10:06 AM EST

Patrick J. Leahy, D-VT

Mr. LEAHY. Madam President, I am glad to see my colleague and neighbor from New York in the chair, an extraordinarily hard-working Member of the Senate. I am not surprised, on a Saturday morning, that she is here.

Before I begin, I wish to state my appreciation for the kind words from the majority leader for the Senator from Vermont. He and I have been friends for decades. I am glad to see the work he has done in bringing this bill to the floor. I intend to work closely with him.

Decision time is near on health insurance reform. I will vote today to end the filibuster so the Senate can begin this important, historic debate to improve and reform our Nation's health insurance system. Let's not duck the debate. Let the debate begin. Let's not hide from votes. Let's have the courage to vote. Stand up and vote on the amendments. Let the American people know where we stand and not say: Well, it never came up because of the filibuster. We can end the filibuster today. We can

get going. We can let every American know where we stand.

The sentries of the status quo again have spared no effort to kick the can down the road, as they have done before. The country suffers when there is a failure to act on serious challenges that millions of ordinary Americans face in their daily lives. This is a defining moment for the Senate and for the country. I rank this along with other major decisions such as the creation of Social Security and Medicare and the Civil Rights Act. We have been talking about health insurance reform for more

than 70 years, before I was born. The Senate should not now prevent a real debate on health reform by hiding behind the figleaf of a procedural filibuster.

A bill worthy of this debate has been produced, after months of arduous work. Opponents of reform, unfortunately, have wasted much of the public's time by provoking arguments over their distortions about what health reform means. Spurious rumors were spread about death panels. One mailing opposing this bill claimed that reform would mean denying care to people based on their voting records. How desperate can these entrenched powers get, those who want to stop health care reform? These are the

tactics of obstruction in the service of the status quo.

Meanwhile, what the American people yearn for are constructive solutions. They want an honest debate, not a filibuster. That is what they deserve, and that is what we owe them.

A Vermonter came by my office to talk about health reform, as so many have over the last several months. I hear this every time when I am home in Vermont. If I am in the gas station putting gas in my car, if I am in the grocery store, if I am coming out of church on Sunday, I hear this. This Vermonter is a physician. He has a special perspective from inside the system. He recalled stories about his father, also a very respected doctor, who practiced in the days before Medicare. He remembered

the devastation his father felt when he was forced to turn away elderly Vermonters because they did not have health insurance.

It may be difficult today to even imagine this, but before Medicare, older Americans were routinely driven into poverty during their retirement years by health expenses. Before Medicare was launched in 1964, nearly half of seniors over 65 had no health coverage and more than one in three

lived in poverty. Today, because of Medicare, virtually everyone 65 and older has health insurance. The poverty rate among seniors has plummeted. More than 100,000 Vermonters have Medicare insurance.

The arguments that were made against creating Medicare may sound familiar. Opponents of Medicare, when it first came up, tried to demonize the plan. They claimed it would never work. How could government run a program like this? They ignored those older Americans living in poverty. But eventually Members from both sides of the aisle, Republicans and Democrats, worked together. They passed a bill that is one of the most successful and popular programs in America today. Vermont's entire congressional

delegation, which at that time was Republican, supported passage of that landmark legislation.

Today, we have a health system with contradictions. Federal investments in research and private investments in development have produced modern medical marvels in the equipment, training, techniques, and drugs that are available to many Americans. Yet in the prices we pay, in the lack of access to basic medical care, in the loopholes and the redtape that plague ordinary Americans in our health insurance system and in overall results in so many categories, we get far less for our enormous health

care spending than do the [Page: S11908]

citizens of countries whose health care costs are only a fraction of what ours are. Tens of millions of Americans have no health insurance at all. Employers who want to offer health insurance to their workers are being priced out of even having that option anymore.

Self-employed Americans must pay dearly to afford any insurance, and they can lose their coverage at the whim of an insurance company's bureaucracy. In no modern nation except ours are families actually driven into bankruptcy by illness. In fact, medical expenses are one of the top reasons for bankruptcy in America today.

In the absence of a fair and sensible health insurance system, families, businesses, and taxpayers have been dragged along by an inflationary curve that only worsens with time. Next year, small businesses, already suffering from skyrocketing medical costs, will see their premiums rise by an average of 15 percent. That is twice the rate of last year's increases. Drug companies have boosted prices of brand-name drugs by about 9 percent over the last year--the steepest increase in years. All you

have to do is look at the huge salaries paid to their executives, and you know where that money is going. It is not going to help the health care of the average American.

Can't we fashion an American-made solution so our citizens can have high-quality, affordable care and access to basic health insurance? Of course we can. We are Americans. We can develop that.

The bill introduced this week by the majority leader and by Senators Baucus, Dodd, and Harkin will give millions more Americans access to quality, affordable health care. It would end discriminatory treatment of those who change jobs or have preexisting conditions.

I have pushed and will continue to push to accomplish the three c's of choice, competition, and cost control, as we reform our health insurance system.

I am encouraged that the Senate bill includes a public option that I have strongly supported.

I might say, the majority of Americans strongly support it. I will stand with others as we make our case for keeping it in the reform plan as part of this process.

I was proud to join Senator Brown and a core group of more than 20 other Senators who introduced a resolution affirming our support of a public option. A public option would give consumers more choices to select affordable and quality health insurance plans, while helping to drive down overall medical costs through real competition in the health insurance market.

To further enhance the advantages of a competitive market, I have introduced the Health Insurance Industry Antitrust Enforcement Act of 2009. This would repeal the antitrust exemption for health insurance and medical malpractice insurance providers. Closing this loophole in our antitrust laws is long overdue, and I will offer my legislation as an amendment to the bill to do that. Antitrust enforcement promotes competition. It helps to lower prices and expand consumer choice.

Another factor that contributes to the rising medical costs all Americans face is fraud within the health insurance system. The scale of health care fraud in our system today is staggering. Studies estimate that between 3 percent and 10 percent of all our health care spending, both public and private, is wasted through health care fraud. That is somewhere between $60 billion and $220 billion each year--money we should have for health care, not going in the pockets of crooks.

To help wring this waste out of our system, Senator Kaufman and I and others have proposed the Health Care Fraud Enforcement Act. Our bill would toughen sentences for those who commit health care fraud, strengthen support for prevention, investigation, and prosecution of health care fraud, and sharpen the legal tools we need to go after this fraud. It would prevent waste in spending. It would hold accountable those who do the stealing. Experience shows antifraud efforts give taxpayers

a superb return on investment, with a payback of between $6 and $14 for every dollar we spend on enforcement.

I am pleased the majority leader included provisions in this bill to address the issue of health care fraud. I will work with Senator Kaufman and others to strengthen that bill.

Vermont has helped pave the way for some of the reforms included in this bill, and now, for the third year in a row, Vermont has been ranked as the healthiest State in the Nation. Vermont is one of the earliest leaders in expanding the State Medicaid Program, under reforms led by former Gov. Howard Dean and others. Yet under the current form of this bill, Vermont would not share the enhanced Federal match to be offered to other States. That would amount to a regressive policy with adverse practical

ramifications for Vermont, a State that is a leader in expanding access to health care. I was heartened in my conversation this morning with the majority leader when he told me he will try to correct that problem. But we cannot correct any of these problems until we debate the bill. Let's not hide under our desks because we are afraid to stand up and vote and debate.

The people of Vermont have given me the honor of representing them in the Senate for 35 years. I have joined in many debates that were contentious yet ultimately productive. I have been on the winning side. I have been on the losing side. But as we leaf through the pages of history, we can read of many times when the Senate has shown its remarkable ability to rise up to reflect the conscience of the Nation. Those moments were forged in the crucible of national need, against the anvil of the tempered

will of the Senate's membership.

This Senate can do that again. Our dear friend, Senator Ted Kennedy, said it so well in the letter about the health reform imperative that President Obama read to a joint meeting of Congress. This is what Senator Kennedy reminded us:

What we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.

This is such a time. It is my hope and belief the Senate I love will once again rise to the occasion.

Madam President, I yield the floor.

10:20 AM EST

Michael Bennet, D-CO

Mr. BENNET. Madam President, I would like to first thank the Senator from Vermont for his excellent remarks in support of what is, after all, just a vote to get us started on the debate on health care, a procedural vote to allow us to be able to amend and improve the bill in the coming weeks.

Madam President, virtually every single Member of this body in the Senate is a Member of the baby boom generation. In my view, it is a generation of Americans--I was born in the last year of that generation--given more opportunity than any generation of people in the history of this planet because our grandparents and our parents were willing to make hard choices, understanding that part of our national creed, part of our legacy is assuring that we are expanding opportunity for those who come

after us.

We are having this health care debate at a moment in our country's history beset by incredible economic difficulties. This is the worst recession since the Great Depression. But we now know even during the period of economic growth before our economy fell into this terrible recession that working families were struggling.

During the last period of economic growth, median family income in the United States actually declined. As far as I know, it was the first period of recovery in the history of the United States when median family income actually went down. It was at the same time the cost of health insurance was soaring--in my State by 97 percent--with the cost of higher education in my State going up by 50 percent.

We were saying to working families: You are living in an economy with incredible weakness, where the growth is surging ahead of a mountain of debt, but you are not getting ahead.

Just this week, we learned that in the great State of California they are increasing the tuition for their universities by 30 percent. The University of California, the California system has been the envy of the world for decades, and now it is being put out of the reach of working families.

So we have much to do--much to do--to make sure we honor the legacy of our parents and our grandparents. We honor the legacy of the ``greatest [Page: S11909]

generation'' and this generation, the baby boom generation, to ensure that we leave behind us not diminished opportunity but more opportunity for our kids and our grandkids.

There is much we need to do to make sure we have a health care system that works not just for a few people but for everyone, an education system that works not just for a few kids but for everyone, and that we have an economy in the United States that values the contribution that everybody can make.

My sense in this health care debate is that the people of my State--and I know people around the country--are deeply dissatisfied with business as usual. They hate the current system. They know it is not working for them and their families. They know they are not able to make the choices they need to make to have stability for their families so they can get ahead economically.

But, on the other hand, they are deeply worried about our capacity to make it worse. It is hard to blame people when you hear the special interests' rhetoric coming out of

Washington, DC, or when you turn on your cable television set at night and watch what people have to say. You can understand why people are concerned that we have the capacity to make it worse.

But that is why I am so pleased about the piece of legislation the majority leader has brought before us. We have never been closer to reforming our health care system, so we can address runaway health care costs, enact insurance reform, construct stability and predictability in health care for families and small businesses.

The Senate legislation before us is that promising new way forward. Coloradans, as I said, have not been shy at all about letting me know about their views of the current system and what their concerns are about what we might do.

Like people across the country, they know the current system does not work for them. But they are worried, as I said a minute ago, that we are going to make it even worse.

This bill represents a substantial improvement over business as usual. I congratulate the majority leader for listening to not just a small group of people but to people across the aisle, to people all across the country in crafting this piece of legislation.

First of all, the most important principle of the bill is that it is paid for. We already had about $5 trillion of debt when the last President became President. We are now at $12 trillion. There has been an unbelievable spike between 2000 and today. We have put an enormous burden--as the father of three young girls, I feel this very personally and very keenly--an enormous burden on our kids and our grandkids.

Our debt is now $12 trillion. Our entire gross domestic product--our entire economy--is $14 trillion. Our deficit is $1.4 trillion, 12 percent of our gross domestic product. That is utterly unsustainable. We know the biggest driver of our medium-term deficits is rising Medicare and Medicaid costs, and the biggest driver of those is rising health care costs.

This bill, unlike Medicare Part D--a very worthy program passed during the last administration--this bill is paid for. That drug program for seniors was not paid for. Instead of paying for it, instead of making hard choices, what we said to our kids and our grandkids was: You pay the bill. By the way, that is what we have said about tax cuts. That is what we have said about the wars in Afghanistan and Iraq. We have to put an end to this. This bill at least starts to head us in the right direction.

It does not fix our fiscal crisis, but it is an important step forward.

As I mentioned a few minutes ago, for working families, the current system has been a complete disaster, as their income has remained flat or gone down, as their health care premiums have gone up by 97 percent. Even though there is a lot of conflict out there about what the way forward should be, about a specific policy choice here versus a specific policy choice there, I can tell you, one thing everyone in my State agrees with is that their health care has not improved by 97 percent over the

last 10 years. They are paying more and getting less. Coverage is getting weaker, as it gets more expensive.

Small businesses are getting crippled by the system we have today. They pay 18 percent more than large businesses to cover their employees, just because they are small. Sometimes people say to me: Well, Michael, don't you know that is because the pool of employees is smaller? It is harder to spread the risk. I say: I understand that. But as a businessperson, from a business perspective, that is ridiculous--the idea that a small businessperson, trying to execute their business plan, trying

to execute their vision to grow their business, is going to spend 18 percent more for something and not get 18 percent more productivity out of it, or not get 18 percent, in this case, better health care coverage out of it. In fact, the reverse is true. It is ridiculous.

By the way, one of the things that is interesting to me about this debate over a public option is that people do not seem to understand what is actually happening before our eyes. As the costs of insurance are going up every year, few and fewer people are able to get insurance through their employer, fewer and fewer employers are able to offer insurance to their employees, which is heartbreaking for many of our small business owners because these are family businesses that for years have provided

health insurance to their employees. They view it as part of their pact with their employees to help them get ahead. But they cannot do it. So they are dropping them from the rolls.

Where are these folks ending up, those who are now uninsured? Well, two places: Medicaid, if they are poor enough, or in the emergency room, getting covered with uncompensated care that we, the taxpayers, are paying for.

We have a public option. It is the least intentional and most expensive public option you can imagine. When we are talking about the changes we are making here, we need to understand what is going on in the daily lives of people all across our country.

The figures we have from the Congressional Budget Office show that this bill will reduce the deficit, not add to it, will cut our deficits over the first 10 years by $130 billion, over the next 10 years by $650 billion. That is $780 billion.

One thing we know about those numbers is they are not going to turn out to be exactly accurate. But here is the goods news: The CBO is unable to score the benefit of prevention. They are unable to score the benefit of wellness. They are unable to score or focus on primary care instead of emergency room care. There is good reason for that because that comes down to execution--how well is the program implemented. Those of us who are proponents of reform carry a very heavy burden to make sure the

execution is good and that we carry this through. But the good news is, if we do a good job, we will save money.

I want to say a word about Medicare because there has been a lot of discussion from people who are opposed to reform who are saying we are cutting Medicare. They are saying we are hurting seniors. But what they will not tell you is that the worst possible scenario is not taking action now on critical Medicare reform. As I said earlier, and said in many speeches, our Medicare Program, on its current path, is headed for fiscal crisis.

Policy experts on both sides of the aisle have said we need to reform our Medicare delivery system. We need to stop basing payments on every procedure and every test. Instead, we should look at successful models such as our own Denver Health, the Rocky Mountain Health System, and the Mayo Clinic in Minnesota. We know they have better quality and better outcomes, not just for seniors but for everyone.

This bill builds on what works locally. That means protecting the guaranteed Medicare benefits for every senior, and for years to come. It improves Medicare solvency. We make sure doctors will not see a 20-percent cut in their payments. It makes the entire Medicare system more affordable and will save taxpayer dollars.

Critics say no to reform. They are content with a system that pays by the test, test after test, instead of outcomes and patient-centered care. That approach will assure that Medicare is bankrupt by 2017. We need to do better than that for seniors. We need to protect Medicare.

Included in this health care reform bill is a version of a bill I introduced [Page: S11910]

based on great work being done in Colorado. It is called the Medicare Care Transitions Act. We looked at the $17 billion Medicare was spending on hospital readmissions. Currently, one out of every five patients leaves the hospital and returns within the same month. We looked at places in Denver and Grand Junction where the readmission rates are 2 percent compared to the national

rate at 20 percent. What we saw was that they coordinate care. As people go from place to place, these health care systems track where they go with a system of electronic medical records, what medications they use, what doctors they see. They focus on patients--on patients--when making decisions.

So when we talk about these delivery systems being unnecessary, tell that to the 12 million Medicare seniors who got readmitted to the hospital within the very first month they were let out of the hospital. We owe so much more to these seniors, and we owe a lot more to the American people.

Health care reform must stop the rising costs that are bankrupting working families, small businesses, and our economy. If you like your coverage, you should be able to keep it. We need to put an end to denials based on preexisting conditions. We need to give people more affordable options, including a public option. One thing is clear. Business as usual cannot be an option. The debate is bigger than politically charged issues. We have to keep our eye on the ball and not get distracted by the

same old, tired, special interest politics that have kept us from reforming our health care system since Harry Truman was President.

Health care reform should not be about changing our laws on abortion. I think the House went astray when it adopted new language with unintended consequences for women. The Senate bill already makes sure we do not use taxpayer dollars to fund abortion. That is why I opposed the House Stupak language.

I want to end this morning on what I am for. I am for insurance reform. I am for making our small businesses more competitive by reining in skyrocketing health care costs. I am for reducing premiums for working families. I am for more consumer choice, including the ability to voluntarily choose a public option. By the way, one thing I have noticed is that as people start to understand they are going to be required to have health insurance as part of this plan, what they are saying is, I want

all the options. I want a private option, a public option, a nonprofit option. I want to be in a position to make the best decision for my family.

I am for reform that squeezes our wasteful spending so we can reduce our deficits in the long term. Throughout this entire debate, my focus has been on our working families and small businesses. There is plenty in this bill for you.

The time for talking is over. We should pass this bill. But tonight what we should do is make sure we allow the Senate to debate the bill, to improve the bill. There are things in this bill I want to change and things I want to make better in the coming weeks. But I believe that if we pass this reform, we will have taken a very important step forward to saying we are here to honor the legacy of our parents and our grandparents. We are here to say as one generation to the next that we are going

to carry that legacy forward and make sure we are making the hard decisions to provide more opportunity for you, not less. This is only one step of that.

I mentioned education earlier. I mentioned our economy earlier. My hope is that in this debate, what we can do is begin to learn how to set the special interests aside for the benefit of the American people. If we can do that, there is not a doubt in my mind that we will honor our grandparents' legacy.

Thank you, Madam President. I yield the floor.

10:35 AM EST

Ron Wyden, D-OR

Mr. WYDEN. Madam President, even though America has the best doctors and the best nurses, our Nation spends too much on health care for what it gets. Because the problem in American health care will not cure itself, I rise in support of this motion to proceed to beginning the debate about how to fix American health care.

Before I lay out the many provisions in Majority Leader Reid's bill that constitute real reform, I wish to talk for a couple of minutes about how the Senate can come together, Democrats and Republicans, to fix American health care. I have had a chance to visit with almost every Member of the Senate in their office on this issue, to listen to them, and it is very clear to me that both Democrats and Republicans have valid points. I believe my party is absolutely right in saying you cannot

fix American health care unless all Americans get good quality, affordable coverage. If you don't cover everybody with that kind of coverage, what happens is those who are uninsured shift their bills to the insured folks who are already getting shellacked, and there is an underemphasis on prevention. So my party is right that to fix this, we have to offer all Americans secure, quality, affordable coverage.

I think colleagues on the other side of the aisle have valid points as well. They focus on the need for marketplace forces, for choice, for competition. I subscribe to each of these principles as well.

I think many believe it is an absurd fantasy that before the Senate completes its work on this legislation, the Senate could actually come together, Democrats and Republicans. I simply don't share that view. Let me be clear: It is my intent when this bill gets to the floor to work very closely with Majority Leader Reid and with all of our colleagues to finally break through, to get beyond some of the polarization, the near brawling we have seen in townhall meetings where folks sit in

opposite sections depending on their political points of view. That is not the American way to face big challenges. This certainly is such a challenge.

I believe fixing the economy and fixing American health care are two sides of the same coin. We can't spend more than 16 percent of our gross product on health care, spot our foreign competition hundreds of millions of dollars a year, and have enough money left over to focus on education, transportation, and domestic needs. The reason so many Americans don't see their take-home pay go up is because health care gobbles up all the costs in sight. So this is certainly a big enough challenge that

it demands that the Senate get beyond the fighting--near brawling--about this subject across the land. On the basis of the conversations I have had with colleagues, I continue to believe the Senate can break through and produce a bipartisan bill, working with Senator Reid, working with colleagues on both sides of the aisle.

In terms of the real reforms that are in Senator Reid's bill, some of the most important have to do with the delivery system--the way American health care is essentially experienced across the land. The fact is that today's delivery system essentially rewards inefficiency. Payments are based on volume rather than quality. In my part of the country, we have plans like Kaiser and Group Health, and we have actually been in the forefront of trying to move away from a system that rewards

inefficiency, rewards volume. What we have shown is that changing these incentives pays off. People can be healthier and America can do it for less money.

Senator Reid's bill begins to move in the direction of what we have been doing in our part of the country for some time. His bill promotes what are called accountable care organizations. There are also changes in reimbursement. Probably folks on Main Street are not familiar with what is called ``bundling.'' In effect, instead of paying for each specific service, under bundling there is essentially one payment to reward trying to deliver care in an integrated fashion.

We have been able to have included in the legislation incentives to care for folks at home. The majority leader included a version of the bill I introduced called the Independence at Home Act that is backed by many colleagues on the other side of the aisle, and many Democrats as well.

When we think about the challenges of American health care going forward, we certainly ought to agree it makes sense to deliver more good quality, affordable care at home, rather than forcing the sickest Americans to spend a big chunk of their day fighting through traffic simply to get to a doctor's office, and we have the technologies, we have the trained physicians and nurse practitioners to offer these kinds of services [Page: S11911]

at home. I highlight the fact

that this is real reform, it is in Senator Reid's bill, and Republicans and Democrats alike are behind it.

The majority leader makes a number of long overdue changes in the private health insurance market. In many respects, today the private health insurance system is simply inhumane. What we have is a system that rewards cherry picking; where the private insurance companies take only the healthy people and send the sick people over to government programs more fragile than they are. What we need is a very different system where the private insurance companies compete on the basis of price, benefit,

and quality, and not who is the best at selecting out the good risks.

