers invest billions annually underwriting the development and distribution of prescription drugs and insulating private drug companies from direct competition. However, once we write the check to these companies to support this research, the American health care consumer is sometimes abused through exorbitant and unethical price gouging for the drugs their tax dollars went to develop. Currently, there is inadequate regulation on the pharmaceutical industry to ensure drug companies won’t charge grossly excessive amounts to Americans, including vastly more than these companies charge consumers in other countries.

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As an example, Xtandi, a prostate cancer drug, was developed at the University of California Los Angeles (UCLA) with taxpayer-funded research grants, and support from the United States Army and the National Institutes of Health (NIH). UCLA then licensed the drug to a small biotech company in San Francisco. Pfizer Inc. paid $14 billion to acquire that company in 2016, and now charge Americans $129,000 for one year of treatment with Xtandi, compared to the $30,000 the drug is priced at in Canada. Not only is this price discrepancy unfair on its face, but it is also made worse by the fact that Americans are being charged twice—as taxpayers for the research and development, and then as consumers who need the drug, at an absurdly high amount. Some lawmakers, including Austin’s own Congressman Lloyd Doggett, have rightly asked NIH to consider overriding Xtandi’s patent over this egregious pricing issue.

Representatives Peter DeFazio of Oregon and Senator Bernie Sanders of Vermont recently proposed legislation with the goal of establishing a rule forcing federal agencies and nonprofits (that receive federal funding) to negotiate affordable pricing with manufacturers before the agencies can allow for exclusive rights to companies that make pharmaceutical or other health care products. I strongly support this legislation.

Medicare Part D Prescription Drug Negotiation and Formulary

The Veterans Health Administration (VHA) pays 40% less for pharmaceuticals than Medicare does. The VHA has the power to negotiate drug prices and has its own drug formulary. While Medicare has neither, it does benefit from existing negotiation used by private insurers. Still, it is possible that a more large-scale negotiation by Medicare itself may result in cost savings for beneficiaries. A bill that would allow for that process has already been introduced by Senator Amy Klobuchar of Minnesota and Representative Peter Welch of Vermont. By allowing Medicare Part D to utilize the same tools as the VHA, we may be able to reduce costs for taxpayers.

Addressing the Opioid Crisis

Prevention

As has been requested by 35 State Attorneys General, Congress should require that health insurance plans provide coverage for non-opioid pain treatments. Health care providers certainly need to do more to ensure they are prescribing appropriately, but the reality is that the conversations between patients and providers about alternative methods for pain treatment often don’t happen because of outdated insurance policies. In most cases, patients know that their insurance company will cover a bottle of opioids; but will not be as generous in covering sessions of physical therapy or nutritionist consultations that could be needed to truly address the root of a patient’s pain.

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Congress should also do more to encourage drug and pharmacy companies to fill opioid medication in locked containers that are only accessible to the patient they are prescribed to. Many young people are accessing their parents’ prescriptions and continuing along a devastating pathway of addiction. We must also educate patients who are prescribed opioids about the dangers of sharing their prescriptions instead of having the friend or neighbor seek health care for themselves to learn about what treatment is best for their condition. Preventing teenagers, family members, and others from obtaining drugs from their friends and relatives in the first place can help prevent their addictions altogether.

We also must ensure that patients who truly need opioids to treat their conditions continue to do so. Policies that are at once too restrictive and too broad can create unintended harm, and can lead to some of these patients turning to deadlier street drugs to treat their pain, like fentanyl and heroin.

Treatment

Many individuals experience an opioid overdose before realizing they need or being encouraged to seek treatment for their addiction. First responders like law enforcement officers, emergency medical technicians, and firefighters are responding to an increasingly large number of medical calls for drug overdoses. Many states and localities have allowed or required these first responders to carry naloxone, the opioid-equivalent of an EpiPen for allergies, to immediately reverse the overdose of these individuals. However, we must ensure that all first responders are legally allowed to carry this medicine and allocate funding to help them do so.

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Making naloxone accessible to individuals who themselves are addicted or who know individuals at risk for overdose over the counter can also decrease the number of deaths from this devastating illness. Not only should naloxone be accessible at the pharmacy, but prescribers should be encouraged to “co-prescribe” naloxone with opioid medication.

Congress should also encourage more physicians, nurse practitioners, and physician assistants to apply for DATA (Drug Addiction Treatment Act) waivers to prescribe medication-assisted treatment.

A Better Approach to Mental Illness

Untreated mental illness can often lead to drug addiction, crime, and suicide and costs America more than $300 billion a year. As a country, we need to move in the direction of treating mental illnesses as a health issue the same way we treat other chronic diseases—with a focus on the causes, not just the effects—and provide money in innovation and execution for this work. Americans with mental illness should have access to appropriate medications, evidence-based services, and treatment.

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It is critical that we continue to move toward universal health care and it is essential we do not leave mental health behind. Improving access and outcomes, while reducing the cost of treatment for patients, should not simply be goals of health care reform with regard to physical health, but also mental health.

Investment in prevention, early intervention, services integration, and recovery is essential, as is an investment in support efforts. It is imperative that Americans have access both to acute inpatient care, as well as the community services necessary to prevent the repeated need for inpatient care, allowing them to succeed and flourish in society.

All too often, people who need appropriate mental health care wind up in the criminal justice system, where their mental illness cannot be optimally addressed. The criminal justice system is an inappropriate and ineffective means of addressing severe mental illness. A comprehensive criminal justice reform policy must address the issue of incarceration of the severely mentally ill. We simply should not be incarcerating non-violent offenders with mental illness, and violent offenders with mental illness who are incarcerated should have access to adequate and appropriate treatment. By reducing what we spend on incarcerating the mentally ill, we can use the savings thereof to invest in social support systems to enable people to succeed in society.

Innovation in mental health treatment is something that the market alone doesn’t incentivize optimally without collective societal support. Consequently, I support increased funding of neuroscience, behavioral pharmaceutical, clinical, and service system research.