Senator Reid's bill does away with the unconscionable practice of pre-existing condition exclusions and the practice of rescission where the insurance companies abruptly drop coverage for the sick. The bill also does away with charging a person more simply because they are sick, because they are a woman, or because they work in a high-risk job.

These are very constructive insurance reforms. We are going to try to build on those as we go forward in the legislation. Colleagues should make no mistake about it: The insurance changes in Senator Reid's bill are very real reform.

I wish to focus for a few minutes, though, on what I think is the great promise of this legislation for health care in the future. Since World War II, there has essentially been no market for American health care. Back in the days of wage and price controls, we didn't have a way to get good health care to Americans and we simply said we will put it on the backs of employers. They were patriotic citizens then, like there are patriotic citizens now, and they said, We will figure out how to do it.

We are going to have to pass on the costs in the form of higher prices for goods and services. That probably made sense back then. We had people essentially work at a job for 20 or 25 years, and after their last day at work they got a gold watch and a dignified retirement. Today, there is a very different economy. The typical worker

changes their job 11 times by the time she is 40. She needs a different set of health care choices. She needs the opportunity to be empowered to go into the marketplace to hold insurance companies accountable and to get more value for her health care dollar. The majority leader in his bill lays the foundation for this kind of system.

He establishes a system of what are called health insurance exchanges. They are kind of like farmers markets for health insurance. Senator Reid has improved this so that these farmers markets, these exchanges, could only let in good-quality plans, and under Senator Reid's bill, it will be possible to more easily compare the plans in these exchanges. This is something I have been interested in for years, really going back to the days when I was co-director of the Oregon Gray

Panthers, because I think it is simply bizarre that it is possible in other parts of American life--in a Costco store or any other big store--to compare products, look at alternatives, have a measure of uniformity, and not have that in American health care.

What Senator Reid's bill does is set the foundation for a marketplace so that health care in 2009 will be dramatically different than it was, say, 60 years ago, in 1949, when I was born. I don't see anybody outside the Capitol driving a car from 1949, but much of American health care still resembles the middle of the last century. Senator Reid, through his legislation, lays the foundation for modernizing that.

I would like to see more people in these new marketplaces, the exchanges, more quickly. Under the estimates we have been given, only about 10 percent of our population would be able to enjoy the fruits of real choice and real competition. Real choice and real competition in that marketplace is the path to holding premiums down. My goal in the years ahead is to allow every consumer--every consumer, for example, in New York and Oregon--to be able to deliver an ultimatum to their insurance company.

That ultimatum should be: Treat me right or I am taking my business elsewhere. It is that simple. That is the way we do it in every other part of American life.

By the way, that is the way it works for all of us here in the Senate. We belong to a real marketplace. We belong to a real exchange called the Federal Employees Health Benefits Program. If a Member of the Senate doesn't like his health care coverage in November of 2009, come January of 2010, that Member of the Senate can take his business elsewhere, to another insurer that does a better job. I think that kind of marketplace--the marketplace every Member of the Senate now enjoys--ought to be

available to everybody else in the country. I think there ought to be public choices. I think there ought to be private choices. I think all Americans ought to be able to have access to all of those choices. We are not going to be able to have real insurance company accountability, real choice, and real competition unless we make the exchanges robust and get more people in.

To illustrate the fact that the majority leader and other leaders, such as Chairman Baucus, are open to new ideas, just yesterday the majority leader and Chairman Baucus and I agreed on an approach that will allow more people to enjoy the marketplace, the fruits of a competitive system, more quickly, when they indicated yesterday they would support my legislation to expand access to the exchanges for those who otherwise would have forgone having health insurance under health

reform. Let me emphasize that--letting folks get to the exchanges who otherwise would have no health insurance at all. We have been able to do it. According to the CBO, we will be able to add an additional million people, middle-class folks walking on an economic tightrope, at 10 percent or less of what it would cost to have those people get their coverage through

Medicaid or through subsidies. It is my intent to work with the majority leader and Chairman Baucus closely to allow others to have a chance to be part of this kind of competitive system. I commend the majority leader and Chairman Baucus for their commitment to work with me, as this bill goes to the floor, to expand access to the marketplace.

Let me close with one last point. I see my colleague from New Mexico in the Chamber, and he is a welcome addition to the Senate.

A lot of Americans listening may wonder why the Senate is turning its attention to health care when there is so much economic hurt in our land. The fact is, fixing the economy and fixing American health care are literally two sides of the same coin. We have to rein in these costs. We have to rein in these costs for Americans to have more take-home pay, to be in a position to pay for essentials, and to allow our workers to compete in ferociously challenging markets around the world.

It is time to move beyond the townhall brawls of this past summer and for the Senate to work with Senator Reid and all colleagues to break through and deal with this critical issue, the premier long-term challenge of our time for our economy, and do it in a bipartisan way. I urge my colleagues to vote for the motion to proceed.

I yield the floor.

10:52 AM EST

Tom Udall, D-NM

Mr. UDALL of New Mexico. Madam President, I appreciate very much listening to Senator Wyden and his comments on health care reform. He has been one of the leaders when it comes to working in the Finance Committee and looking for significant reforms on health care. I look forward to working with him in that capacity.

The health care reform we are debating today will impact every person in this country. Whether you are searching for affordable insurance for yourself or watching helplessly as a loved one is denied coverage, every American stands to gain something through this historic legislation.

In my home State of New Mexico, the people I represent don't just have a lot to gain from this reform, they also have a lot to lose if this reform is not enacted. For New Mexicans, the status quo isn't an option. That is because without this health care reform our State is expected to experience the largest increase in insurance premiums of any State in the Union. In 2016, without this reform, a family of four in New Mexico can expect to pay an astounding $28,000 a year in health care premiums.

That will consume more [Page: S11912]

than 56 percent of that family's projected income for the year. Affordability is already one of the key barriers to obtaining coverage in my State. Since 2000, premiums for residents have risen 110 percent. As a result, almost one in four people doesn't have insurance, giving us the second highest uninsured rate in the Nation.

Enactment of this reform legislation would make as many as 249,000 middle-class New Mexico residents eligible for premium credits to ease the burden of these high costs. In addition, almost 238,000 New Mexicans would be eligible for new private coverage through the exchange or through their employer and another 124,000 would be eligible for the new expanded Medicaid coverage. For the families who already have insurance, they win too. They will likely see lower premiums, thanks to the increased

competition in the market. The bottom line is that with this reform the vast majority of New Mexicans would have access to quality, affordable health care for themselves and their families.

Reform will also benefit New Mexico's small businesses. In 2006, less than 35 percent of small businesses in my State offered coverage for their employees. That figure means our State ranks dead last in employer-sponsored insurance in the Nation--a dubious distinction, to say the least. I have talked to a lot of these small business owners over the past month. They all tell me pretty much the same thing: I would love to offer coverage to my employees, but it is just too expensive. They say they

are having a hard time affording insurance for their own families. To those small business owners, I say that help is on the way. The Patient Protection and Affordable Care Act will help you provide insurance to your employees by providing Federal tax credits of up to 50 percent of premiums should you choose to offer coverage.

In addition to lowering costs for individuals and families and helping small businesses, this reform would also give our rural communities additional tools to provide quality, affordable health care for all of their residents.

Of the 2 million people who call New Mexico home, about 700,000 live in rural areas. They are more likely to be uninsured and often must travel hundreds of miles for

preventive or emergency care--if they are able to find any care at all.

In this bill, we have included pay incentives to recruit more physicians to serve in these underserved rural areas. We will improve dental services in rural areas, we will extend Medicare payments for ambulances in rural areas, and we will expand the Telehealth Program so that rural residents may receive specialized treatment not available in their local areas.

Finally, we make sure this legislation won't result in an unfunded mandate for our State government, which is already experiencing the pain of budget cuts, thanks to the economic downturn. This legislation would require the Federal Government to cover 100 percent of the cost of the Medicaid expansion from 2014 to 2016 and 95 percent of that cost after that.

When it comes to health care today, too many New Mexicans are living on a cliff, teetering on the edge of financial ruin. All it would take is an illness or job loss, and they could fall into the abyss of medical invoices, bill collectors, and bankruptcies. For these New Mexicans, the status quo isn't an option. This bill offers a life rope to these New Mexicans to pull them back from the precipice. Passing it would provide stability and security to those who have insurance, affordable coverage

to those who don't, and lower costs for families, businesses, and government.

This is a historic moment. I urge my colleagues to join me in seizing it. Let's begin the debate on this long-overdue legislation to reform our broken health care system.

With that, I yield the floor.

10:59 AM EST

Judd Gregg, R-NH

Mr. GREGG. We are joined by a number of the distinguished members of our caucus. They have thoughts they want to express. We want to discuss a couple of points.

Before I turn to the Senator from Missouri, I want to make a point, because I have been listening to a lot of the discussion on the floor, and I have participated and listened to a lot of it on television, from my colleagues on the other side of the aisle. They continue to use this number. They claim this bill will cost $800-some-odd billion and that is the number that has been reached as the expenditure on this bill. That is a totally dishonest number. That is the ultimate shell game. That is

Washington cynical politics.

Do you know how they get to that number of $800 billion as a cost of the bill? It is a 10-year number, by the way. That is a lot of money, $800 billion. That would run the State of New Hampshire for probably 100 years. Missouri is a little bigger, but it would run that State for a while, and it would probably run Alabama for a little while. South Dakota could probably run for 200 years on that. That is not the real cost of this bill, though. That is not the cost of the bill.

The way that number was arrived at--and I think the American people need to understand this. If that number was so dishonestly arrived at for the number of the bill, what is wrong with the rest of the bill that they haven't been told about? That was a 10-year score for what the bill cost was, but they don't start spending money under this bill until the fourth and fifth year. In fact, the cynicism exceeds that. They couldn't get the score they wanted--they couldn't get the score they wanted from

CBO, so they moved back another year in the 10-year cycle.

They went from 4 years to 5 years as to the starting point of most of the spending in this bill.

What they claim to the American people is the 10-year bill is going to cost about $800-plus billion. But what they don't tell the American people is they are not spending anything in the first 4 or 5 years of the bill. No, they do raise your taxes throughout the 10-year period. They do cut Medicare throughout the 10-year period. But they don't spend the money. They don't start the programs until the year 2014, when this bill is fully phased in.

When all these new programs, this massive expansion of entitlements is created, brand-new entitlements, when all this new spending occurs, this bill will cost $2.5 trillion over that 10-year period--$2.5 trillion. That is the real cost of this bill. That is how this government is going to grow in a 10-year window as a result of this spending.

I say to my colleagues, I think most of us understand we already have a huge debt problem in this Nation. We are passing on to our kids a country with so much debt they are not going to be able to afford it. Every year for the next 10 years, without this health care bill, the President has proposed budgets which will run a $1 trillion deficit, every year, on average, for the next 10 years. Sometime this month, we are going to have to raise the debt ceiling of this country because we reached $12

trillion in debt. Then it is going to have to be raised again because we are running up these massive deficits.

The debt owed by this country will exceed 80 percent of our gross national product--80 percent of our gross national product at the end of that 10-year period--and will exceed 60 percent of our gross national product within 2 years. Those are unsustainable numbers. Yet a bill is being proposed that is going to expand the size of government by $2.5 trillion.

It is alleged it is paid for, and we are going to get into a discussion in some depth because I think that is an equally cynical number as a result of bait and switch.

I just wished to clear the air as to the real cost of this bill because I found it uniquely cynical that it would be represented that this bill costs $890 billion, whatever the number is. It does call into issue the credibility of the rest of the numbers that are being thrown out by the other side of the aisle when they use that number, which is a 5-year number that they claim covers the 10-year cost, when they don't do anything in the first 5 years.

I appreciate the indulgence of the Senator from Missouri. I understand he wishes to speak and then we will go to the Senator from Alabama and then the Senator from South Dakota and [Page: S11913]

then have a discussion about some of the issues, such as costs, how it affects Medicare, how it affects small businesses, how it is going to affect your personal insurance.

11:04 AM EST

Kit Bond, R-MO

Mr. BOND. Madam President, I thank the Senator from New Hampshire. I wish to clarify some things he said because they are truly important. I wish to make sure everybody understands it because Senator Gregg, in his position on the Budget Committee, as well as his other positions in writing this bill, is intimately acquainted with the costs of this bill.

The cost for 2010 to 2019, how much was the cost for that 10-year period?

11:04 AM EST

Judd Gregg, R-NH

Mr. GREGG. That is $1.2 trillion because between the period 2010 and 2014, there are no expenditures because they don't start the programs until 2014.

11:06 AM EST

Judd Gregg, R-NH

Mr. GREGG. Actually, if you accept these assumptions that we are going to cut Medicare by $1 trillion and take that to create a new entitlement instead of using it to help Medicare be more solvent and then we are going to raise taxes and fees by $1 trillion--remember, most of this is not going to come out of the wealthy. It is going to come out of small businesses and higher premium costs to people on insurance or it is going to come out of HI taxes. If you accept that logic, which I find to

be a bit of a reach, then it will not have any impact on the deficit in that timeframe because they have cut Medicare to pay for it, and they have raised all these taxes to pay for it.

11:07 AM EST

Judd Gregg, R-NH

Mr. GREGG. That is a fascinating question because I was chairman of the Budget Committee the last time we tried to do something in the area of the rate of Medicare costs because we received a directive from the Medicare trustees that Medicare had to be made more cost-effective or else it was going to go broke. So we suggested, when I was chairman of the Budget Committee--and everybody in this room voted for it, by the way--that we should reduce the rate of growth of Medicare by $10 billion on

a $1 million timeframe. In other words, Medicare was going to spend $1 trillion over a period, 5 years. We were going to suggest a $10 billion reduction in that rate of growth which was going to be paid for by requiring people who were getting Part D premiums and had high income to pay for part of their premiums--people such as Warren Buffett would not be subsidized by people working down at the local restaurant.

We did not get one vote from the other side of the aisle. We passed it by having the Vice President sit in the chair and break the tie. That was $10 billion over 5 years.

So I think this idea that you are going to do $1 trillion over 10 years and pay for this--first off, if you are going to reduce spending or raise Medicare taxes, it should go to pay for Medicare solvency because Medicare is insolvent. It shouldn't go to create a new entitlement. Senior citizens, paying into Medicare all their lives, should not have their money taken to start a brand-new entitlement for other people, and that is what this bill does.

As a practical matter, we are not going to do that. We know that. We know this is all going on the debt. Ninety percent of this is going to end up on the debt.

11:08 AM EST

Kit Bond, R-MO

Mr. BOND. I thank my colleague from New Hampshire because he has been a very solid, consistent, credible voice. What he is pointing out today is that the legislation we are debating has major implications for every American family, every American taxpayer, every American small business.

In the 1992 election, President Clinton's famous slogan was: ``It's the economy, stupid.'' Seventeen years later, it is again the economy that is a major issue facing the people. But this time the majority party does not seem to be paying attention. Instead, the majority has used its supermajority position to spend trillions of dollars that we don't have, including a misnamed stimulus that stimulated the growth of the deficit and the Federal Government but not jobs. We had takeovers and bailouts

of banks, insurance companies, and major auto manufacturers. They have adopted a budget that would double the debt--the debt our grandchildren owe--in 5 years and triple it in 10.

It is little wonder that the unemployment rate has skyrocketed, because employers are afraid to hire. Families are seeing their budgets strapped such as never before. But the bill before us is a crowning achievement of the drive to destroy our economy and hope for the future.

Just 1 year after a narrowly averted financial collapse, with unemployment at its highest level since 1983, instead

of how to create jobs, we are debating a bill that will take over one-sixth of our economy and likely kill jobs.

Don't get me wrong, our health care system is in need of reform. It costs too much, too many people are uninsured, there are too many junk lawsuits and too much defensive medicine and not enough focus on prevention and wellness.

While we all agree reform is necessary, the American people expect us to answer the questions: How much will reform cost and can we afford it? Will it lower health care costs? Can you keep your current plan? What role will the government play?

The answer to two and three on this bill is: No, it will not lower our health care costs; no, you will not be able to keep your current plan.

Then the question is: Who will make health care decisions? We are seeing evidence that they have government committees that say when you can get a mammogram, when you should get Pap screening.

Will Americans and Members of Congress have time to evaluate what is in the legislation? We hope today, as yesterday, that we will bring out for the American people the cost of this bill because what we are seeing in this massive pot, 2,047 pages, is there is a lack of commonsense reform. It is filled with costly budget gimmicks and asks the people of America to spend over $2 trillion on proposals that will heap a mountain of debt on our children and grandchildren.

Two trillion dollars is an almost unfathomable amount of money. But in Washington, trillion is the new billion, and that is not the kind of health care reform Americans want. It is not reform at all. It spends too much, it taxes too much and it cuts Medicare too much and does not provide reforms we need. Nearly $ 1/2 trillion in taxes will be added on the backs of the American people, $28 billion in taxes on businesses, which will kill jobs at a time when we have over 10 percent unemployment

and even higher if you include the number of people who are no longer working or underemployed. These higher costs will ultimately be passed on to American workers and consumers.

Anybody who thinks you are going to tax health care insurers, device providers and expect that those costs will not be passed on to the consumers--that is you and me, Madam President. The head of the Congressional Budget Office and the Joint Committee on Taxation have said these higher taxes are passed along, and they will land on families, small businesses, and individuals.

It will also force Americans into a government-run health care plan. It will ration care and limit access to lifesaving treatments and put a bureaucrat between you and your doctor. In life, two things you can count on are said to be death and taxes. I didn't expect to see them both in a health care reform proposal. [Page: S11914]

We call this a pig in a poke. The only way to sell a pig in a poke is to hide from Americans what their tax dollars are buying. If I were to outline all the problems in this 2,000-page bill, we would be here until Thanksgiving. It is sort of like a mosquito in a nudist colony--there are so many targets to attack in this bill we don't know which one to hit.

Let me give you just a few. As the Senator from New Hampshire pointed out, the real cost of this bill to the American people is a whole lot more than they admit. The majority is claiming that the bill only costs $850 billion, but the way the majority gets to say that is because they are pulling a great smoke-and-mirrors trick.

Even more incredible is the Democrats' claim their bill will cut the deficit. It is a great scheme, but no one outside Washington actually believes this health care bill will do anything but increase costs and pile more debt on our kids and grandkids, and they are right.

Right now, as the ranking member of the Budget Committee has pointed out, the national debt already exceeds $12 trillion. This bill will put more on that. The true cost of the bill is not just a ``he said, she said.'' Even the nonpartisan Congressional Budget Office acknowledges that the majority's bill includes gimmicks that hide the true cost of the bill.

Part of the majority's scheme to hide from Americans the true cost is the great stunt, as the Senator from New Hampshire described, to push back implementation of parts of the reform to 2014 but start collecting money in taxes now. That means tax now and pay later. That sure makes your numbers look good, doesn't it?

For example, Medicaid expansion does not begin until 2014. That is in section 2001. Section 1311 says health insurance exchanges are not fully operational until January 2014. Section 1323 says a public health insurance option is not available until 2014. Most of the major insurance reforms, however, in section 1253 take effect in 2014.

The tax on health insurance starts in 2010. That is section 9010. Section 9009 says the tax on medical devices starts in 2010. Section 9008 says the tax on pharmaceutical manufacturing starts in 2010. That is even worse than the Senate Finance Committee bill which initially had it starting in 2013, but it is a great gimmick to allow them to hide the cost of the bill. Claiming savings of $122 billion by recording taxes over 10 years and only scoring costs over 6 years would get an officer in a

publicly traded corporation sent to jail. Move over, Bernie Madoff. Tip your hat to a trillion-dollar scam. This is magnificent, and that is in this bill. I am glad all Americans can read it. They can check out the sections I cited.

Even the Congressional Budget Office has called ``bull'' on this stunt, saying it would be difficult to maintain the savings the majority has been touting. No wonder. And the true cost, as the Senator from New Hampshire has pointed out, is $2.5 trillion. But it will also be increasing taxes. In fact, everyone will be taxed one way or another. Forget what the President promised about no taxes. Sections 9004 and 9010 will tax Americans who have insurance. Section 1501 will tax Americans who do

not have insurance--almost $8 billion. Taxes will be placed on medical device manufacturers, section 9009; and as the CBO has said, those taxes will be passed on in the form of higher prices and thus in the form of higher insurance premiums.

Because of the tax on health insurers, section 9010, the CBO and the Joint Committee have said these taxes will be passed on in the form of higher health care premiums. Pricewater-houseCoopers says that is $487 a year per family. That is how much these taxes on the health insurers and health payment plans will cost the average family.

Employers will be taxed. About $2 billion in new taxes will be placed on employers who do not meet government approved health care plans. That is section 1513. That is where American workers are going to pay for it because that is where they lose their jobs. Headlines in the Wall Street Journal and letters I have seen from leaders of businesses say we are not expanding; we cannot afford to expand; we cannot afford to take on more employees.

Why are we having a jobless recovery? Because the threats of Washington's overspending, overcontrolling, overtaxing, and overregulating are telling prospective employers that they are about to hit the ditch with all the things the Government is putting on them.

For all of the taxes and mandates, according to CBO, about 5 million Americans would lose their employer coverage. That is because the costs would go up, the regulations would go up. Currently, 83 percent of Americans have health insurance, and they are concerned that it costs too much. Americans want affordable health care, but this bill raises the cost of health care. New taxes and mandates will be passed on to American families, the American taxpayers, and American small businesses.

The bill still leaves 24 million Americans without insurance. According to the CBO, the government-run plan will have higher premiums, and the CBO said it will drive up the cost of health care. This was supposed to lower the cost of health care. It will not do anything of the kind.

To sum up, $2 trillion in more spending gets the American taxpayer, in the 2,074 pages, a Federal bureaucracy that increases the cost of health care, raises premiums, slashes Medicare for seniors, and puts unfunded burdens on States.

Let me just make two last points: The States, according to CBO, will get coverage for these new Medicaid eligibles for the 2 years that they will get covered and then they will dump it on the States--$25 billion. There is a $25 billion cost.

The Senator from New Hampshire and I were both Governors of our States. I can tell you, States do not need that kind of burden, particularly in their difficult circumstances.

Slashing Medicare for seniors? In Missouri, Medicare already only pays 80 percent of the costs. More and more hospitals and doctors have to limit the number of Medicare patients they can accept. If we continue, and if they push through this Medicare cut, then fewer and fewer Medicare patients are going to be able to get health care.

I hope my colleagues will listen to what the American people are telling us and vote against the bill. That is certainly the message I am getting from Missouri.

I yield the floor.

11:21 AM EST

Jeff Sessions, R-AL

Mr. SESSIONS. Madam President, I thank Senator Bond. He has certainly delineated some of the fiscal impossibilities in this bill, as has our former Budget chairman, now ranking member of the Budget Committee, Judd Gregg. He studied this very hard. The information he provided to this Congress and to the American people is accurate.

I have tried to think what I should say about this bill this morning and be realistic and honest and boil it down to its essence. The 2,000 pages that sit on that desk, how should we talk about it?

Let me just say the claim from our colleagues is that they have a great plan to reform health care and it will fix the problems in health care. We do have problems in health care that need to be fixed. They are going to provide methods and additional funding and provide millions of people with insurance who didn't have it before--although 24 million will remain uninsured. At the same time, they will save $130 billion over 10 years, and we are supposed to be grateful and say how pleased we are

that you have been able to pull off this event.

But the first reaction most American people have had, and it is a sound one, is, wait a minute, that is pretty dubious. How can you do that? Do you remember that song from the ``Sound of Music''? ``Nothing comes from nothing, nothing ever could,'' sang Julie Andrews.

The result is the phrase I came up with: ``Shell game.'' Senator Gregg used that phrase. I think that is exactly what we are talking about. When it became obvious to everybody who could add that this great vision, the wild chimera they had that they could do all these things, would not work as they dreamed it, the mountebanks began their chicanery.

In my remarks I will not attempt to point out all the manipulations in this bill, just some of the more obvious that are inescapable. [Page: S11915]

First, you ask: Why do they do this? The answer is the numbers don't add up. They cannot make the numbers do what they want them to do. So they either have to be honest and talk about massive cuts openly or massive tax increases. The American people are not sure about that. To add a whole new monumental health care program at a time of colossal financial stress in our country, with debts the likes of which our Nation has never ever seen before, are we now going to start off on a monumental multitrillion-dollar

bill that will not pay for itself?

We have this great promise, and it is not adding up. Do they slow down? Do they begin to think if they can't do everything they promised in the campaign, and they would love to do, and they wanted to do, what progress can they make step by step in a rational way that we can afford in this time of unemployment and unprecedented deficits? No, that is not what they decided to do.

What they decided to do is go forward anyway and call anyone who had the temerity to say their ``emperor has no clothes,'' that they are ``Dr. No,'' they are against everything. They don't believe in any reform.

That is kind of the idea we are hearing, and that is not correct.

The bill is just too much, it goes too far, too fast, and costs too much. We don't have the money. The American people know this. That is why they oppose this bill. They are not opposed to reform and progress. They are opposed to this legislation, this 2-foot tall, 3-foot tall, 2,000-page piece of legislation.

They don't dislike President Obama, but they don't like this policy he is trying to promote. You say: Let's have some facts about it. I can't explain everything, but I want to share a few things.

Madam President, I ask to be notified after 5 minutes.

11:21 AM EST

Jeff Sessions, R-AL

Mr. SESSIONS. Madam President, I thank Senator Bond. He has certainly delineated some of the fiscal impossibilities in this bill, as has our former Budget chairman, now ranking member of the Budget Committee, Judd Gregg. He studied this very hard. The information he provided to this Congress and to the American people is accurate.

I have tried to think what I should say about this bill this morning and be realistic and honest and boil it down to its essence. The 2,000 pages that sit on that desk, how should we talk about it?

Let me just say the claim from our colleagues is that they have a great plan to reform health care and it will fix the problems in health care. We do have problems in health care that need to be fixed. They are going to provide methods and additional funding and provide millions of people with insurance who didn't have it before--although 24 million will remain uninsured. At the same time, they will save $130 billion over 10 years, and we are supposed to be grateful and say how pleased we are

that you have been able to pull off this event.

But the first reaction most American people have had, and it is a sound one, is, wait a minute, that is pretty dubious. How can you do that? Do you remember that song from the ``Sound of Music''? ``Nothing comes from nothing, nothing ever could,'' sang Julie Andrews.

The result is the phrase I came up with: ``Shell game.'' Senator Gregg used that phrase. I think that is exactly what we are talking about. When it became obvious to everybody who could add that this great vision, the wild chimera they had that they could do all these things, would not work as they dreamed it, the mountebanks began their chicanery.

In my remarks I will not attempt to point out all the manipulations in this bill, just some of the more obvious that are inescapable. [Page: S11915]

First, you ask: Why do they do this? The answer is the numbers don't add up. They cannot make the numbers do what they want them to do. So they either have to be honest and talk about massive cuts openly or massive tax increases. The American people are not sure about that. To add a whole new monumental health care program at a time of colossal financial stress in our country, with debts the likes of which our Nation has never ever seen before, are we now going to start off on a monumental multitrillion-dollar

bill that will not pay for itself?

We have this great promise, and it is not adding up. Do they slow down? Do they begin to think if they can't do everything they promised in the campaign, and they would love to do, and they wanted to do, what progress can they make step by step in a rational way that we can afford in this time of unemployment and unprecedented deficits? No, that is not what they decided to do.

What they decided to do is go forward anyway and call anyone who had the temerity to say their ``emperor has no clothes,'' that they are ``Dr. No,'' they are against everything. They don't believe in any reform.

That is kind of the idea we are hearing, and that is not correct.

The bill is just too much, it goes too far, too fast, and costs too much. We don't have the money. The American people know this. That is why they oppose this bill. They are not opposed to reform and progress. They are opposed to this legislation, this 2-foot tall, 3-foot tall, 2,000-page piece of legislation.

They don't dislike President Obama, but they don't like this policy he is trying to promote. You say: Let's have some facts about it. I can't explain everything, but I want to share a few things.

Madam President, I ask to be notified after 5 minutes.

11:26 AM EST

Jeff Sessions, R-AL

Mr. SESSIONS. A critical, essential part of fixing a broken health care system is to end the growing problem of payments to our doctors. Republicans and Democrats have not been good on this issue in the past, but the problem grows worse each year. Essentially, in the balanced budget amendment of 1997 we limited the amount of payments to doctors. After a while it became clear the cuts were too severe, and each year we put money back in. But the law still mandates major cuts. In fact, today if

we don't do what we call the doctor fix each year, they will have a 23-percent reduction in reimbursements, they get paid less. This is for Medicare. And they get paid less for Medicare than other insurance already, so doctors are going to quit doing it if we have a 23-percent reduction in what they get paid for doing their work.

How much does it cost to permanently fix that as the medical profession assumed we were going to do and as the President and his team have indicated they plan to do? It costs $250 billion. That is a lot of money. That is not a new program, this is an obligation that we have now. Does this plan fix that? It fixes it for 1 year. So it goes out 1 year and then the CBO score assumes the doctor payments will drop 23 percent and be 23 percent lower for 9 years.

If we add that up, that is $250 billion. It allows the folks in the know here to manipulate the numbers and hide a $250 billion debt we owe. We can't cut doctors that much, and we are not going to do it. We have not been doing it, and we will fix it every year, in fact, and that is--what I will say is, we will spend the $250 billion, and it should be in this bill. They didn't do it.

Just a few weeks ago, they met in this secret room down the hall, and they got to talking and said: What are we going to do about the doctors? How are we going to fix the doctors?

We could raise taxes.

Well, we raised taxes $500 billion. We can't raise them any more. Can we cut Medicare?

Gosh, we have cut it $500 billion. We can't do that.

What can we do? We promised the doctors fix to get them their pay.

So they offered--it would be hilarious if it weren't so serious--they offered legislation a few weeks ago to just pay the doctors all this money permanently, outside of the health care reform in a separate bill, every penny of it going to the debt, unpaid for.

Even 13 Democrats couldn't swallow that. They voted no, and it failed. But the House did it. They passed it, did they not, I ask Senator Gregg, unpaid for? Horrible. Another $250 billion added to our debt.

So that is a shell game. It is like you have a hole in your roof and you don't want to spend the money to fix it, so you move across the hall into another room and pretend the hole isn't there. Somehow you are not going to fix it when you know you have to fix it.

They say: Don't worry. See, our plan is budget neutral. It is deficit neutral.

If you take the $250 billion, one thing right there, it is not neutral. It is in deficit already.

It is in deficit already. You have to watch that pea and see how it moves around in the shell. But what we need to have a sense of is that this is a program we have never had before. It not only adds to the debt by not fixing the doctor payments, it raids existing programs, Medicare and Medicaid, both of which are in serious trouble. It raids them in the first 10 years and, as Senator Gregg said, much more later, $549 billion. And it raises taxes $493.6 billion. So it is pretty easy

to say I have a deficit-neutral program if I assume I am going to take $500 billion out of Medicare and raise taxes $493 billion. It is budget neutral. Everybody should thank me. That is what the paper said the other day: Budget neutral. We are so proud of ourselves.

The American public are not buying this. They are a little bit skeptical. Medicare is going broke. Everyone knows that. We have been working on that for a number of years. All of us are concerned about this iceberg in front of the Titanic which is Medicare's deficiency.

11:32 AM EST

Jeff Sessions, R-AL

Mr. SESSIONS. I thank the Chair.

We need to save this program before we create a new one. It is so simple. If we are going to raise taxes $500 billion, has anybody asked where that money should go? Should the $500 billion in new taxes go to create a new program or maybe should it be used to put Medicare on sound footing or maybe it should be used to pay for military expenditures that have the highest budget in years, or maybe to reduce the debt which, I point out to friends and colleagues, is the greatest debt this Nation has

ever seen. There has been nothing like it ever. In 2008, our debt was $5.8 trillion. In 5 years, 2014, it will be $11.8 trillion. In 2019, it will be $17.3 trillion, tripling in 10 years. According to the Congressional Budget Office score, it does not include money to fund the health care program.

How big are those numbers? I won't spend a lot of time on it. I will point out that people can understand when you borrow money, this debt doesn't come from thin air. You borrow it. China, other places loan us money. We owe them money. That is how we get the money. And look at the interest rate. My goodness. Alabama's budget is about $8 billion a year; $800 billion in this year is 100 years of our budget. The interest the United States paid on our debt in 2009 was $170 billion. That is a lot

of money. The Federal highway bill is $40 billion. All of the Federal highway spending is around that amount. But in 10 years, according to the CBO, we are going to be paying in that 1 year interest of $799 billion. It is like nothing we have ever seen before. That is why people say our spending is on an unsustainable course.

The first thing we need to do to bring spending under control is to fix the critical problems that must be met. You don't start new programs that are likely to spiral out of control and far exceed the prognostications we have seen today.

I thank the Chair for the opportunity to share my thoughts. I am glad our colleagues are here. I know others would like to talk.

I yield the floor.

11:35 AM EST

John Thune, R-SD

Mr. THUNE. Madam President, I appreciate the great job done by my colleagues from Missouri, Alabama, and New Hampshire in pointing out many of the concerns we have with regard to this bill and why we think this is a bad direction to go.

You have heard my colleagues talk about a massive expansion of government, tax increases, premium increases; obviously, the very serious problem we have with our national [Page: S11916]

debt and the deficits we are racking up every single year, to the tune of about $1 trillion or north of there, $1.4 trillion last year, on a pathway to hit that target this year.

I have heard my colleagues on the other side talk repeatedly about Republicans not having their own solution. I have to say, maybe the reason they haven't been seeing the Republican solution is because they have been hiding behind this voluminous 2,100-page bill at a cost of $1.2 billion per page. Republicans--hundreds of times, if not thousands--have come to the floor and outlined a step-by-step solution to dealing with the health care crisis and the concerns most Americans have which is the

high cost of health care. Unfortunately, many of my colleagues on the other side perhaps have not been able to see that because they can't see around this $2.5 trillion expansion of the Federal Government they seem intent on pushing through the Senate. Republicans have talked about buying insurance across State lines, small business

health plans, tort reform, incentives for wellness and chronic disease management. There is a whole range of things that could be done to address the concerns of the American people about the high cost of health care that do not involve a $2.5 trillion expansion of the government, a 2,100-page bill, at a cost of $1.2 billion per page.

The other thing I have heard my colleagues say is we have to do something. People in this country are dealing about the high cost of health care. They are. We all hear it. We hear it from small businesses, from families, and from individuals. Everybody is concerned about the high cost of health care. In fact, a number of my colleagues on the other side have said of all the bankruptcies that occur every year, most occur because of the high cost of health care. Get this, America: Under their proposal,

you will go bankrupt sooner. Because they drive the cost of health care up. They don't do anything to bend the cost curve down.

I want to show a chart which points out what happens to the cost curve under the Democratic plan we are talking about. The blue represents the current cost curve. That is the increase in health care costs we would see if nothing is done, year-over-year increases into the future. What we would expect, if we were going to reform health care, is that line starting to bend down a little bit so that health care increases go down over time instead of up.

What happens? Under this proposal--and this is the CBO; this isn't what I am saying or any of my Republican colleagues, this is what the Congressional Budget Office says--the Democratic plan we are talking about increases the cost of health care. It bends the cost curve up; $160 billion more will be spent on health care if their plan gets enacted. All those people who are concerned about the high cost of health care today are not getting any relief under the Democratic plan. In fact, their lives

will get much worse--in particular, those who already have health care.

There are some in this proposal who will get some subsidies to buy insurance in a health care exchange. That affects about 19 million Americans. But there are 182 million Americans who currently have health care who, if this bill passes, are going to be faced with higher taxes and higher premiums. That is the way it works. They are ineligible to get any subsidies to buy insurance. In fact, they don't have any more options available to them. What they are facing is higher taxes that they will

be faced with under this bill, as well as higher premium costs.

If you are the average person who is worried about cost, which I think most Americans are, and you are watching what is happening here in Washington, you have to be asking yourself: What is the whole purpose of going through a health care reform debate if, in fact, it doesn't do anything to drive down the cost of health care?

My colleagues have pointed out that when you spend $2.5 trillion, when you expand the Federal Government by that amount, when you raise taxes on medical device manufacturers, on prescription drugs, on health plans themselves, and when you cut Medicare providers and, if you believe this, this is something that seems hard to fathom, that any of this would ever take effect, but this $2.5 trillion is paid for in the form of Medicare cuts and tax increases, tax increases when it is fully implemented

over a 10-year period, as the Senator from New Hampshire pointed out, about $1.2 trillion, about $1.1 trillion in Medicare cuts--who in this Chamber believes that $1.1 trillion in Medicare cuts is going to occur? There was a discussion between the Senator from New Hampshire and the Senator from Missouri about what happened a few years ago when the Senator from New Hampshire was chairman of the Budget Committee and proposed cutting $10 billion out of Medicare over a 5-year period, which amounts

to $2 billion a year. What we are talking about here is $1.1 trillion over 10 when fully implemented or $100 billion a year. When he proposed cutting $2 billion a year over 5 out of Medicare, there wasn't a single Democratic vote in support of that. In fact, the Vice President had to come back from a trip to Pakistan to vote on it to try and reduce Medicare by $10 billion. They are talking about, when it is fully implemented, $1 trillion in Medicare cuts. Do you know who that hits?

11:42 AM EST

John Thune, R-SD

Mr. THUNE. That is where a big share of the savings is going to hit, senior citizens, right squarely between the eyes, if they get benefits under Medicare Advantage. In addition, $135 billion comes from hospitals; $15 billion from nursing homes; $40 billion from home health agencies; $8 billion from hospices. Does anybody believe all that will happen? And if it doesn't happen, guess what, it all goes on the Federal debt.

I thought it was interesting that last week when the President was in Asia, the Chinese raised the issue with him about what happens if health care reform passes. They weren't worried about universal coverage or a public option. They were worried about what impact it is going to have on the deficit.

According to the New York Times and their reporting on his trip:

The Chinese wanted to know in painstaking detail how the health care plan would affect the deficit, said one participant.

They are worried about their investment because they are the biggest buyer of American debt. What happens to all these Medicare cuts that are proposed? We couldn't get 51 votes to cut $2 billion a year out of Medicare a few short years ago, and they are talking about cutting, when it is fully implemented, $100 billion a year. Does anybody believe we will cut $15 billion out of nursing homes? I don't think so. Here we are. How do we pay for it?

If it isn't paid for in Medicare cuts or tax increases, it all goes on the Federal debt which is growing at over a trillion dollars a year.

This is a bad deal for the American taxpayer. It is a bad deal for the 182 million Americans who already have insurance. They don't get anything out of this. What do they get? Higher taxes and higher premiums.

Listen to what CBO says: $160 billion in additional health care costs over this time period. It bends the cost curve not down but up. That is what we get. That is why so many business organizations have come out opposed to this, because they know the impact it will have on small businesses. The best way to get health care coverage to more people in America, as long as we continue to have an employer-based health care system, is to get people a job. People who are struggling with the economy right

now and losing jobs, the thing we ought to be doing is figuring out how can we provide incentives for small businesses to put people back to work, not how can we kill jobs by raising taxes on small businesses.

That is exactly what we are doing right here. That is why every business organization--the National Federation of Independent Businesses, to the Chamber of Commerce, the National Association of Wholesaler-Distributors, right on down the list--is opposed to this bill. They know the impact it would have on small businesses and their ability to create jobs. The best [Page: S11917]

way--best way--you can get health insurance today in America is to get a job. This bill

kills jobs.

I yield to the Senator from Louisiana.

11:45 AM EST

David Vitter, R-LA

Mr. VITTER. Madam President, I rise to share the same sorts of concerns as my colleague from South Dakota. I share the concerns, more importantly, of citizens all across Louisiana who have echoed those same thoughts to me over and over again as I have traveled the State. Like so many of my colleagues, I have spent a lot of time these last few months reaching out to my constituents, my fellow citizens in Louisiana, in every part of the State.

During the August recess, obviously, there were lots of townhall meetings around the Nation. I held 21 in Louisiana, in every corner of the State. Since then, I have held six more townhall meetings. I continue to do other types of outreach. For instance, yesterday--since we had a 1-day opportunity--I flew home specifically to do a few things, including having a roundtable of doctors, including two past presidents of the AMA, other health care providers, small business representatives, leaders

in the pro-life community, and it was a roundtable discussion specifically to focus on the Reid bill.

In all that process, since the August recess and even before, I have heard certain themes over and over again, no matter where I was in Louisiana. One of those themes was great concern about what this Congress is thinking of doing on health care but not just because of the significance of health care, which is vitally important, which is personal to every American, but also because of how it fits into a trend so many Louisianians and so many Americans are seeing over the past year--a trend of

dramatically increasing Federal Government power and intervention and dramatically increasing Federal Government spending and debt.

People have been passionate about health care. Again, part of that is because that is a very personal issue, and a bill such as this affects literally every single American. But, again, a big part of it has been that Louisianians are also connecting the dots. They see a bigger picture, which concerns them. Louisianians have been connecting the dots to a government takeover of banks and insurance companies and car companies, with the CEO of GM literally being fired and hired in the Oval Office,

and now, potentially, one-sixth of the U.S. economy through health care.

So there is a broader concern and theme I have heard over and over, which is an explosion of Federal Government power and intervention and an explosion of Federal Government spending and debt. This bill, unfortunately, does nothing except to confirm my constituents' worst fears in that regard. It is more of the same. It is more of that theme. It is another big dot they will be connecting in that trend, and I share that concern.

One specific issue that goes to that concern is the so-called government option or public option because that strikes a lot of people, including me, as a big, open door to dramatically increasing the Federal Government's role and dominance in health care in our country--one-sixth of our economy. Why do I say that? I truly believe the government option--if this bill passed or anything similar to it passed--would be the dominant option overnight and, perhaps, the only option in a few years.

Let me explain why. I will just point to one provision, which is the so-called pay-or-play mandate on business. Under this Senator Reid bill, as under previous versions of this idea, such as the Senate HELP Committee bill, a business--virtually any business in the country--would, for the first time, have a legal mandate, and the mandate would be to provide health insurance up to a certain minimum defined by Federal bureaucrats or the business would have a choice. The choice would be, if you do

not want to provide that health insurance, well, you can write a penalty or fee check to the government instead.

What is wrong with that? Well, the penalty or fee check in this bill is pretty much set at $750 per employee per year. How does that equate into a business's bottom line in the choice businesses would face? Well, businesses that do provide health insurance nationally pay an average of not $750 per employee per year but $6,100 per employee per year. So what sort of choice do you think that is going to present to business? What sort of result would you expect?

In this brave new world, if the bill passes, everyone is guaranteed coverage in some form or fashion, and business has a choice: $6,100 per employee per year or $750 per employee per year. I think, for a lot of small businesses under extreme competitive pressure, that is not going to be a hard choice. It is going to be an easy choice. The result for tens of millions of Americans who have coverage now they are reasonably satisfied with through their employer, the result is going to be getting

dumped off that coverage, with businesses saying: Well, there are other options now. There is the government option. Good luck. We can't afford it. We have to be competitive. We have to go with our bottom-line decision--$6,100 per employee per year or $750 per employee per year. I think the clear result will be tens of millions of Americans getting dumped off coverage they have now that they are reasonably satisfied with.

Do not take my word for it. Other outside experts, the Lewin Group and others, say dumping will occur and could, in fact, be massive; tens of millions of Americans--under their analysis of a previous bill that had largely the same provisions--over 110 million Americans. So that is a problem with regard to ballooning Federal Government intervention, power, domination of the marketplace.

Again, as I said a few minutes ago, another part of that theme and concern I heard over and over was ballooning Federal Government spending and debt. Here again, this Reid bill does nothing to allay those fears. In fact, it does a lot to increase those fears.

There has been a lot of talk and a lot of reports of the CBO score of $848 billion over 10 years. First of all, $848 billion is a lot of money. That is a lot of Federal Government spending and growth. It is hard to get your hands around that figure. What does that mean? If someone had started spending $1 million a day when Jesus Christ was born and kept spending $1 million a day, we would not yet be up to that figure. So that is a lot of money.

But what is worse, that figure is artificially low. The true cost of the bill is much greater. There are a number of budget gimmicks the ranking member on Budget, Senator Gregg, and others have talked about that prove that $848 billion figure is truly low compared to the full cost of the bill.

What am I talking about? Well, the biggest budget gimmick is the fact that the spending side of the bill does not kick in for the first 4 years. The tax side, of course, as always, kicks in immediately. So the tax increases, the fee increases, et cetera, kick in immediately. But the benefit spending side of the bill does not kick in for the first 4 years. So that is what will occur in the first 10 years of the bill's life, should it be passed. Therefore, in that CBO score of the first 10 years,

what the CBO is scoring is 10 years of tax increases and only 6 years of spending. So that is a huge budget gimmick which helps produce that artificially low $848 billion or so.

In fact, we should be looking at the first 10 years of full implementation; in other words, the first 10 years when not only all the tax provisions are kicked in but everything on the benefits spending side is kicked in. That is basically from 2014 to 2024. What are the numbers there when you look at the real first 10 years, the first 10 years of full implementation? The real numbers are not $848 billion--as big a figure as that is, spending $1 million a day since Jesus Christ was born and you

still would not be up to it--but there the analysis is $2.5 trillion over 10 years.

Again, Louisianians see this, Americans see this as another big dot to connect, part of a huge trend of exploding Federal Government power and exploding Federal Government spending and debt. What does that represent in terms of that explosion of spending and debt? It also represents enormous new taxes, and that goes to the cost issue my distinguished colleague from South Dakota was talking about.

When I talk to Louisianians specifically about health care--not just these [Page: S11918]

broader trends and these broader concerns they are very focused on but specifically health

care; OK, we have to fix certain issues in health care--what is the top issue? Virtually everyone in Louisiana says cost, ballooning cost. Whether they have coverage now or they are struggling to get coverage, the issue is cost. What can we do about cost?

Again, this bill does nothing to fix that. It makes it worse. As was illustrated with Senator Thune's graph, it pushes the cost curve up and not down. Part of the reason it does that is, in that $2.5 trillion of activity there are enormous taxes, and those taxes become built into health insurance premiums. So premiums do not go down, they go up. They go up in a major way.

What are some of these we are talking about--again, enormous tax increases, enormous tax increases across the board, taxes on choice and well-being. Flexible spending which allows individuals to have a tax-free account for medical needs, that is limited. That is downgraded and capped at $2,500 a year. Taxes on over-the-counter medicines that many patients' families and seniors depend on, that is a tax increase of $5 billion; reduced deductions for health expenses, again, another tax increase;

higher Medicare payroll taxes; the rate on wages in excess of $200,000, a very large tax increase; over and over again, major tax increases. The bill would impose $28 billion in new taxes on employers that do not provide government-approved health care plans. There is a tax increase of $53.8 billion, over 10 years, in terms of the Medicare population.

So, again, there are huge tax increases that are part of that, and that is the major reason that cost curve is not being pushed down. In fact, it is being pushed up.

As I approach this bill, after looking at it carefully over the last few days, my first bottom-line question is: How does it respond to those dominant concerns I have heard over and over again from Louisiana citizens all across the State over the last several months? What does it do about ballooning Federal spending and debt? What does it do about the growth of government power and intervention and the cost of health care?

Sadly, it fails on all those accounts. It moves us in the wrong direction on all those accounts. So I urge my colleagues to adopt a different approach, to vote no tonight, to not move to this approach, to adopt a far more focused, positive approach that responds directly to those concerns of the American people.

I yield back my time.

12:01 PM EST

Kirsten E. Gillibrand, D-NY

Mrs. GILLIBRAND. Madam President, I ask unanimous consent that the next hour be under the control of the majority controlled as follows and in the order listed: Senator Gillibrand, 5 minutes; Senator Whitehouse, 20 minutes; Senator Landrieu, 17 minutes; and Senator Cantwell, 18 minutes.

12:01 PM EST

Kirsten E. Gillibrand, D-NY

Mrs. GILLIBRAND. Madam President, as I rise today to speak in support of the Patient Protection and Affordable Care Act, I wish to say that this is truly historic legislation which I am very proud to support which will ensure all Americans will have access to quality, affordable health care. It will at long last make the necessary changes to contain costs that have truly spiraled out of control, and it will make enormous progress to address the many disparities in our health care system that

are discriminatory toward women.

The Congressional Budget Office has determined this bill will provide coverage for more than 94 percent of Americans--98 percent when accounting for the elderly population--while reducing the spiraling costs of health care and trimming the deficit over the next 10 years and beyond.

Sixty years after Harry Truman first talked about the need to guarantee affordable, quality health care for all Americans, we are on the brink of a historic vote to move one step closer to achieving this goal.

In 1994, the last time we seriously considered health care reform, opponents argued that if we reformed our health care system, health care spending would skyrocket and health care quality and access would decrease. The opponents succeeded in 1994, and health reform was defeated. But in the absence of reform, look at what has actually occurred. Since 1994, family premiums have risen by over 150 percent. In 1993, the average annual premium for employer-sponsored family coverage was $5,000. This

year, the cost for coverage is over $13,000 per year. By 2016, family health insurance is expected to reach over $24,000. In my State of New York, that is simply unaffordable.

Today, we spend more than 16 percent of our gross domestic product on health care, nearly twice the average of other developed nations--an astounding $2.2 trillion every year. What do we get in return? More than 47 million Americans are uninsured. In 2007 and 2008, 86.7 million Americans--1 out of every 3 Americans under 65--went without health insurance for a period of time. Every day, 14,000 Americans lose their health insurance.

Many of the same opponents who defeated reform in 1994 are trying to do it again. I ask them to please consider what has actually occurred over the last 15 years. Think about the damage that has been caused to our economy, our families, our workers, and consider taking a stand that is on the right side of history this time.

The bill before us lays a foundation for truly reforming our health care system. I commend Majority Leader Reid for his work in merging the two Senate committee bills.

This bill includes a robust public plan for which I have strongly advocated. I believe this will increase competition and lower costs across the system. Through a public plan and the establishment of health insurance exchanges, the bill makes quality health care truly affordable and accessible to everyone--all Americans. The health insurance exchanges will streamline the system and offer insurance at affordable premium rates, capped by income, for low- and middle-income Americans. No longer will

health care be out of the reach of millions because of cost.

This bill also ends discrimination against women, which we have faced in our health care system for far too long. Women shoulder the worst of the health care crisis, including outrageous discriminatory practices in care and coverage. The National Women's Law Center reports that a 25-year-old woman pays up to 45 percent more for the same health insurance coverage than a man her age. Some of the most essential services required by women are simply not covered by insurance plans, such as childbearing,

Pap smears, and mammograms. A standard in-hospital delivery costs between $5,000 and $10,000, and much more if there are complications. This bill ends the practice of denying health care to those with preexisting conditions. In the current system, pregnant women are often turned down for health care coverage because

insurance companies would rather evade this cost. Pregnancy should never be the basis for losing coverage. In America, this sort of institutionalized discrimination is wrong. This reform bill ends the practice of charging women more than men and requires that these basic health care services are included.

The bill also lays the groundwork to reward health care providers for the quality of care they provide, not necessarily the quantity. Hospitals and clinics across the country will model the success at places such as Bassett Healthcare in Cooperstown in upstate New York. It also uses new methods to reduce medical errors and prevent costly illnesses.

Some would prefer that we continue on the current path, leaving millions without insurance and paying for it through a hidden tax that all insured Americans pay to cover the cost of emergency care. But the majority of Americans think the time has now come to address this problem and fix our broken system.

The vote today is an important step on the road to reform. In the next few weeks, we will all have the opportunity to debate this bill and make important modifications. I am encouraged to see improvements from previous bills in the merged bill before us, including [Page: S11919]

better protections for middle-class families' benefits and increased funding to States for Medicaid, both of which I look forward to continuing to improve.

12:07 PM EST

Kirsten E. Gillibrand, D-NY

Mrs. GILLIBRAND. I thank the Chair.

I welcome the opportunity to work with my colleagues on this historic legislation. For the next few weeks, I will work to strengthen the provisions for States such as New York that have strong Medicaid Programs, and I will also work to ensure that funding for our safety net hospitals remains intact.

Now is the time to act. The bill before us provides quality affordable health insurance for every American, reins in the high costs, makes our system more efficient, and addresses some of the grave disparities in the system that discriminate against women. I urge my colleagues to join me in voting yes on the motion to proceed on this bill.

12:08 PM EST

Sheldon Whitehouse, D-RI

Mr. WHITEHOUSE. Madam President, I had the occasion to listen to some of the remarks of our colleagues on the other side of the aisle. It forces the conclusion that the irony department of the Republican Party is working overtime these days.

The criticisms of this bill are over deficit and cost. We are hearing these criticisms about deficit from the party that, when it had control in the Bush years, ran up over $8 trillion in our national debt--$8 trillion, the biggest spendthrifts in history, an orgy of fair-weather debt. They didn't have any hesitation about deficits then. On the wars in Iraq and Afghanistan, we have never heard any interest in having those paid for on a current basis. Borrowing for wars is completely satisfactory

to them, it appears. When they had the chance to amend Medicare, they added Part D, and they ran up the cost immensely by providing a special protection for the pharmaceutical industry so that it can dictate prices to the Federal Government. The Federal Government can't negotiate with the pharmaceutical industry for Part D pharmaceuticals. That costs

the Federal Government a fortune. Do they mind? No. They spend on deficits over and over. Now, when at last we take on the insurance industry, suddenly they discover a concern about deficits. Well, I would urge that based on that trajectory, these remarks have a lot less to do with the deficit than they do with protecting the insurance industry.

There is another clue of this as well, and that is the concern about cost. We all, indeed, are concerned about cost. But I think the best thing we could do about cost in health care is to pass a public option. Why do I say that? I say that because the Director of the Congressional Budget Office has said that changes in government policy which we adhere to in this bill have the potential to yield large reductions in both national health expenditures and Federal health care spending without harming

health. It is not just a possibility. He goes on to say: Many experts agree on the general direction in which the government must go to get those cost savings. But they conclude they can't put a specific score on them yet for the following reason: The specific changes that might ultimately prove most important cannot be foreseen today and could be developed only over time through experimentation and learning.

Now, who is going to develop those changes that will save costs while improving the quality of our health care system over time through experimentation and learning? The public options. There will be public options, if the original health plan is followed, in all 50 States. Each would have to stay within its State on balance, solvent, could not go to the Federal Treasury to make up losses. So they have to look for reform in order to continue to succeed. They would be 50 engines of reform, of

experimentation, and of learning.

Who is against the public options? The insurance industry, because they don't want the competition. They love an environment in which they are immune from the antitrust laws--almost uniquely in American business--and in which they have incredible market share. In many cases, there are only two dominant insurers in the entire market around this country. So they love having these huge market shares to be able to dictate price, to be immune from the antitrust laws, and they don't want the competition.

Guess who else is against the public options. Our Republican friends. It is very hard to find any daylight between the position of the insurance industry and the position of our Republican friends.

The problem with this is that it is not just about numbers and it is not just about statistics; it is about people. It is about people by the hundreds of thousands, but it makes their stories better when you actually come down to cases. So let me mention a few cases.

I talked a few weeks ago about one of my very dearest family members who fell victim to the system when his insurance company tried to deny him the indicated treatment prescribed by a world-class physician from the National Institutes of Health on the grounds that it was so-called ``not the indicated treatment.'' This was an individual who had received a devastating diagnosis. He had gone to the top expert for that diagnosis in the country at the National Institutes of Health. He had been told

what he should do. He had been told, indeed, that was very standard. This was not anything exotic; this was essentially the automatic way you should treat a particular condition. When he filed it with his insurance company, some faceless bureaucrat said: No; we know better than the top expert at the National Institutes of Health. That is not the indicated treatment.

From that, and from thousands and thousands of Americans who have had their claims denied and have had insurers try to intrude between them and their doctor and interfere with the care their doctor thinks they need, we can tell one thing: the insurance companies do this for a bad motivation, which is to save costs. Of all of the stories I have heard, of all of the stories our colleagues have related here on the Senate floor, never once has there been a story of an insurance company that stepped

in and said: Oh, wait a minute, that is not the indicated treatment; the indicated treatment is actually more expensive than what your doctor has indicated. Always, it is less expensive. Go figure.

I wish to share another story today about a person who is close to me, a member of my staff. His name is Richard Pezzillo, and he has hemophilia. He has gotten the treatment he has needed so far, but he has been lucky, and it illustrates how luck now enters into our equation in health care.

In 2003, after a very turbulent airplane flight, Rich unfastened his seatbelt from the airplane, collected his things, and suddenly realized things were going badly wrong. He started to feel tremendous pain. He started vomiting blood. Simply wearing his seatbelt in that turbulent aircraft had caused Rich to begin to bleed internally, inside of his stomach, eventually requiring that his gallbladder be removed.

Rich is a kind and thoughtful young man from North Providence, RI. He was hospitalized in very serious condition. He spent nearly 3 weeks in the hospital. Thankfully, he received excellent treatment, and today he works here in my Washington office. The doctors, the nurses, and the hospital staff in Rhode Island gave Rich the best treatment. He now leads an energetic, vigorous life and does well at a challenging job.

But the stunning part about Rich's story is his treatment and his treatment cost--$1.5 million. At least that is what they said. If you look at a copy of the billing sheet, you will see that the insurance company said that his billing, here, for instance, was $366,240.

The insurance company allowed only $106,000. That is what was actually paid, which gives you a sense of how much funny business is going on in the private health insurance industry and in the health care sector, when an insurance company can get away with paying about one-third of the bill's cost.

We have heard a lot of talk about how burdensome it is for Members of Congress to make it through a 2,000-page long health care bill. If you actually reduce its size to the substantive [Page: S11920]

language--and I am elaborating on what the House bill would do, which is about the same as ours--the substantive language is less than a Harry Potter novel. My daughter could read Harry Potter novels when she was 13. I don't think it is asking too much of our colleagues

to plow through a bill that represents one-sixth of our economy--when it is the size of a Harry Potter novel. It would be a good idea.

Rather than fighting about the 2,000-page bill, how about Rich's $1.5 million health care bill? The hard truth is, Rich was able to get lifesaving treatment because he was lucky, since he hadn't graduated from college yet and was still covered by his parents' insurance policy. Because he was covered, the hospital only charged his insurer less than half of that--$106,000. What if things had been different? What if he needed treatment a couple of years later when he wasn't on his parents' policy

and couldn't afford his own? What if he had applied for his own coverage but was denied by an insurance company because his illness was deemed a preexisting condition? What if Rich's father lost his job and his health insurance along with it or what if Rich's parents' policy had a limit on benefits, and they had to pay the rest of the $1.5 million out of pocket?

Rich would have been a victim not just of his illness but of the health care status quo. If he or his family had been uninsured, they almost certainly would not have been able to afford the full care Rich needed. Their financial future would have been irrevocably altered--probably ruined.

Luck is no way to run a health care system. Unfortunately, Americans need all the luck they can get when dealing with health insurance companies that use every bit of their bureaucratic guile and financial might to delay and deny health insurance benefits they are obligated to provide.

For example, in March 2006, the Arizona Department of Insurance ordered health insurance giant United Healthcare to pay fines of more than $364,000--the largest in the department's history. Regulators found that the company illegally denied more than 63,000 claims by doctors without examining all of the information needed to accept or deny a claim. It looks as if they were just on automatic pilot to deny them.

In January 2008, California insurance regulators found that a subsidiary of United Healthcare had committed more than 130,000 violations of law in handling claims. For example, the company inappropriately denied more than $750,000 in claims on the grounds that insureds had a preexisting condition. The regulators found that the companies ``made large-scale and willful decisions to use broken systems to process claims and respond to providers, while continually and effectively collecting premiums.''

The total potential liability of the company for all violations is $1.3 billion.

Last year, United Healthcare's CEO, Stephen Helmsley, made $3.2 million and holds almost $120 million in stock options.

The health care reform bill we are talking about today would right this massive power imbalance between the health insurance industry and ordinary Americans who are getting rolled over by it. It would empower average Americans to take control of their health and financial future. Rather than taking their health insurance premium dollars to the health insurance ``casino,'' they could take them to the bank.

Unfortunately, many on the other side of the aisle wildly misrepresent both the status quo and how reform would empower consumers. The opponents of reform depict our bill as an Orwellian takeover of the system.

Madam President, let me close with a story that illustrates how ironic and completely wrong these cries of ``death panels'' or ``government interference'' really are.

In 2000, Christiane Hymel--insured by a subsidiary of Blue Cross Blue Shield of Louisiana--scheduled an appointment for a routine physical. During the examination, she reported to her doctor her history of back pain and weakness in her legs over the past year and a half. Her doctor ordered x rays of her spine and referred her to a neurologist.

The neurologist, after detecting troubling symptoms, ordered an MRI. In accordance with her insurance policy, the doctor sent Blue Cross a request to preauthorize the MRI. The day before the MRI was scheduled, Blue Cross denied that request on the basis that the service was for a preexisting condition--Mrs. Hymel's back pain.

Mrs. Hymel appealed the insurance company's decision in accordance with the terms of her policy, but Blue Cross never processed the appeal.

After Blue Cross denied coverage for the MRI, Mr. and Mrs. Hymel were told that the MRI would cost about $4,000. They started saving up for it. It took 3 months to save up the money necessary to pay cash for the procedure, but they eventually did. The MRI showed that Mrs. Hymel had massive tumors involving ``nearly the entire cervical and thoracic [spinal] cord.'' She was immediately scheduled for surgery. Helpfully, Blue Cross stepped in to deny coverage for that as well, stating it was for

a preexisting condition.

Mrs. Hymel's neurosurgeon later testified at trial:

Tumors inside the spinal cord are growing tumors, as they grow, they cause damage to vital structures in the spinal cord, which are important to walking, sensation, and breathing.

The longer the wait in removing a tumor, the more damage the tumor will cause to the spinal cord. The doctor testified:

Two-thirds of Mrs. Hymel's current condition and disabilities were the direct result of the growth of the tumor during the 3 to 4-month delay between the time Blue Cross denied the MRI until the time Mrs. Hymel was able to pay for it by herself. Additionally ..... this delay also caused the tumor's quick recurrence, necessitating the second surgery.

In ruling for Mrs. Hymel in her lawsuit against Blue Cross, the court described the consequences for Mrs. Hymel of this 3-month delay the insurance company caused by denying her MRI:

Mrs. Hymel testified that when she first woke up from surgery, she could not move her arms or head and she thought she was paralyzed. She felt painful burning sensations in her body. ..... While she was in the surgical ward, she contemplated committing suicide. During her hospital stay, she suffered from bowel obstruction, fecal impaction, and had to wear diapers. Mrs. Hymel didn't see her children in the hospital until two weeks after the surgery, and when her children finally saw her, they

were scared of her and would not touch her. Mrs. Hymel spent approximately eight months in a wheelchair after her surgery.

Mrs. Hymel is house-bound, she cannot take a shower, work in her garden, ride a bike, swim, or drive, as she had frequently enjoyed prior to the surgery. ..... Mrs. Hymel must also take large doses of medication to relieve the burning and shocking sensations from which she suffers. She cannot be touched on her back or leg, because the second something touches her lower back, it's like fireworks that go off.

Every day that insurance companies delay or deny payment is another day they earn interest on your premiums, adding to their profits and adding to the funds that support their massive executive pay packages. When Blue Cross of Louisiana failed to pay for Mrs. Hymel's MRI, it wasn't just making a mistake, it was making a calculated decision--a heartless, profit-maximizing decision. Christiane Hymel's story isn't just a sad tale, it is a symptom of a disease that is spreading through the private

health insurance system.

For many Americans like Christiane and Rich, our health care system is a casino, where a roll of the dice or spin of the roulette wheel determines one's fate. Such an irrational and random system doesn't comport with the society that Franklin Roosevelt described in his 1944 State of the Union:

We have come to a clear realization of the fact that true individual freedom cannot exist without economic security and independence. Necessitous men are not free men.

These days I think it would be more proper to say necessitous men and women are not free men and women.

By passing health care reform, we will take health insurance off the casino floor for the average American family and make it a reliable part of every family's economic foundation. No longer will happenstance or chance determine whether treatment will be paid for. No longer will the casino wheel determine whether Rich Pezillo gets his treatment or that Christiane Hymel does not. Parents of kids like Rich Pezillo would not worry whether their son's illness could lead him to be [Page:

S11921]

turned down for that preexisting condition or whether a layoff or lack of insurance could deny their son the treatment he needs.

Necessitous men and women are not free men and women. Let's redeem FDR's promise by passing health care reform. Let's bear in mind, as we go forward, the nature of the arguments that are made against health care reform and the astonishing coincidence between the arguments made between health care reform by our Republican colleagues and by the barons of the health insurance industry. There seems to be literally no daylight between those arguments.

If we are going to turn around the extraordinary spiraling costs of health care, we are going to have to do it by reforming the delivery system. The best way to do that is the public option. Yet they oppose it.

Madam President, I yield the floor and suggest the absence of a quorum.

12:29 PM EST

Maria Cantwell, D-WA

Ms. CANTWELL. Mr. President, my colleague, Senator Landrieu, was going to be next, but I will switch times with her. She will join us on the floor shortly.

I want to join my colleagues this morning and talk about this important issue of controlling health care costs. That is why we are here. We know Americans are facing higher and higher health care costs and that we can do something to drive down the costs of our health care system. We know health care costs are not only strangling us, but they are impacting our constituents, our budget, and they are leaving 47 million Americans without insurance.

Our aim is to promote better quality care and get costs under control. Whether those costs be to consumers struggling to pay insurance premiums or to our government, we need to make sure we are doing all we can. Doing nothing in this debate is allowing health care costs to continue. I want to make sure my colleagues on the other side of the aisle who talk a lot about this legislation understand that if we do nothing, we are going to leave the American people and our budget in serious danger by

not controlling health care costs.

As always, in this debate we must keep in mind Federal spending, and the numbers on Federal spending are stark.

In terms of doing nothing, if the U.S. Government does nothing, health care spending will double in the next decade. That is, we spend about $810 billion on health care. That is one-third of our total Federal budget. If we do nothing, Federal spending is going to go to $1.56 trillion. That is because we are not controlling health care costs, baby boomers are reaching retirement, and Medicaid and Medicare costs are ballooning. One-third of our Federal budget is a big enough bite. But if we do

nothing, then our health care priorities are going to push out other priorities of our Federal Government.

The biggest area where we could control costs is in Medicare. Medicare is 57 percent of all Federal spending, and it is getting bigger. By 2020, Medicare spending alone will reach $1 trillion, doubling the $466 billion we spend today. That is to say that Medicare spending has been doubling in the last 10 years, and if we do nothing as our colleagues on the other side of the aisle are suggesting by not moving forward on this legislation, then it is going to double again. This is unsustainable

because if we do not address this, Medicare is going to bankrupt us.

The prospects are just as daunting when it comes to our Medicaid budget because Medicaid spending over the next several years will also double, and it has doubled in the last 10 years. States are struggling, as many of us know, with what they can do to help sustain Medicaid since they pay for part of that for individuals.

So we see we are in a situation where doing nothing is an irresponsible way to go. In fact, for our constituents, they are seeing a 120-percent increase in insurance premiums. While we are worried about the impact on the Federal Government, they are worried about the impact on them, on their individual budgets. That means the average family today pays about $7,000 more per year for the same health care benefits than they did a few years ago. If you think about that, that means that is less money

for them, less money for their families, less money to meet the other bills in the family.

Why has this happened? If we look at what has happened in our country, we see that wages have not gone up. In fact, during that same 10-year period of time, wages have only gone up 29 percent, health insurance premiums have gone up 120 percent. And where has the insurance industry been? The insurance industry has seen a 428-percent increase in profits over the last 10 years.

That is why we need to do something about controlling health care costs. We cannot let the American people continue to be subject to such huge increases in premiums and then have the insurance industry walk away with huge profits and American consumers make less and less.

What is going to happen if we do nothing, if we do not advance this bill to control health care costs? Those same premium increases we have seen in the last 10 years are also going to go up again. In fact, they are projected to go up another 7.9 percent in annual growth. That is, every year, they are going to go up another 8 percent. That is unsustainable. That means somebody is going to be paying $10,000 or more than what they are paying for their health insurance today for the same health care

benefits. That is why doing nothing and not advancing this bill is just acquiescing to the fact that everybody is going to pay more for health care.

What makes this number so scary is that it is four times the rate of inflation over the same period. That means what we need to do is look at general inflation, which is usually about 2 percent. But health care inflation, as is shown on this chart, is more like 8 percent. If we do nothing to change this, Americans are going to continue to do with less because health care costs are demanding more and more of their budget.

What do we do about this? We certainly want to make sure that we change the system, and that is one of the reasons I support driving down costs by having a public option. We know that two factors are involved: We don't have enough competition and there are very concentrated markets in health insurance across the country. Many times there are only one or two insurance providers providing coverage in a market. They might have 94 percent of the market. It is too concentrated. We know if we provide

an alternative in the marketplace, we can help drive down costs.

One provision in this bill of which I am very supportive is the basic health plan because it lets States negotiate with private insurers for lower costs. In my State, this program has been in place for 20 years. It has been able to provide those who participate in the program--about 70,000 people today--a 30- to 40-percent savings if they had to buy that plan as an individual from a private insurer. That is incredible success in driving down the cost.

Why? I call it the Costco model because like when you go to Costco and you buy in volume, the State of Washington, buying in volume on behalf of those individuals, was able to drive down the cost of health care for those individual citizens. They were able to choose between four different plans, and they were able to get access to a very good proposal for health care for them.

The underlying bill includes language that says you could provide this basic health plan if States opted into it and cover 70 percent of the currently uninsured in America. I like this proposal because it gets us cheaper insurance for that population.

Why subsidize insurance companies by giving tax incentives to buy more expensive insurance when what Americans want is to drive down the cost of health care by having the same negotiating clout that big businesses or other entities have?

I hope we can continue to work and maybe even expand this provision to make it even more robust and to drive down costs.

What is clear is that the cost of the uninsured is adding to our health care [Page: S11922]

costs. In fact, the fact there are people in America who are uninsured is adding about $1,000 to our health care premiums overall. That is about $43 billion a year to our health care system.

If we can change our health care system and get more people into something such as the basic health plan, we would be able to drive down costs, and that is why that plan is so valuable.

We should not forget that our current system, besides insurance reform, needs provider reform. The reason why provider reform is so important is because our current health care system is flawed. It is driving up the cost of Medicare and health care in general because of the payment system. Basically, the current payment system perpetuates more spending. In fact, there is something like $700 billion in waste in our current system. If you think about it, it is this fee-for-service loop that I call

it where you order more and you end up having more waste in the system, you have more spending, you have more use, and it keeps going. That is primarily because we pay doctors on volume. We pay doctors for how many patients they see every day, and we pay them for how many tests they order. Consequently, the cost continues to spin out of control.

As I was saying, we spend about $700 billion on health care that we do not need to spend. That is in duplicated tests, unnecessary procedures, excessive insurance overhead, uncoordinated speciality care, and preventable hospitalization.

We heard from many people during the health care debate that we have to do something to change this system. In fact, one of the witnesses before the health care committee said:

We have to go after how we reimburse physicians. The current system is the most broken part of Medicare.

What are we doing in this legislation to fix that? We are changing the way we reimburse for health care. In fact, we are going to look at how to get lower costs with better results. This is important because I don't think there is a person in America who doesn't know what it is like to go into a doctor's office and feel they are always in a hurry or feel as if the doctor didn't hear everything you had to say. This is about changing and rewarding physicians on the outcome of your health care so

you can have shorter waiting times, better access to doctors, more coordinated care, and

better outcomes.

We think if you change the health care system, which this bill does, to drive down costs and get better outcomes, we are going to have better health care in America.

We can continue on the path which I think my colleagues on the other side of the aisle want by not voting to move forward on this legislation, we can have less coordinated care, going from specialist to specialist without having that care coordinated and have unnecessary tests, but then everybody in America is going to be paying for those costs. Everybody is going to be paying higher health care premiums because of it.

What we need to do, which is what exactly this bill sets us on a course and path to do, is to pay for value not for volume, to pay physicians on the value they deliver and the outcome of their patients instead of volume.

If we did nothing else in health care reform but to change our payment structure to focus on this premise--paying for value and not for volume--then we would be delivering great long-term savings to our health care system.

We have other things we need to do, and that is in the area of long-term care and Medicaid because in our long-term care system, we are seeing a doubling in health care costs, primarily because of long-term care. When you think about our Medicaid budget, everybody thinks Medicaid is this program to help the low-income population. Medicaid is turning into a long-term care program for the elderly in America. That is, they cannot get long-term care access so they are spending down so they qualify

under Medicaid to basically get on that system to cover their long-term care.

We can see that right now Medicaid is paying half of its funds, and that is an expense that is going to continue to grow.

We have made some reforms in the State of Washington to make that cheaper. We have said let's invest in home care instead. Instead of having everybody go to nursing homes, whether they need to be there or not, let's focus on the long-term care system reforms that keep people in their community and instead use the Medicaid budget to advance other things while keeping patients at home.

I think every senior in this country would rather have their health care delivered at home than in a nursing home, but our current Federal system continues to reward long-term care in nursing homes instead of in community-based care. This legislation starts us on a path to change that direction, to move closer to long-term care community services.

We did this in the State of Washington, again, over 20 years ago and have reaped huge benefits. If we took an individual in the system today, the cost is only about $22,000 per individual. If we had not reformed the system as we did 20 years ago, we would be paying $42,000 for that same individual. So we have been able to drastically cut the amount of money we are spending on long-term care.

This legislation includes the same kind of cost control reforms in long-term care as some States have already implemented. That is why we have to get at controlling health care costs. If we do not control health care costs in this area of long-term care, we are not going to control health care costs overall in America.

What does reform mean? Why are we here today to talk about the cost of health care and what we need to do? Why are we here talking about advancing this legislation so we can get this debate on the floor for the American people?

It is clear we need to have more competition through a public option, we need smarter reimbursement rates to incentivize value, and we need better use of Medicaid dollars.

12:45 PM EST

Mary Landrieu, D-LA

Ms. LANDRIEU. Madam President, I first want to commend my colleague, Senator Cantwell, the Senator from Washington State, who has worked so hard and so long and in such a professional way. She has been extremely helpful to me through this process, and I want to acknowledge that and thank her.

Before I make a statement, I also want to comment about a few other colleagues who have been extremely helpful and supportive, not just to me but I think to the entire Senate, beginning with Senator Harry Reid, our leader, who, with patience and persistence and care, has led us to a bill that is before the Senate. The question today is whether we should proceed. I would like to say that, in my view, no other Member of the Senate could have accomplished what he has today. I think many

Senators share that sentiment.

No. 2, I want to recognize the extraordinary work of the Senator from Oregon, Senator Ron Wyden, who, 2 years ago, before the Presidential election had really gotten underway, before it was really ever clear as to who might win, Senator Wyden put down a bill called the Healthy Americans Act, which I was very proud to support, and I still am so proud of that effort today. That bill has the support of seven Republicans and seven Democrats. It is a truly bipartisan effort that

would accomplish, in my view, what many Americans are asking for: a marketplace that is fixed and reformed, more affordable choices for individuals and small businesses and families, and a real effort to curb the rising and alarming cost to the Federal taxpayers, given that the percentage

now of our GDP spent on health care is almost exceeding 16 percent, twice as high as any nation in the world. That is alarming. The Healthy Americans Act went a long way to help frame my thoughts on this debate. We are going to continue to work together through this process.

I also thank Senator Blanche Lincoln who, because of her persistent leadership, has pushed and prodded Members of this body to ensure that we [Page: S11923]

had the time necessary to review this bill. In so doing, she helped to assure our constituents, whether they are for or against the direction we are moving, knew that we had the time necessary to make an informed decision. I think I have used that time very well these last 2 1/2 days. I have been in

meetings with economists, on the phone with health care experts, talking with people from my State as well as around the Nation. I have used that time well and wisely. Senator Lincoln led the charge to ensure that we had the time we needed, and I am glad to have supported her in that effort. I know she will be speaking on the floor later today, giving her final views on where we are. I commend her for her leadership.

Madam President, I come to the floor today to acknowledge to speak on the business before the Senate today, and that is the question of whether to proceed to debate on the Patient Protection and Affordability Act, a bill that is the best work of the Senate to date on a subject of significant importance to the people of my State and the country. I have decided to vote today to move forward on this important debate.

My vote should in no way be construed by the supporters of this current framework as an indication of how I might vote on the final bill. My vote is a vote to move forward, to continue the good and essential and important and imperative work that is underway.

After a thorough review of the bill, as I said, over the last 2 1/2 days, which included many lengthy discussions, I have decided that there are enough significant reforms and safeguards in this bill to move forward, but much more work needs to be done before I can support this effort.

Over the past many years, and in particular the last 6 months, I have heard from people all across Louisiana that their insurance premium costs are simply too high and continue to rise without warning, threatening the financial stability of their families and their businesses. I have also heard the pleas and cries of many people who need health coverage but they cannot find it anywhere within reach of their budgets.

Through months of public meetings in VFW halls, school gyms, and in hospitals and health clinics from New Orleans to Shreveport, and in large and small communities throughout my State, it is clear to me that doing nothing is not an option, nor is postponing the debate.

Spirited debate and good-faith negotiations in this Senate have produced a bill that contains some amazing and cutting-edge reforms that will, I am hopeful, reduce costs for families and small businesses while reducing the debt burden of the Federal Government. But these reforms must be implemented properly and carefully, and they must be put in place in a timely fashion.

Small business owners across the country have told me time after time that in order to grow their businesses and create jobs, they need affordable health insurance and they need stable and predictable costs. Yes, they would like their costs to be lowered, and I am going to stay focused like a laser on doing just that. But what they also need is predictability--they need to be able to plan for the future, something they cannot do when the cost of healthcare spikes violently from year to year.

As we all know, today, under the status quo, small business owners are frequently confronted with impossible choices when an employee or employee's family member gets seriously ill. They can expect exorbitant cost increases of up to 20 percent in their premiums when just one of their employees gets sick. Then they are confronted with the excruciating choice of going to that employee and those family members and saying: I am sorry, to save my business and the other 10 employees, we need to let

you go. Here is $1,000 or $2,000 or $5,000. You are on your own. Good luck.

That is a tragic story, painful, depressing, and it has to stop.

I appreciate the hard work of many business owners and organizations that have helped to craft portions of this framework because they have remained at the negotiating table. They didn't run and hide, they remained at the table. I am asking them today to stay at this table.

Before I discuss the work that needs to be done to improve this bill, I would like to discuss some of the points in this bill that encourage me to move forward.

Small business owners, under the current framework of this bill, would no longer be confronted with these kinds of volatile costs. This bill prevents insurance companies from escalating their rates or dropping their coverage after someone gets sick. That important change goes a long way in stabilizing the amount small businesses will have to pay for their health plans, and it allows business owners to do what they do best--plan smart investments, grow their businesses, and then help us grow our

economy.

In recent years, economists have found that workers' wages have remained largely stagnant. Why? Because employers are paying more and more for health care that we are indirectly subsidizing through the current Tax Code and so have less and less money to pay real wages that workers in large and small businesses could actually take home, put in their pockets, and spend in much more productive ways. The bill we are debating would encourage employers to move away from high-cost benefit plans, and

instead increase the amount that working families can take home. That is an important change from the status quo.

In addition, this bill would ensure that the majority of Louisiana families would pay no more than 10 percent of their income for health care. That is still high. But today families in Louisiana pay an average of 30 percent of their income on healthcare costs. And economists project that if we do nothing, that total will climb to 60 percent of an average family's income that will have to be spent trying to afford health care. This bill changes that trajectory. So while some people still think

that 10 percent or 12 percent may be too high, it is a lot better than 60 percent, which is the direction we are heading today if we do nothing. That is real progress.

These reforms I have just mentioned are necessary and are too important a goal for the Senate to abandon its work. But, as I have said, there is a great deal more work that needs to be done.

I would like to mention briefly just a few of the significant changes I would like to see be made to this bill.

No. 1, in order to increase choices for small businesses, we must enhance and expand tax credits that are in this bill for small businesses, particularly for business

with 25 fewer employees. If we can expand tax credits for slightly larger small businesses with between 25 and 50 employees, that would be significant progress. Current projections are that 96 percent of all businesses that have more than 50 employees have coverage. That is a good statistic, and those larger businesses have some choices. But we need to give small businesses more choices. It is these small businesses that are leading the country on its way out of this recession. And we need to

help them in that effort.

In addition, I will continue to fight for more tax equity for the 27 million Americans who are currently self-employed. Every chairman of the Small Business Committee--both Republican and Democrat, I understand, for the last 25 years--has asked for this to be addressed. It is time to make progress on that effort now.

No. 2, in order to really deliver our promise to hold down costs for families, we should think about focusing on ways to prevent premiums from being excessively raised between the time this bill is enacted, if it ever is, and the time it actually goes into effect. Many of the provisions in this bill, because of cost considerations, which I understand, do not go into effect until 2014. Well, today is 2009. That's a long time between now and then, and we need to make sure that companies do not

jack up their premiums in anticipation of the market reforms this bill will make, as we have seen the credit card industry do in anticipation of the important reforms we made earlier in the year. Americans cannot afford to allow that kind of predatory behavior.

Finally, I remain concerned that the current version of the public option included in this bill could shift significant risks to taxpayers over time unnecessarily, and I will continue to work with my colleagues to find a better and bipartisan solution for this [Page: S11924]

issue. I have suggested that a freestanding, premium-supported, competitive community option that would trigger on a date certain, if our private market reforms fail to work, might be a possible

compromise. That would include language that Senator Snowe and other of my colleagues have been working on for several months.

Because I am hopeful we can make progress on each of these concerns and others through an amendment and debate process that is open and transparent, I believe that it is incumbent upon me to allow the bill to move to debate on the Senate floor.

I stand ready to work together with my colleagues to fashion a principled and hopefully bipartisan compromise in the end to achieve what the people in my State need, and what many Americans need, and which we really have to do our best to try to give them.

Finally, I know my time is up, but I would like to ask a personal privilege for just 1 more minute to address an issue that has come up, unfortunately, in the last 24 hours, driven by some very partisan Republican bloggers. So I think I need to respond and will do so now.

One of the provisions in the framework of this bill has to do with fixing a very difficult situation that Louisiana is facing. For reasons that are simply beyond my comprehension, some partisans have decided to attack me for leading an effort to address a serious budget shortfall facing my state.

The reason for this situation goes back to the disastrous hurricanes of 2005. I am not going to review the horrors of Katrina and Rita. The levees broke, and by the way, the courts have just ruled that the Corps of Engineers was, as I have said from the beginning, responsible. But I will comment more on that at another date.

But, nonetheless, in 2005 Louisiana experienced two of the worst natural disasters in recent memory. In an effort to aid the recovery, Congress stepped in with a massive aid package for Louisianans--thank you--that infused grant dollars and direct assistance.

Some of necessary one-time recovery dollars, in addition to the increased economic activity, were calculated into our State's per capita income. The result has been that Louisiana's per capita income----

1:00 PM EST

Mary Landrieu, D-LA

Ms. LANDRIEU. The result is Louisiana's per capita income was abnormally inflated. You can understand that. There were billions of dollars that came in from insurance and road, home, and community development block grants.

In addition, labor and wage costs went up because there was a constriction in the market, which any economist can tell us always happens after a natural disaster. As a result, when we did the calculation under the law, it made us seem as if we were a state with a high per capita income like Connecticut and not a state with a low per capita income like Louisiana, almost as if we had become rich overnight. That was not the case. Our State is still as poor as it was, if not poorer as a consequence

of those devastating storms. I am not going to be defensive about asking for help in this situation. It is not a $100 million fix, it is a nearly $300 million fix. It is the No. 1 request of my Governor who is a Republican. He explicitly asked that I pursue these funds. It is unanimously supported by every Member of our delegation, Democratic and Republican. I am proud to have asked for it. I am proud to have fought for it. I will continue to. But that is not the reason I am moving to debate.

The reason I am moving to the debate, as I expressed in this statement, is that the cost of healthcare is bankrupting families and it is bankrupting our government. We cannot afford the status quo.

I thank my colleagues for their graciousness. I know I have gone over my time, but I wanted to get that on the record. I support moving forward with the debate and look forward to working with them to improve it.

I yield the floor.

1:02 PM EST

Orrin Hatch, R-UT

Mr. HATCH. Madam President, I wish to express my deep concerns about Senator Reid's bill on two very critical issues. These are not the only things of which I am critical but I wish to focus on two issues: coverage of abortion and conscience clause protections for medical providers opposed to abortion.

As we can see, the Stupak compromise amendment, which was supported by 64 House Democrats and a majority of Republicans, reads:

No funds authorized or appropriated by this Act may be used to pay for abortion or to cover any part of the costs of any health plan that includes coverage of abortion.

That is all it says. It should be abundantly clear to each Member of this body. The House of Representatives overwhelmingly passed pro-life language exactly 2 weeks ago that is markedly different from that contained in the Reid proposal. The House provisions, in contrast to the terribly flawed provisions in the Reid bill, contain language that would not only safeguard the rights of the unborn but would also prevent medical providers from being coerced into performing procedures that violate their

conscience. The Stupak-Pitts amendment was adopted by a significant margin, 240 to 194. That represents 55 percent of the House of Representatives, including 25 percent of the Democratic caucus.

Even more telling happens to be two polls released this week by the Washington Post and ABC News and CNN. They confirmed that 61 percent of the American population do not support Federal funding for abortion. This vote should serve as a strong signal to each Member that these protections cannot be ignored and must be contained in any measure we adopt. Unfortunately, the language in the Reid bill explicitly allows what the Stupak-Pitts language would prevent. The Reid language authorizes abortion

in the government-operated health plan or the public option and Federal subsidies for insurance coverage that include abortion. It is not the Stupak-Pitts language.

The sanctity of life is not an issue that can be traded away for political expediency. During committee consideration of the health reform legislation, I offered two important pro-life amendments. The first amendment, which I offered in both the HELP Committee and the Finance Committee, strictly prohibited Federal dollars being used to finance elective abortions. The second amendment provided conscience clause protections to medical providers opposed to abortion. In other words, we should never

force people who have a conscience against abortion to have to perform abortions or participate in abortions. This language was based on the Hyde-Weldon provision contained in every Labor-HHS appropriations bill since 2004. It also was included in the House-passed bill. Both my amendments were defeated.

I notice my colleagues, Senators Brownback and Johanns, are in the Chamber. I ask both of them: What is wrong with including the Stupak-Pitts language in the Reid bill?

1:06 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. Madam President, I, first, thank my colleague for offering these amendments in committee.

In both the HELP and Finance Committees, you said: Let's put in the Hyde language, and both times the amendments were defeated in committee. I appreciate my colleague raising it. Proponents of the Reid bill will tell us the abortion funding language is essentially the Hyde language included in the annual Labor-HHS appropriations bill. That is plain wrong. The Hyde amendment specifically removes abortion from government programs. The Reid bill specifically allows abortion to be offered in two

huge new government programs. The Reid bill tries to explain this contradiction by calling for segregation of Federal dollars when Federal subsidies are used to purchase health plans. This segregation of funds, though, actually violates the Hyde amendment, which prevents

funding of abortion not only by Federal funds but also by State matching funds within the same plan. Simply put, today Federal and State Medicaid dollars are not segregated, and the Reid bill specifically authorizes something the Hyde amendment specifically rejects.

1:07 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. If I might join in, it is enormously important we lay a good record as to what this is all about and why the Hyde amendment has been the [Page: S11925]

law of our Nation for so long. It is important. Therefore, I direct a question to Senator Hatch.

Please, if you would, describe how the Hyde amendment works today.

1:08 PM EST

Orrin Hatch, R-UT

Mr. HATCH. Today's Hyde language, which has been in every annual Labor-HHS appropriations bill since 1976, specifically prohibits Federal dollars being used to pay for abortions except if the pregnancy was the result of rape, incest, or the life of the mother is in danger. The Hyde language applies to all five of the federally funded health care programs: Medicare, Medicaid, Indian Health Services, TRICARE, and the Federal Employees Health Benefits Program or the FEHBP. However, it is important

to note that today there is no segregation of Federal funds in any Federal health care program--none. For example, the Medicaid Program receives both Federal and State dollars. There is no segregation of either Federal Medicaid dollars or State Medicaid dollars.

States that do provide elective abortions for Medicaid beneficiaries must do so from a completely different account; that is, State-only dollars. No Federal or State dollars from the State Medicaid Program may even be placed in that ``State only'' pot of money.

1:09 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. That was an excellent explanation of what Hyde is about. It underscores why we are so upset about the unbelievable expansion that is going to occur if this Reid bill is passed. You mentioned the Federal Employees Health Benefits Program. Let me take a minute to talk about how that works because, again, I think it underscores the point we are making today. Let me give an example. The current Federal Employees Health Benefits Program does this. It has 250 participating health plans

that do not cover abortion. Federal employees pay a share of the cost.

The Federal Government, through tax dollars collected, pays the balance. So it is a mixture of Federal employees' contributions through their paychecks and the Federal Government getting the money through tax dollars. Federal employees cannot opt for elective abortion coverage because taxpayer dollars are subsidizing the cost of their employee plan. You can see how we have tried to remain true to the distinction you talked about. As many have said during the debate, if it is good enough for Federal

employees, then why isn't it good for the rest of the citizens?

I ask Senator Brownback, what is in the Reid bill that does not reflect the current Hyde language? And if I could maybe direct that to both of you or to Senator Hatch.

1:11 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. Well, if I could follow up quickly on the last point, I think it is clear that if we are not going to put this in the Federal employees benefit insurance system, then we should not put it in this system. Yet this is a billing expansion that is taking place. The Democratic health bill would explicitly authorize abortion to be covered in the government option. It also mandates that there must be abortion coverage in every insurance market in the country. This is an enormous expansion,

a radical departure from the 30-year policy that represents the Hyde amendment. The abortion language that was included in the bill is a huge departure from 30 years of bipartisan Federal policy prohibiting Federal tax dollars paying for elective abortions. The language in the Senate bill explicitly authorizes the Secretary of Health and Human Services to include abortion in the public option and permits government subsidies for plans that pay for abortion.

The Capps language, commonly referred to in the Senate bill, contains a clever accounting gimmick that proponents say separates private and public funds for abortion coverage. However, it has been proven over and over by outside reviewers that the Capps measure would include both abortion coverage and funding in the government-run public option as well as for those plans in the insurance exchange. Representative Bart Stupak, a Democrat from Michigan, explained the issue very clearly

in an op-ed he wrote yesterday. He wrote:

The Capps amendment, which is the basis of the Senate language, departed from Hyde in several important and troubling ways: By mandating that at least one plan in the health insurance exchange provide abortion coverage; by requiring a minimum $1 monthly charge for all covered individuals that would go towards paying for abortions; and by allowing individuals receiving Federal affordability credits to purchase health insurance plans that cover abortion. Hyde currently prohibits direct Federal

funding of abortion. The Stupak amendment is a continuation of that policy--nothing more, nothing less.

I would like to ask Senator Hatch about this provision, about what we need to talk about on the exchanges and the types of plans that will be included in the exchanges and about how this is an expansion of the abortion language.

1:14 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. The Reid health care reform bill would require at least one health care plan to offer elective abortions in each State health insurance exchange. However, nothing in the Reid bill ensures that the one plan that must cover elective abortions be the plan that is most affordable or least affordable. In other words, if I do not wish to have a plan that covers elective abortions but all I can afford is that plan, where does that leave me? Should my constituents have to compromise their

own moral code in order to receive health care; in other words, that they would have to buy a plan that covers abortion?

1:15 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. Today, no Federal health program requires the coverage of elective abortions. This is a clear departure from current law, and I cannot imagine us forcing people to pay for insurance that covers abortions when it is so unconscionable to so many of the American people.

I also would like to make one other point perfectly clear. The Stupak-Pitts compromise amendment would not prohibit the ability of women to obtain elective abortions as long as they use their own money to purchase these policies. I think it is important we get that piece of it clear as well.

1:15 PM EST

Orrin Hatch, R-UT

Mr. HATCH. I am glad the Senator did clarify that.

I say to Senator Johanns, isn't it true that the Stupak amendment, passed in the House by a considerable margin, allows women to purchase, with their own money, separate supplemental health coverage that may include the coverage of elective abortions--if they do it with their own money?

1:16 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. I say to Senator Hatch, I am glad you raised that issue. Yes, that is correct. Your understanding is correct. Women would be allowed to purchase separate elective abortion coverage with their own money.

I ask Senator Brownback, do you have a comment on that, or a question?

1:16 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. Well, I think this is a key thing for us to keep in mind, that it is true that women can purchase separately, with their own money, use their own funds to be able to provide for their own abortion coverage. But what we are saying here today is that we should not have this as part of the Federal Government. We should not have it as part of the Federal funding program. We should not be using taxpayer dollars to fund abortions, as we have not done for 30 years. That has been the longstanding

bipartisan program. But it is not prohibited that an individual could go ahead and buy this service on their own.

1:17 PM EST

Orrin Hatch, R-UT

Mr. HATCH. Well, I would add, too, it is absolutely correct that the Stupak language allows women to purchase both a supplemental policy for the coverage of elective abortions and a comprehensive health care plan that includes coverage of elective abortions as long as they pay for their plan with their own money. It allows that.

1:17 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. Let me just interject something here because I think this is a very important point to make, following up on what Senator Hatch just said. Some say that a person would never want to purchase a separate rider to cover abortion. It just would not happen, they say. But they misunderstand what the Stupak language actually allows.

Let me be clear about this. If a woman wants her health insurance plan to provide elective abortion services, she does have the choice to purchase a health insurance plan that provides that on the exchange. She just has to pay for it with her own money. Am I correct in that interpretation or have I misunderstood that? [Page: S11926]

1:18 PM EST

Orrin Hatch, R-UT

Mr. HATCH. That is correct. A woman may purchase with her own funds either a supplemental policy that covers elective abortions or an entire health plan that includes the coverage of elective abortions. Look, a woman has always been able to do that, and frankly, we do not deny her the right to do that. What we say is, taxpayers should not be paying the cost of it. They should not be called upon to pay for elective abortions.

1:18 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. I say to Senator Hatch, as someone who has been in this body for some years and as someone who has followed this issue courageously for many years, what we are asking for, again, is just what has been established since 1977 in this body and in the House.

1:19 PM EST

Orrin Hatch, R-UT

Mr. HATCH. Yes. That is current law, that Federal funds may not pay for abortion or plans that cover abortion. Now that is the fundamental component of the Hyde language. And to be clear, the Stupak language does not prevent people from purchasing their own private plans that include elective abortion coverage.

Let me just change for a second here. I would like to now talk about the conscience clause. To me, this is extremely important: the conscience clause protections for medical providers. The conscience clause protections in the final House bill for pro-life providers are not included in the Reid bill. They are in the House bill but not in the Reid bill. The House adopted language that codified the essence of the Weldon-Hyde conscience protections, including in the annual HHS appropriations bills

since 2004.

This summer, the House Energy and Commerce Committee accepted these protections unanimously during consideration of their bill. Let me emphasize that point: unanimously, there was not one objection to it. That means all members of the committee--with ideologies ranging from the chairman, HENRY WAXMAN, who represents Hollywood, CA, to the ranking Republican, JOE BARTON, who represents a conservative congressional district in Texas--they all recognized the importance of adopting this

language.

In contrast, the Reid bill has stronger protections for abortion providers than for providers who have conscience objections to abortion. On one hand, abortion providers may not be ``discriminated'' against for performing any abortion anywhere. On the other hand, pro-life providers must cite a particular ``moral or religious belief'' to prevent discrimination. This is narrower than current law under Hyde-Weldon.

Moreover, it does not extend the protections to pro-life health plans. In other words, a Catholic health system that requires a local hospital to stop providing abortions in order to become part of its health system could be accused of discrimination.

What is wrong with this picture?

Let me ask Senator Johanns, don't you think it makes sense to protect health care providers who have objections of conscience to abortion so they are not forced to provide abortions?

1:21 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. Absolutely. As the Senator offers this explanation about a Catholic health care provider, it hits right to the heart of this issue. I most certainly agree with the Senator and I want him to know that many Nebraskans agree with him and agree with me on this issue.

I got a letter recently from a gentleman out in western Nebraska, from a little community called Ainsworth--a great area of our State. He wrote to me and said this:

I urge you to support freedom of conscience which protects professionals from being forced to participate in abortion and other anti-life practices, which include end-of-life issues.

I had another constituent from Gretna, NE, more on the eastern side of our State, and this constituent wrote to me and said this:

I am also very disturbed to learn that health care workers may be forced to act and speak contrary to their own consciences. I find it shocking to believe that this is being considered within a serious conversation/debate.

We are going to put up a chart. President Obama has weighed in on some of these issues. President Obama gave a speech to a joint session of Congress. We all remember that was on September 9 of this year. He said this:

And one more misunderstanding I want to clear up--under our plan, no federal dollars will be used to fund abortions, and federal conscience laws will remain in place.

The President has gone on to state on multiple occasions that he would not support abortion in a health care bill. The President has stated that over and over. The President has also stated on multiple occasions--both as a candidate and as President--that it is his goal to lower the incidence of abortion. That is what he says, not what the Democrat-led Senate has done, though, relative to this bill, which he has embraced. And it is not what the leadership has done in this bill.

You see, my colleagues, I see this as a radical abortion approach, a radical piece of language. And you can go right to the bill itself, to pages 116 to 124 of this 2,074-page bill, and you can read it yourself.

I have to tell you, there is so much about this bill that is bad policy, but this is especially damaging. The President promised us he would not let it happen. Do the President and the Members of his party, who control the Senate, who wrote the bill behind closed doors, do they really believe abortion is health care? Why didn't they just strip this language out? Why didn't they adopt the Stupak language, which was voted upon in the House, the Stupak compromise? Why didn't they adopt that, knowing

that 64 Democrats had signed on to that language?

What do you think about the President's commitment and his promise to us not to use Federal dollars to fund abortions? I say to Senator Brownback, I would like to hear his thoughts on that.

1:25 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. I was there that evening, along with

the Senator and Senator Hatch and almost all of the Senators, when the President was addressing us on health care. I remember vividly sitting there and listening to these words, the ones you just mentioned. He was very clear, very concise; there was no fudging around on it:

And one more misunderstanding I want to clear up--under our plan, no federal dollars will be used to fund abortions, and federal conscience laws will remain in place.

Yes, that is specifically violated in the bill, and they had a very simple route to change it. They could have just put the Stupak language in that has already passed the House. That is the Hyde language that has been agreed to by this body and others for 30 years here. Instead, they put in this abortion-expansion language.

I will show another chart here a little bit later on. The last time we funded abortions here was between 1974 and 1977, right after Roe v. Wade and before the Hyde language in 1977. Do you know how many abortions were funded annually by the Federal Government at that period of time? If we are going back to that policy, if we are looking to go back to that era where the Federal Government was funding it, Medicaid funded as many as 300,000--300,000 annually. Now, I would ask everybody, pro-choice

or pro-life, do you want your taxpayer dollars to pay for 300,000 abortions a year? I do not think anybody wants to see us do that.

President Clinton we all remember very clearly saying often that he wanted to make abortion safe, legal, and rare. Adding 300,000 does not do that.

So the President took the time, in a carefully tailored and vetted speech that all of us were there to hear--the Presiding Officer, as well; it was nationally televised in prime time--to tell Congress the words we have quoted here today and to make that specific promise. And that promise is broken in the Reid legislation before us today. We sat there in the House Chamber and heard him say those words. Our constituents watching the speech at home heard those words. I have to believe these are

the kinds of broken promises that are making our constituents lose their trust in government.

But the fact is, as so many people have pointed out, abortion is very much in this health care bill. Many Democrats and Republicans acknowledge this. Mr. Stupak, whom I have quoted several times, is just one of them.

If we want to do more than just pay lipservice to lowering the incidence of abortion, we need to oppose the motion to proceed, and we should have had the Stupak compromise language included in the bill in the first place since the President clearly stated he did not want Federal dollars to be used for the funding of abortion. [Page: S11927]

Consider the fact that when Federal funding is not available for abortion, fewer abortions occur. When Federal funding is available, as we have seen in the past, thousands more will occur.

As shown on this chart, here is why the Hyde amendment is so important. The administrators running the Medicaid Program funded, as I noted, over 300,000 per year. That is almost 1 million abortions paid for by the country's taxpayers out of their pockets when the Hyde language was not the law of the land. That was until the Hyde amendment was enacted in 1976 because the American people disagreed with being forced to pay for abortions. Whether they are pro-choice or pro-life, they did not want

taxpayer dollars to go for this.

One other example of government ushering abortion policy through health care legislation is when the Commonwealth of Massachusetts recently passed its State-mandated insurance, Commonwealth Care. They failed to include an explicit exclusion of abortion, like Senator Hatch tried to get in committee or like they had in the House language, the Stupak language, so abortions there were funded immediately in Massachusetts. In fact, according to the Commonwealth Care Web site, abortion is considered

covered under ``outpatient medical care.''

The Federal Government should not go down this road. The President made a commitment to the American people, and the Democrat-led Senate has failed to include that commitment in this bill. They included radical language that will increase the incidence of abortion.

I say to Senator Johanns, don't you think it makes sense to protect health care providers, when we look at that issue here, who have objections of conscience to abortions so they are not forced to provide abortions?

1:30 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. Madam President, pro-life groups weighed in on this bill immediately. For all of the complexity, for all of the definitions, for all of the buried language, they saw immediately what this bill was all about. Pro-life groups across the board have opposed the provisions of this legislation. No pro-life group has taken the bait. They represent millions of Americans across this great country.

Let me, if I might, take a moment and quote from what they have said. The National Right to Life Committee--and again I am quoting--says this:

Senate Majority Leader Harry Reid has rejected the bipartisan Stupak-Pitts amendment and has substituted completely unacceptable language that would result in coverage of abortion on demand in two big, new Federal Government programs.

The United States Conference of Catholic Bishops has weighed in. They said this one is the worst bill so far--the worst one so far on this issue. Again, I am quoting:

The conference believes the bill violates the long-standing Federal policy against the use of Federal funds for elective abortions in health plans that include such abortions, a policy upheld in all health programs covered by the Hyde amendment: the Children's Health Insurance Program, the Federal Employee Health Benefits Program, and now in the House-passed Affordable Health Care for America Act. We believe legislation that violates this moral principle is not true health care reform and must

be amended to reflect it. If that fails, the current legislation should be opposed.

The Family Research Council says this, describing the legislation as a:

..... direct attack on the principles set forth in the Hyde amendment over 30 years ago. This bill is one only an abortionist could love.

Concerned Women for America said the following:

In a dramatic departure from current policy, the Patient Protection and Affordable Care Act will provide government funding for elective abortions. Over all, this bill raises serious pro-life concerns.

Senator Hatch referred to polls. The polls indicate the majority of Americans do not want their tax dollars paying for elective abortions. According to that CNN/Opinion Research Corporation survey, 6 in 10 Americans favor a ban on the use of Federal funds for abortion. It also indicates that the public may also favor--literally favor--legislation that would prevent many women from getting their health insurance plan to cover the cost of abortion even if no Federal funds were involved.

This poll indicates that 61 percent of the public oppose the use of public money for abortions for women who cannot afford the procedure.

I have to ask the question of Senator Hatch: When will we listen to the American people on this important issue?

1:34 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. I have. We have seen the polls. We have gotten letters from our constituents. Consistently, in poll after poll, we can see what the American people are saying. They do not want their tax dollars to fund abortions.

1:34 PM EST

Orrin Hatch, R-UT

Mr. HATCH. Madam President, let me ask a question to both Senator Brownback and Senator Johanns. I know my constituents are very upset about the possibility of their tax dollars being used to pay for elective abortions. I even brought a few of their letters down to the floor so I could read them. If you don't mind, I wish to read them. Can I take a few minutes to do that?

1:35 PM EST

Orrin Hatch, R-UT

Mr. HATCH. These are just a few. We have all kinds of letters. I thought I would mention a few of these since they are on point here, as far as I am concerned.

Here is one from a woman, a Ph.D., the President of AUL Action, Charmaine Yoest:

DEAR SENATOR: On behalf of Americans United for Life, AUL Action, I write to express our strong opposition to the Senate proceeding to Majority Leader Reid's health care reform bill, the Patient Protection and Affordable Care Act. Majority Leader Reid's bill does not include the Stupak-Pitts language added to H.R. 3962, which is necessary to prevent Federal funding of abortion. AUL Action will score against all votes to proceed to this bill because it does not contain the Stupak-Pitts

language. Majority Leader Reid's bill explicitly allows the Secretary of the Department of Health to include abortion coverage in the ``community health insurance option'' and allows Federal subsidies to go to private insurance plans that include abortion coverage. In addition, the bill also requires that at least one private plan in each

exchange provide coverage for all abortions. The passage of a health care reform bill without language explicitly excluding abortion coverage and funding is unacceptable to pro-life Americans. We strongly encourage you to vote against all procedural motions to move to the majority leader's bill, including cloture on the motion to proceed.

Sincerely,

Charmaine Yoest, Ph.D.,

President and CEO of AUL Action.

Here is another one. It is from one of my personal constituents.

DEAR SENATOR: As an American with a growing disdain for the heavy handedness and disregard for the wishes of the American people, I adamantly oppose any plan brought to the table that would require me to pay for abortions with my tax dollars. Any government-run health care system with this provision is bad for America and violates the deep convictions of many Americans. Furthermore, I am infuriated by Senate Majority Leader Harry Reid's deceptive course of action in secretively creating

his own version of a health care reform plan. Reid's underhanded tactic diminishes the opportunity for public debate and scrutiny which flies in the face of our legislative process. I strongly oppose Harry Reid's health care overhaul plan to nationalize our system. I urge you to oppose any nationalized health care bill and any plan containing an abortion mandate.

Here is another one. This is an e-mail to me. It says this:

Hello, Mr. Hatch. I am writing for 4 registered voters in my family which include my husband, my parents, and myself. We are very concerned about the Federal health care legislation. We believe that it must support several of our beliefs. We believe that life must be respected and cared for from conception to natural death. As such, we do not want any of our tax dollars going to abortions or euthanasia. We have a desire for the continued support of the Hyde amendment of 1976. Our family supports

charities which provide counseling and material goods needed by families who have an unplanned pregnancy. We want to support them in having the baby and caring for themselves and the child. We do this by donating things that are needed by the mom-to-be during her pregnancy. We also have donated furniture and other things needed by the baby. These have been given to Birthright--a program supported by donations. We want access to health care for all. This includes fair treatment of our immigrants.

We do not want any of their health care that they may be receiving right now to be taken from them. In the [Page: S11928]

Bible, God tells the Jews to be kind to the aliens, as they themselves were aliens at one time in their promised land. Our family also wants a freedom of conscience clause that allows for health care workers to refuse to take part in procedures involved in an activity that goes against their choice. Please consider our beliefs.

Whether you agree with every word of these, they are interesting.

Here is another one:

During the floor debate on the health care reform bill, please support an amendment to incorporate long-standing policies against abortion funding and in favor of conscience rights. If these serious concerns are not addressed, the final bill should be opposed. Life should be respected from conception to natural death. I am a retired teacher and am hoping to be able to receive the care I choose to have until my natural death. My care should not be based on my productivity in society years from

now. Thank you for your stand on abortion in the past.

Then she has a PS:

My parents don't have and do not know how to use a computer to contact you. They feel the same as my husband and I feel about the above issues.

Then she lists the names of her parents.

Here is another one:

DEAR SENATOR HATCH: I am a registered Democrat strongly in favor of health care reform. I am also committed to protecting the unborn and to safeguarding the conscience of each health care provider who is uncomfortable with providing abortion services. During floor debate on the health care reform bill, please support an amendment to incorporate long-standing policies against abortion funding and in favor of conscience rights. If these serious concerns are not addressed, the final bill

should be opposed. Genuine health care reform should protect the life and dignity of all people from the moment of conception until natural death.

Another one.

SENATOR HATCH: During floor debate on the health care reform bill, please support an amendment to incorporate long-standing policies against abortion funding and in favor of conscience rights. If these serious concerns are not addressed, the final bill should be opposed. Genuine health care reform should protect the life and dignity of all people from the moment of conception until natural death.

I also have a petition to Senator Orrin G. Hatch opposing using taxpayer dollars to fund abortion. This petition says:

One out of every three babies conceived is a victim of abortion, a tragedy that has claimed more millions of innocent lives since the Roe v. Wade Supreme Court decision legalizing abortion on demand. Every abortion is a gruesome act that ends an innocent human life and cannot be tolerated in a civil society. The pro-abortion lobby is seeking to hide abortion funding into virtually every piece of ``must-pass'' legislation, including continuing resolutions, budget and authorization bills, so-called

``economic'' bills, and even the Defense authorization bill. I urge you to actively oppose and, if necessary, filibuster all attempts to use the budget to force Federal funding of abortion and abortionists and to pack the courts with activist, pro-abortion judges.

I thought I would read a few of those interesting letters to set a tone here. I have received all kinds of letters, but I chose a few, at random, to read on the Senate floor this afternoon.

1:42 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. I was recently at a Veterans Day parade in Leavenworth, KS, and I had a number of people coming up to me opposed to the health care bill. I had one come up to me and say they were in favor of it and all the rest were opposed. It starts on the basis that it is fiscally insane what we are considering doing with $12 billion in debt, and then we are going to add a multitrillion-dollar entitlement program on top of this. The Federal Government is hemorrhaging money. Why on Earth would

we do that? Then they are scared about what else is in the bill, and then this feature comes up as well.

Finally, Senator Johanns was putting in statements from various groups, and I ask unanimous consent that this statement from the United States Conference of Catholic Bishops be included at the end of our colloquy.

1:43 PM EST

Sam Brownback, R-KS

Mr. BROWNBACK. The Catholic Bishops issued this yesterday and said this:

The legislative proposal recently unveiled in the Senate does not meet these moral criteria. Specifically, it violates the longstanding Federal policy against the use of Federal funds for elective abortions and health plans that include such abortions--a policy upheld in all health programs covered by the Hyde Amendment, the Children's Health Insurance Program--

SCHIP, which Senator Hatch helped to get started--

the Federal Employees Health Benefits Program--

that Senator Johanns spoke about--

and now in the House-passed ``Affordable Health Care for America Act.'' We believe legislation that violates this moral principle is not true health care reform and must be amended to reflect it. If that fails, the current legislation should be opposed.

This is the Catholic Bishops, generally in favor of health care reform, and they are saying this fails on this account and must not be in this legislation and can't be considered as part of health care reform.

1:44 PM EST

Orrin Hatch, R-UT

Mr. HATCH. I ask Senator Johanns, where do we go from here? We are going to have a cloture vote at 8 o'clock tonight on the motion to proceed. What would be the advice on that?

1:45 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. I thank the Senator. Let me, if I might, before I address that, tell my colleagues how proud I am to stand here with these two champions of this issue, Senator Brownback and Senator Hatch. They have a remarkable history of every time they had an opportunity standing strong on an issue that I must admit is not the most popular issue in Washington, DC, to promote, and I admire their courage.

To address the relevant question of the day, the Stupak protections, that compromise that was reached in the House, it is not in this bill.

Of course, since it is not in this underlying bill, this Reid bill, it is very unlikely to be in the final bill. I wish somebody could disprove this. But, very simply, there aren't enough pro-life Senators to break this provision and get the Stupak amendment passed on the Senate floor if we propose it as an amendment--and I am sure it will be--there just aren't enough.

That is why I have been making the case over the last 48 hours that the motion to proceed is the key vote on abortion in the health care debate. The most important pro-life vote that a pro-life Senator will cast, I believe, in the entire time they are here is on this motion to proceed. I have seen all the arguments from many, saying this is a procedural vote; that there is nothing to worry about; that it just begins debate, and we might potentially vote this bill down, and we can do some amendments

and some tweaking.

But the facts suggest otherwise. The Congressional Research Service has looked into this. Between the 106th and 110th Congresses, there were 41 cases, according to the Congressional Research Service, in which the Senate approved a motion to proceed and then proceeded to a vote on the final bill. Do you know what the end result of those 41 cases were, when the motion to proceed was approved? It was 40 times out of 41--about 97 percent--went on to receive final approval. In other words, all but

one passed into law.

This suggests to me this vote tonight at 8 o'clock on the life issue is very well determinative. Some of my colleagues also argue if we don't like the bill, we should not block the opportunity to amend it, and they say let us proceed.

I don't believe, if you are truly pro-life as a Senator, you can make that argument. Here is why: Everybody in the Senate knows what it will take to amend the Reid bill on something like this. It will take 60 votes. It is the way the Senate operates. It will take 60 votes. Again, I say to Senator Hatch and Senator Brownback, I wish I could count 60 pro-life Senators. I wish I could do that. But by anybody's count, I believe--mine included--there aren't 60 here.

I believe if you are pro-life, every opportunity you get to stand for the life issue, you must stand for that issue. These truly are our most vulnerable citizens. I feel very strongly that at 8 o'clock, when we are gaveled to a vote, we need to stand up on this issue--this life issue--or there is a 97-percent chance it is lost.

I will conclude my thoughts on this by saying this: There were many strong and courageous pro-life Democrats in the House. I watched that. That was remarkable. Can you imagine the pressure they were put under? This evening, we just need one--not many, just one Democrat--who will come here and say I am pro-life. If we don't stand together tonight, this bill will radically expand abortion, and I cannot live with that. [Page: S11929]

1:59 PM EST

Al Franken, D-MN

Mr. FRANKEN. Madam President, I rise today to express my strong support for the Patient Protection and Affordable Care Act.

I commend Leader Reid, Chairman Harkin, Chairman Baucus, and Senator Dodd for their leadership that has brought us to this critical point. We are on the verge of passing legislation that will do more than any bill in recent history to make our country healthier, our economy more stable, and our working families more secure.

Make no mistake, this bill will change. There will be amendments to it that will make it an even better bill. There may be amendments that make it less to my liking and, therefore, a less good bill, to my point of view. But the final bill will make health care available to more tens of millions of Americans. It will make health insurance more secure for all Americans who have it and will put an end to the unsustainable trajectory that we are now on with the cost of health care, and will avert

an otherwise inevitable catastrophe to our health care system and our economy.

The reality right now is that we are denying millions of Americans their shot at the American dream because of our irrational health insurance system.

Right now, if you have been sick, insurance companies can refuse to cover you or charge you ridiculous premiums. If you get sick, your insurance benefits can run out when you need them the most.

Right now, people without insurance do not get preventive care. Instead, they go to the emergency room when they cannot hold out any longer. This is the least-efficient and most expensive way to deliver care, and those of us who do have insurance pay for it. It costs every insured family more than $1,100 a year in additional premiums to pay for those who don't have health insurance.

Right now, if you are a woman who has had a C-section or if you have been a survivor of domestic violence, health insurance companies can arbitrarily decide not to cover you. That is because having had a C-section or being a survivor of domestic violence is considered by many insurance companies to be a preexisting condition. That is wrong.

What is even more egregious is that while millions of Americans struggle to pay for health care, insurance executives continue to make obscene salaries. From 2000 to 2007, a period of 8 years, Americans saw their premiums almost double. During that same time, we saw more than 6 million more Americans become uninsured. During that same time, insurance company profits rose 428 percent--428 percent. That is all you need to know to understand why we have to pass this bill--428 percent in 8 years.

No wonder the insurance companies are fighting this bill. Of course they don't want to be subject to antitrust laws. They are making outrageous profits by gouging American families. Make no mistake, that is what this is about.

This bill will change all that. It will fundamentally transform how health insurance works in this country. This bill guarantees secure coverage that will be there for Americans and stay there when they need it the most. This is not going to help just individual Americans; it is going to help small businesses too.

There are urgently needed changes that will go into effect the day the President signs this bill into law. Effective immediately, preventive services, such as colonoscopies and cholesterol tests, will be covered by all insurance plans at no cost. This will make prevention a priority, not an afterthought. We will detect cancers earlier and stop chronic diseases, such as diabetes, in their tracks. Not only will this save innumerable lives, it will lower the long-term cost of health care for all

of us. This is one of the key [Page: S11931]

ways health care reform transforms our system of sick care into a true health care system.

Effective immediately, any new health insurance plan will let your children remain on the family policy until they are 26. That is big. Say you are a parent whose kid has been ill in the past, maybe she had asthma and she just graduated, say, from the University of Minnesota. Your daughter is just out of school, and she wants to find a job. We all know this is a big enough challenge in this economy. While she plans for her future, the last thing she should have to worry about is how she is going

to get health insurance.

The good news is, after health care reform, she will have secure coverage until she gets on her feet. She can either stay on your plan until she is 26 or once the exchange is up and running, she can purchase an affordable plan through the exchange.

Also, effective immediately, we will hold health insurance companies accountable by making them give rebates if they spend more than 20 percent of premiums toward profits, marketing, or administration. I am proud to have championed this safeguard with my colleagues, Senator Rockefeller and Senator Whitehouse.

The current reality is, most of us do not know where our health insurance premiums go. It is challenging enough to understand a billing statement from your health insurer, much less track where your money is being spent. We are going to change that.

Thanks to Senator Jack Reed, the Senate bill also requires transparent reporting of how health insurance companies are spending your money. This transparency is especially important as we cover an additional 3l million Americans under this bill. We know from their profit margins that right now insurance companies are price gouging. But clear reporting will help us hold them accountable for every dollar we invest in health insurance.

Based on our experience in Minnesota, I know we can do even more to rein in marketing, wasteful administrative costs, and profits in health insurance. In the coming weeks, we will debate this bill, amend it, and make it even better. I will be pushing to require an even higher percentage of your premiums go toward actual health care.

The reason I believe we can provide higher quality care without excessive profits is because Minnesota already does it. We are distinguished by the fact that 90 percent of Minnesotans are served by a nonprofit health plan. These plans outperform their national peers and are able to put an average of 91 cents of every premium dollar toward actual health care services--91 cents out of every dollar.

In other plans throughout the Nation, you may find less than 60 percent of your premium is put toward health care. The rest is for overhead, marketing, and profits. By taking the profits out of the health insurance industry--not taking them out but lowering them to a reasonable level--Minnesota health plans do a better job of helping our residents live healthier, longer lives. As we begin debating this bill on the Senate floor, it is essential that health insurance companies get the message loudly

and clearly that their top priority must be serving patients, not creating more and more profits, not a 428-percent increase in profits in 8 years.

Under the Senate bill, we will stop insurance companies from denying you coverage or charging you more because of preexisting conditions. This will end the egregious industry practice of discriminating against survivors of domestic violence. Insurance companies also will no longer be able to charge women more for their health coverage just because they happen to be a woman.

We will ban lifetime caps and end unreasonable annual limits on your benefits. These insurance market reforms will help Americans, but they will be particularly life changing for families such as the Battersons who live in Bloomington, MN. Linda Batterson has three daughters. She owns her own business, and her husband Bud is a realtor.

The Battersons have some relatively minor health problems--asthma, allergies, and back problems. But because health insurance companies can charge them more based on their health history, their only health care option in Minnesota is a high-risk pool. This year they are paying nearly $21,000 for health care--$21,000 for their insurance. This is not a Cadillac plan. Neither the Battersons' businesses nor their family can sustain these costs.

But the good news is, the Battersons will get relief under our bill. They will be able to go to the exchange and find an affordable plan. Health insurance companies will not be able to charge the family more because of their health history. If companies are going to raise rates, they will have to publicly disclose and justify any increase.

I think we can all agree that one group of Americans who suffer under our current system is small businesses. Across Minnesota--from Bemidji to Spring Valley--I have talked to small business owners who want to do the right thing. They want their workers to be healthy, but they cannot afford the current unpredictable and skyrocketing rates.

In Minnesota, we have 92 percent of our State covered, and we have invested resources to create the MinnesotaCare Program to make sure low-income residents are covered. But even with all this success, the uncontrolled cost of health insurance is forcing us to tighten our belts and make sacrifices that no American should have to make, such as small businesses having to choose between laying off workers or dropping health insurance for everyone.

I am pleased to tell you this bill will bring real relief to small businesses across our country. We will even the playing field so small businesses can do the right thing for workers without sacrificing their bottom line. This will make them competitive with large employers and with companies from overseas so they can attract the best and brightest workers.

Right now, small businesses are often priced out of the markets. They may be lucky to find just one or two carriers willing to cover their workers. So the first important change that health care reform can bring is choice of plans for small businesses. They will be able to participate in the exchange which will offer them a choice of reliable plans. This coverage will be less expensive and provide better coverage than what is available today.

Right now, if you are a business with, say, 15 employees and 1 of them gets sick or has a baby, your premiums are going to go up dramatically. That is because your risk pool is 15. But when you choose from policies on the exchange, your risk can be pooled with hundreds or even thousands of other businesses. That is the whole point of insurance, to spread the risk over the greatest number of people.

The second key benefit for small businesses is tax credits to help business owners purchase coverage. Effective immediately, these credits will ease the burden on small business owners who offer coverage but are being squeezed in the current market. For business owners who have not been able to offer insurance, the tax credits will provide a new incentive to begin covering their workers, keeping the workforce healthy and productive.

Today I have touched on just a few elements of the health care reform bill. I will be back. I have touched on insurance market reforms and provisions tailored to the needs of small businesses. But this just scratches the surface. The public option will bring much needed competition, and the incentives for high-quality care will make us all healthier. Taken together, these elements will bring our country into a new era in which high-quality and affordable health care is a reality in this country.

Passing national health care reform this year is my top priority because I have listened to Minnesotans across my State. They have told me loudly and clearly that the current health insurance system is not working for them, and they have told me they want access to care. I have heard them.

They want to know they can start a small business without worrying about the cost of health insurance because one of their kids has a preexisting condition. They want to know they will have health care when they need it the most.

They want insurance companies to prioritize health services over profits. They are looking for us to fulfill our promise to pass comprehensive health care reform this year. [Page: S11932]

I look forward to working with all of you to make this a reality.

I yield the floor.

I suggest the absence of a quorum.

2:21 PM EST

Blanche Lambert Lincoln, D-AR

Mrs. LINCOLN. Madam President, I have asked for this time today not only to address my colleagues in this body but to speak directly to my constituents at home in Arkansas. After many months of debate on health care, we are nearing yet another important step in a very deliberative process. Today we are voting on whether to continue to discuss how to improve health care in America or to stop the debate.

I personally have carried the mantle to improve health care for Arkansas throughout my public service, like many of my colleagues and so many others as well who have worked hard on this issue. Over the last several decades the advance of medical technology and our Nation's changing demographics have placed new demands on our health care system that it is not designed to meet.

Our vote later this evening is not the first step toward making the necessary adjustments in health care, nor will it be the last, without a doubt. The Finance Committee on which I serve and which is led so ably by my good friend from Montana, Chairman Baucus, has produced what I still describe as the most responsible approach to health insurance reform. We deliberated for more than 22 months, incorporating recommendations from experts all across our great Nation and proved, through

our bill, that America can achieve unprecedented health insurance reforms that expand coverage, reduce cost, and provide stability for those with existing coverage.

We accomplished these goals without posing long-term risk for taxpayers. It was not a perfect bill. We never see perfect bills around here, quite frankly, but I can honestly say I will fight hard so our final product will more closely resemble the commonsense, deficit-reducing plan we produced in the Senate Finance Committee.

At times like this I think it is very important for each of us to remember the very reasons we began this debate. Small businesses and working families are reaching the breaking point financially because of the relentless rise in health care costs. Nationally, our economic recovery will only be slowed by the inflationary cost of health care. Taxpayers and the insured are already bearing the cost of medical treatment for the uninsured at the most expensive point of delivery, in our emergency rooms.

Health care in America today is a model that waits until people get sick rather than focusing on the wellness, prevention, and good management of illness that keeps people out of the hospital and from having the most costly care needs.

Our current health care system wastes money and is so inefficient that the United States spends more than twice as much per person while insuring a smaller portion of our population than the average spending in 29 other industrialized nations. There simply are not enough health insurance options available to most Americans today when in at least 17 States, including my home State of Arkansas, only one insurance company controls more than half the insurance market, and in at least 22 States still

only two carriers control half or more of the market.

Patients and doctors are routinely making treatment decisions with little or no objective information about which treatments are more effective. American capitalism is based on choice and competition because when these elements are present, consumers can most always find the best value for their money. That is not true in health care. So by creating health insurance exchanges through which small businesses and individuals can choose from a menu of private plans, we can enhance cost transparency,

create head-to-head competition, and allow market forces to reduce prices.

These are facts. These are facts, and whether we are Republicans or Democrats or independent, I believe we can agree on most all of them. I know the great majority of Arkansans believe these facts and want to see us accomplish these reasonable goals.

For months now, groups from outside my State have assigned various motives to my deliberations on health care and tried to define the meaning of my vote. According to the last tally, there has been more than $3.3 million worth of media ads that have been purchased in my home State of Arkansas by groups from outside of our State--certainly none by me--and most with my name in the ad. Still, I have continued to approach this issue as I always do. These outside groups seem to think this is all about

my reelection. I simply don't think they know me very well.

I am focused on my opportunity to influence the final version of health care legislation in a way that most helps my State. That is why the people of Arkansas sent me here. They sent me here because they know I am going to work hard to do the best job possible and to do the right thing; to stand my ground on my principles.

I have avoided the extremist claims from the left and from the right and tried to pull the commonsense solutions from among all the policy options so that we get health care reform that benefits Arkansans and all Americans. That is our job in this body, to represent our States in this unbelievably historic body, the Senate.

The truth is, this issue is very complex. There is no easy fix, and it is imperative that we build on what is already working for health care in America and not turn away from the problems we face. We keep building until we can truly say one day that all American citizens will have access to quality and affordable health care. In order to improve upon and build upon what we already have, I do not support the creation of a so-called robust, government-administered public plan.

I believe we should work to make sure we do not expose American taxpayers and the Treasury to long-term risks that could occur over future government bailouts of a public plan. Rather than create an entirely new government-run health plan to compete with private insurers, I support health insurance reform that focuses on changing the rules of our existing employer-based private health insurance system. I believe we should change the current rules that permit insurance companies to bully their

customers and cherry-pick healthy patients, so we can force them to compete with each other.

My first loyalties are with the people of Arkansas--not insurance companies, the health care industry, or my political party. In fact, I authored an amendment during consideration of legislation in the Senate Finance Committee which limits taxpayers' subsidies for health insurance companies that pay their top executives millions in salaries. Responsible health insurance reform should ensure that insurance executives are not receiving a personal windfall, and that companies they work for are not

receiving excessive tax breaks while at the same time profiting from government requirements on consumers to buy insurance.

The reason we are having this vote is because our Republican colleagues object to beginning debate and consideration of amendments on health care legislation. Although I do not agree with everything in this bill, I have concluded that I believe it is more important that we begin this debate to improve our Nation's health care system for all Americans rather than simply dropping the issue and walk away. That is not what people sent us here to do.

Attempts by the National Republican Party and other conservative groups to portray this as a vote for or against this particular health care reform bill are untrue and deliberately misleading. The vote tonight will mark the beginning of consideration of this bill by the full Senate, not the end. Republicans have sought to revive their political party by opposing any real solution to our Nation's health care crisis. In fact, this vote for or against a procedure that allows us to begin debate on

health care reform is nothing more and nothing less. Put simply, those who vote yes on this vote believe our Nation's health care system needs reforming, and they are ready to have an honest and open debate in the Senate about how to best achieve that reform. [Page: S11933]

I

am not afraid of that debate, nor am I afraid of coming before this body to say what I believe is the most important thing we can do to reform health care. I hope none of us are. Our country needs us too desperately now to be making good decisions and moving forward.

I will not allow my decision on this vote to be dictated by pressure from my political opponents, nor the liberal interest groups from outside Arkansas that threaten me with their money and their political opposition; the multitudes of e-mails and ads we have received, unbelievable types of threats about what they are going to do and how they are going to behave. The fact is, I am serious about changing our health care system, as most Arkansans and most Americans are. I am not with those who

seek to avoid the debate, nor with those who use political attacks to achieve their narrow goals. I will vote in support of cloture on the motion to proceed to this bill.

But let me be perfectly clear. I am opposed to a new government-administered health care plan as a part of comprehensive health insurance reform, and I will not vote in favor of the proposal that has been introduced by Leader Reid as written. I, along with others, expect to have legitimate opportunities to influence the health care reform legislation that is voted on by the Senate later this year or early next year. I am also aware there will be additional procedural votes to move this

process forward that will require 60 votes prior to conclusion of the floor debate. I have already alerted the leader and my colleagues that I am prepared to vote against moving to the next stage of consideration as long as a government-run public option is included. The public option, as a part of health insurance reform, has attracted

far more attention than it deserves. While cost projections show that it may reduce costs somewhat, those projections don't take into account who pays if it fails to live up to expectations. If, in fact, premiums don't cover the cost of the public plan, it is taxpayers in this country who are faced with the burden of bailing it out.

Our colleagues cannot ignore the growth in the Federal Government since the year 2000. I can assure you that the American people have not ignored it. According to the American Institute for Economic Research, government spending grew by 55 percent under President Bush. As he was leaving office, government launched a massive bailout of Wall Street. Then it was the domestic auto manufacturing industry that needed taxpayer funds to survive. And finally, in order to revive a dying economy, it took

a government economic recovery package to save or create hundreds of thousands of jobs. We can argue about the necessity of these unprecedented steps, but we need not argue about the impression they have made on the American people. We should be stopping the growth of government, not expanding it more. Without

the public option, we could still force private insurance plans that participate in the exchanges to provide standard benefit packages that are easy to compare and more fairly priced. We will be bringing millions of new customers to the exchanges so insurers should be motivated to lower prices and be competitive.

I have pledged to dialog with Leader Reid regarding my concerns that remain about this bill. I look forward to continuing that dialog on improvements that I believe are necessary in order to meet the challenge. I will be asking my colleagues to consider these additional important changes I believe will improve our chances for real health insurance reform and that can also enjoy the support of most Arkansans and most Americans.

Some of these include that the legislation remain deficit neutral, now and in the future, and curbs future cost, that it protects Medicare beneficiaries for seniors and extends solvency of the Medicare Program, that it improves accessibility and affordability of health insurance for employees and owners of small businesses and the self-employed through access to health insurance exchanges and tax credits, that it enhance choice and competition of health insurance plans for small businesses and

individuals without the inclusion of a government-run public option, and that it build our Nation's health care workforce and ensure continued access to quality health care providers, especially in rural America.

Today I know I will ultimately be held accountable by my constituents in Arkansas for all of my votes on health care, not the National Republican Senatorial Committee, not by other groups from outside my State that continue to engage in a conversation they have begun. I know my decision to support the upcoming cloture vote on the motion to proceed is not my last nor only chance to have an impact on health care reform.

I am optimistic and encouraged about the step we are preparing to take in the Senate, to amend and craft a bill that will improve access to quality, affordable coverage options for the residents and businesses of my State who desperately need relief, a bill that improves the quality and efficiency with which we deliver health care, all without adding to our Nation's deficit and while lowering the cost of health care over the long term. I am committed to using every power of my office to achieve

success on this issue by enacting meaningful reforms that will benefit the people of Arkansas and our Nation.

I have spent the last several months in a passionate dialog with my constituents about health care reform. It was not only in townhall meetings where I heard from Arkansans. I had hundreds of conversations with many of them in groups and one-on-one conversations. They may not be in agreement about solutions, but I can assure my colleagues that each Arkansan I speak to expects us to roll up our sleeves and get this right. We can. Following the vote tonight, the bill that will be laid before us

will not be the only possible solution. I know my decision to support cloture on the motion to proceed is not my last or only chance to have an impact on overall health care reform. My strongest hope is that each of us can lay political fortunes aside and make the tough, commonsense choices our constituents expect of us, whether

you are a Democrat or Republican, and look at what we face and the challenges of our Nation. Make sure that as we are working toward an end result, that each of us is working as hard as we can to come up with a pragmatic solution that our constituents expect of us. We may not get this opportunity again in our lifetime.

Today I am thinking about the Arkansas working family who can't pay their mortgage because of their sick child's medical bills. I am thinking of the Arkansas small business owner who told me that more than 20 percent of the cost of running his business now goes to health insurance for him and his workers. I am thinking about the 450,000 Arkansans who have no health insurance. I am not thinking about my reelection, the legacy of a President, or whether Democrats or Republicans are going to claim

victory in winning the debate. I hope all of my colleagues join me in looking forward to working with the leader and all of our colleagues in the days and weeks ahead as we strive to solve a problem whose solution is long overdue.

I yield the floor.

2:40 PM EST

Carl Levin, D-MI

Mr. LEVIN. Madam President, in a few hours we will take an important step on the road to health care reform. Our vote will come after months of analysis and debate and years of growing concern on the part of our constituents that the American health care system is in need of fundamental reform. Two Senate committees have approved reform legislation. We will vote later today on whether to open debate on a third one which merges the two produced by the Senate Finance and HELP Committees. Much time

and attention has been focused on the provisions in this legislation which will expand the number of Americans who are covered by health insurance, a goal I wholeheartedly share. But a compelling reason for reform and a major reason to vote in favor of allowing the Senate to debate health care reform is the serious and worsening signs that for those Americans who have health insurance, our health care system is no longer working as it should.

Increasingly, Americans with health insurance are at catastrophic financial risk, if they get sick. Increasingly, working families with insurance are unable to afford the escalating premiums they face to maintain their [Page: S11934]

often inadequate coverage. Increasingly, businesses large and small that offer health insurance to their employees are buckling under the crushing weight of spiraling costs for their employees. Increasingly, families find that caps on

their coverage leave them exposed to devastating medical bills. And increasingly, arbitrary insurance company practices that boost their own profits are shortchanging Americans, denying coverage because of preexisting conditions, and searching for ways to deny patients the treatments they need and have paid for through their premiums.

Democrats are not alone in pointing out these problems. The Republican leader himself has said:

Every Republican in Congress supports reform.

That is the Republican leader who said that every Republican in Congress supports reform. He did not say many Republicans. He did not say most Republicans. Every single Republican in both Chambers of Congress, the Republican leader tells us, wants to reform the health care system.

How will any reform happen, reform proposed by Democrats or by Republicans or by anybody? Only when this body can bring a bill to the floor of the Senate for debate and amendment, only when we work with our colleagues in the other Chamber to resolve differences between legislation approved by the Senate and that approved by the House, only when Congress sends the President a bill he is prepared to sign into law. Speeches will not reform health care. Polls and cable television shout fests, none

of that will reform health care. We, the Members of the U.S. Congress, and we alone, can reform health care.

We must listen to constituents, advocacy groups, physicians, insurers, health care experts, economists and anyone else with constructive ideas. Ultimately, it is we who must act. To do that, we must begin to debate here on the floor of the Senate the many complex issues that must be resolved. That is all today's vote will do, give the Members of the Senate the chance to come together in a sincere effort to work together, resolve our differences, and address an issue on which there is, we are

told, even by the Republican leader, general agreement on the need for reform.

Two Senate committees have already spent months seeking the proper ways to reform the health care system. The Senate Finance Committee has held over 50 meetings on health care reform legislation in the last year. The Health, Education, Labor and Pensions Committee spent 13 days marking up its legislation.

So we have made progress. We are at least in position to do what this body was designed to do and is supposed to do: deliberate and decide.

The minority opposes the legislation we are trying to bring to the floor for debate and amendment. They say they do not like the bill. But why deny the Senate the opportunity to debate the subject of health care reform? Why prevent us from considering it? Why not offer amendments to the bill if you do not like it or offer a substitute measure for it?

There are parts of the bill in which I would like to see changes. I would like to make health insurance even more affordable for working families, and I am willing to require that those earning more than $250,000 a year, for instance, pay a higher and, in my view, more fair and more appropriate tax rate to make that greater affordability for working families possible.

Income data shows that in recent years only the wealthiest 10 percent of Americans have seen any real increases in income and that those increases are concentrated in the wealthiest 1 percent of the country, while the vast majority of Americans have lost ground. At the same time, most Americans are coping with falling income, they have been hit with massive increases in health insurance premiums. So I am willing to support an increase in upper income tax brackets to end that unfairness.

Other sources of revenue, such as ending the abuse of offshore tax havens, can and should go toward doing other things we should be doing in this bill. For instance, I am concerned that the annual fee on insurance providers contained in the merged bill would treat nonprofit and for-profit insurers the same way. Millions of Michigan residents receive their insurance from Blue Cross Blue Shield of Michigan, a nonprofit company, which is the insurer of last resort in our State, providing coverage

to residents who cannot find it elsewhere. We need to find ways to reform the insurance market without negatively impacting the not-for-profit insurance companies that are the insurers of last resort and that provide high levels of coverage in return for the premiums they collect.

On these and other issues, I will continue to study the details of the legislation, discuss them with colleagues and constituents, and I will support improvements where needed. What I will not do is vote to block efforts to reform a system that simply is not working well for those who have health insurance, as well as for those who do not.

The need for reform is generally acknowledged. How can we then not open debate? How can we not discuss, offer amendments, consider alternatives, make changes, and vote on reform legislation? That is the only path to health care reform. There is no other way. And for those who proclaim their belief in the need for reform to stand in the way of that debate is, at best, starkly inconsistent.

A vote against even opening debate is a vote in favor of the status quo, which my constituents and the vast majority of Americans can no longer afford. They can no longer afford it because it is bankrupting them, in many cases literally bankrupting them. A study this year, published in the American Journal of Medicine, found that in 2002, 62 percent of all individual bankruptcies in the United States involved medical costs.

That is a tragedy. You should not be forced into bankruptcy because you get sick. But it gets worse. Three-quarters of those bankruptcies involved people who had health insurance when they got sick. Let me repeat that. In the United States, almost two-thirds of all bankruptcies are linked to medical costs, and three-quarters of those bankruptcies occurred even though the debtor had health insurance. That is adding absurdity to tragedy and demonstrates the inadequacy of health insurance for those

who are covered.

We must act to reform a health care system so broken that it crushes Americans under a mountain of debt. One of my constituents, a Kalamazoo man, had what he thought was adequate health care coverage when 3 years ago he needed surgery to replace two sections of his aorta. But his coverage left him an out-of-pocket cost of nearly $40,000. That is the sum that stood between this man and lifesaving surgery. Financially devastated by the costs, he declared personal bankruptcy. He wrote to me:

No one should die because they cannot afford health care, and no one should go broke because they get sick.

He is right.

We must act to reform a health care system so broken that it leaves the mother of a young Michigan State University student worried that her daughter will not get the care she needs. This 24-year-old student has insurance. Yet when she began to have unexplained seizures, her coverage would not pay for all the tests needed to determine their cause. Even after declining some prescribed tests because she could not afford them, the young woman's doctors eventually discovered the cause of her seizures:

a brain tumor. This mother worries that her daughter will lose her insurance, will be forced to declare bankruptcy, and that the family will have to find some other way to cover the massive expense of her lifesaving care--all while coping with the other financial strains hitting her family and so many others. The mother writes:

We will lose too many bright young people if something is not done.

She is right.

We must reform a health care system so broken that it sent a minister from Jackson, MI, on a weeks-long odyssey to keep her insurance because she became pregnant--a joyous event for most families but apparently just another preexisting condition to insurance companies. When this expectant mother moved from a church in Massachusetts to one in southern Michigan, her new church immediately sought, for their new minister, to find her health insurance. But company after [Page: S11935]

company

declined to cover her because of her pregnancy. She and her church spent weeks researching the issue, changing insurance agents, providing document after document, pleading with insurance companies. She wrote me:

I had two volunteers, myself, and two insurance agents working on the situation constantly for over a month.

And she said:

If you have the time and energy, and some good help, and are willing to spend a month hassling with the system pretty much continuously ..... then you can sometimes, with a great deal of luck, work the system.

Reflecting on her experience, this minister writes:

It is clear to me that we are desperately in need of health care reform.

She is right.

The legislation the majority leader has brought forward will do much to ease the hardship on millions of Americans. It has benefits for those who already have insurance through their employer, with steps to rein in skyrocketing premiums and to reduce the risk of financial ruin for those who have health insurance.

In addition to helping those with private insurance, this legislation provides important benefits for seniors covered by Medicare. Medicare beneficiaries will receive free preventive care benefits, and the bill will reduce the enormous costs many seniors face when they fall into that doughnut hole, so-called, in the Medicare Part D prescription drug program. Because of these important improvements in care for seniors, AARP has recommended that Senators vote in favor of beginning debate on this

bill tonight.

The legislation also contains important provisions to improve information technology in the health care sector, pushing for uniform billing practices and developing standards that will lead to the computer systems of health care providers being able to talk to the computer systems of insurance companies, reducing mountains of paperwork and other inefficiencies that drive up health insurance premiums.

Americans who move from one employer to another will no longer face the risk of being denied coverage at their new job because of a preexisting condition.

We must allow debate to begin. If we act, millions of those who already have insurance at work will benefit. If we act, millions without insurance will get it, along with help to pay for it, so we can end the current wasteful

situation in which emergency room care--vastly more expensive than primary care through a family doctor--is used for nonemergency purposes by those without health insurance.

We can only accomplish these things if we vote today to begin debate on this legislation. We can only accomplish these things if we are willing to honestly and vigorously debate the best ways to achieve it. So I urge our colleagues not to close the doors of this Chamber to debate on one of the most urgent problems Americans face. I ask our colleagues to allow the Senate to begin deliberations on health care reform and not to turn away from the opportunity and the responsibility before us.

Madam President, I yield the floor.

2:57 PM EST

Bob Corker, R-TN

Mr. CORKER. Madam President, I know the time is slightly before the hour. I do not know if there are any Democrats who want to speak beyond the Senator from Michigan during this hour. With that, I think we are anxious to get going.

Madam President, I ask unanimous consent that the Republican speakers be permitted to enter into a colloquy during the time controlled by the minority, which I understand ends at 4 o'clock today. Is that correct?

2:57 PM EST

Bob Corker, R-TN

Mr. CORKER. Madam President, just to make sure people who may be watching the Senate floor understand what is happening, Republican Senators took all day yesterday and today to read the bill and to actually go through sections of the bill to discuss it and make sure all of us are very familiar with the various pieces of it.

I think all of us are united in concern about the way this bill is paid for. It is hard for me to believe that anybody could suggest that taking $464 billion out of Medicare, which is insolvent, would be a way to fund a new entitlement; or that pushing down an unfunded mandate to States, which we are going to talk about in just one moment, makes any sense at all--$25 billion worth; or increasing the Medicare tax, which would not be a tax to make Medicare more solvent, but instead go to a new

entitlement program--we all know Medicare is going to be insolvent by the year 2017; and to have a bill that pays for itself over 10 years by having 6 years' worth of costs against 10 years worth of revenue; and then to have something such as the CLASS Act, which I know the chairman of the Budget Committee has called a Ponzi scheme, where, in essence, you create a program that takes

in premiums over a 10-year period on a new entitlement for long-term care--another new entitlement, I might add, in addition to the one we are talking about today--it takes in those premiums but bars any money from going out for 5 years. So what you have is, in essence, a collection system that creates $72 billion. So I think all of us are very concerned about how this is funded.

But today we want to talk about our tremendous concerns with the Medicaid expansion that is taking place. I am joined by a number of Senators who have had vast experience in State government and vast experience in health care.

I think the American people have now realized this bill insures, per the CBO, 31 million additional people. But the expansion that causes that to occur is that 15 million people now will be on Medicaid who are not on Medicaid. It is the largest expansion of Medicaid in U.S. history.

What we are doing to make sure this works budgetarily is we are forcing States to pick up the tab. I got an e-mail last night from my State--and I know other States are going to be talking about that, or people from other States. But last night, the State sent me an e-mail and said this was going to cost our State almost $800 million.

Our State has been well governed for years. The senior Senator from Tennessee was Governor in the middle-eighties. We have had both Republicans and Democrats who have governed our State very well. In our State, we do not expect our revenues to be back to 2008 levels until 2013. So you can imagine that our Governor, who is on the other side of the aisle, is very concerned about us here in Washington saying he has to expand his Medicaid Program. We are going to expand it around the country by 15

million people, and he has to pay for it. He is more than upset about that particular issue.

I know people here in Washington--the Washington establishment--generally speaking, are upset about the fact that States actually balance their budgets.

We don't do that here, but in order to show almost disrespect for the way our States, in most cases, have to balance their budgets, what we are saying is we are going to make it more difficult on them by making sure that in order to reach a goal, we force our States, through an unfunded mandate, to cover an additional 15 million people under their Medicaid programs.

Let me just mention that I thought we were actually going to do health care reform. I know there is probably a lot of laughter taking place in the halls of this building today because I thought when we talked about health care reform, that is what we were going to do.

We know Medicaid is one of the worst programs that ever existed as it relates to health care. Let me just mention a couple stats. The Cancer Journal published that Medicaid recipients were two to three times more likely to die from the disease than people who were not on Medicaid. The American College of Cardiology in 2005 said Medicaid patients were almost 50 percent more likely to die after coronary artery bypass surgery than patients on Medicare or private pay. Forty percent of physicians

in our country don't even take Medicaid. In urban areas, 50 percent of specialists have blocked patients from entering their program.

So I wish to say just this and then I will stop because I want to hear from other colleagues who have been around here for awhile. But when I was back home during August, citizen after citizen said to me: I know we are going to have health care reform. What I would like is just to have what you, Senator, [Page: S11936]

have. That is what I would like to have. I know Senator Burr worked on a bill that would do that. It would create the ability for people to

participate, as we do, in choice. I know Senator Alexander worked with Senator Wyden and others, and I worked with Senator Burr in the first Congress to create legislation that did that. As a matter of fact, Senator Wyden,

from the other side of the aisle, created a bill that did away with Medicaid. It gave Medicaid recipients the same kind of choice that we in the Senate have. But it seems to me, Senator Reid's bill goes in exactly the opposite direction.

What it does, in order to add 31 million people to the rolls, 15 million people are being forced into Medicaid. So I would think, then, that in order to make sure we are treated just like our citizens, one of the first votes we might take is that we agree, as Senators, to be treated the way the majority of people in this program are being treated, and I assume that going on Medicaid with those same results for our families would be something we would embrace. I think all of us heard from citizens

across this country that they want the same choices we have. But in the name of reform, we are going in the opposite way and, again, locking them into nonchoices, nonphysicians, bad outcomes, and going in exactly the wrong way we should be going and, to boot, making States pay for it.

There is one class of people, though, who are not treated that way in this bill. I have tremendous respect for those immigrants who have come into our country in a legal way. Let me make sure people understand that. Sometimes my southern drawl confuses people. I have tremendous respect for people who have come into this country in a legal way. The Reid bill does this. He respects them too. What the Reid bill says is, if you are born in America and you are from 100 to 133 percent of poverty, then

you are barred from receiving a subsidy and are forced to be on Medicaid, but if you come into this country as a legal immigrant, you actually can receive a subsidy to purchase a private insurance policy. I find that most interesting. I don't know if some of my other colleagues--I know Senator Burr has spent a lot of time on this.

I find this reform very troubling. I know the Senator has worked hard to give Medicaid recipients the same choice as we have. I don't know how you feel about the reform that is before us.

3:05 PM EST

Richard Burr, R-NC

Mr. BURR. I thank my colleague from Tennessee. I think it is important, throughout this education of the American people of what is in 2,074 pages, to remind them that for every word in here, it costs the American taxpayer $6.8 million; for every page, $1.2 billion.

I think one has to look a little further at this reform aspect. Does this bill truly reform health care? I think as you read through the bill what you find are the words ``require,'' ``must,'' or ``shall'' 4,677 times. You find the words ``tax,'' ``fee,'' or ``revenue'' 899 times. You find the word ``agency,'' ``department,'' ``bureau,'' ``commission,'' or ``panel'' 470 times. But we are told this bill does reform health care. We are told it increases competition, it provides more choice, it

stimulates innovation. Yet we find the word ``choice'' 40 times. We find the word ``innovation'' 25 times. We find the word ``competition'' 13 times.

I suspect their intent is to fix what they haven't reformed by allowing the Secretary of Health and Human Services, in 1,677 spots, to define or determine what congressional intent was. Think about that. This bill basically turns over a lot of the decisionmaking to the current or future Secretaries of Health and Human Services to decide what we meant in the Congress.

Well, my good friend from Tennessee raised a lot of things on Medicaid, and I wish to talk about Medicaid, but I also wish to mention that, once again, we are paying for this by cutting $464 billion from our Nation's seniors. That is a trust fund. They have paid in premiums. Similar to the CLASS Act--it shouldn't be a surprise to us that they are going to steal money out of the CLASS Act that hasn't even been created yet because in the bill it is taking $464 billion from seniors who have paid

into it for a lifetime, and within that group of seniors, 11 million seniors are going to have their benefits cut because they chose Medicare Advantage as their preferred insurance product. It is not a question of whether they can keep what they have; they can't keep it because their benefits are going to be cut, and that affects America's low-income seniors the most.

As a matter of fact, in this bill, we fix doctor payments for 1 year. So, in 2011, doctors' reimbursements are going to be cut 23 percent. I see Dr. Barrasso on the floor. So we know more doctors are going to stop covering Medicare beneficiaries. The pool is going to get smaller. We are going to affect every senior's health.

3:08 PM EST

Bob Corker, R-TN

Mr. CORKER. In essence, Medicare will become more similar to Medicaid because of this bill. Less physicians will be covering Medicare recipients because this bill, instead of using the $464 billion to make sure physicians are paid, will leverage a new entitlement. So my assumption is, this program, unless something else happens, will become more similar to Medicaid. Medicare will become similar to Medicaid.

3:09 PM EST

Richard Burr, R-NC

Mr. BURR. The Senator from Tennessee is 100 percent correct. Today, 40 percent of our Nation's physicians under Medicaid will not see patients because the reimbursements are so low.

Reform in health care means you have to eliminate cost shifting. As Dr. Barrasso knows, cost shifting means when somebody goes in for a service, gets health care delivered, and doesn't pay or somebody goes in who is underinsured, gets delivered a service, and their reimbursement doesn't sufficiently meet the needs of the cost of that service delivered. But it doesn't stop there. Medicaid reimburses at 72 cents of every dollar of service provided. Today, for every Medicaid beneficiary

in America, every time they receive a service from a doctor, a hospital, or wherever, 28 cents is shifted over to the private side to those who pay out of pocket, to those who have private insurance.

If you are reforming health care, you can't reform health care without eliminating cost shifting. Yet in this plan, we increase the rolls of Medicaid by 15 million individuals. In essence, what that means is we are going to have cost shifting on steroids now. We are going to have more cost shifting than we had before, which means a higher inflation rate on private health care, that which we pay out of pocket or that which employers, in fact, provide for their employees.

As a matter of fact, incorporated in this bill is a disincentive for small business success. I am not sure everybody has read to that point in the bill yet, but for a company that today can't afford, because of their competition to offer health care--the day they hire their 51st employee, the Federal Government will send them a tax bill of $38,250. At a time when we have 10.2 percent unemployment, 11 percent in North Carolina, small business is going to be the engine of job creation in this country,

and we are saying as soon as you are successful enough that you hire the 51st person, if you don't offer the health care we tell you you have to offer, we are going to send you a tax bill of $38,250.

Unfortunately, it doesn't stop there. For the Medicaid beneficiaries, for the Medicare beneficiaries, for everybody in America where we have said drugs are too high, devices are expensive, innovation costs money, what are we going to do? We are going to tax drug companies. We are going to tax medical device companies. We are going to actually raise the cost of our ability to detect something earlier, where our options are greater and, hopefully, through having those options earlier, in fact,

we are going to be able to treat a disease or cure it much cheaper.

I might add it is somewhat ironic that we are going to tax vaccines at a time when the industry is trying to meet the needs for vaccines for H1N1 across this country. This bill puts a new tax on the vaccine industry we have tried to revitalize in America.

Let me suggest to my colleagues, this is not a health care bill. This is a layaway plan. In fact, what we have been presented is a plan where they are asking Americans to pay for it for a number of years--4, to be exact--before they get their product. We are going to pay in, in taxes; we are going to pay in, in Medicare shift; we are going to begin to increase the rolls in Medicaid, to wait 4 years down the road before we get the product, before we get any benefit out of it. What we are going

to find [Page: S11937]

4 years down the road is that costs change. You see, it sold as a $849 billion plan today, an $849 billion health care reform package. Well, that is not what it is. If you look at it truly over 10 years, it is a $1.2 trillion plan. If you wait to start until the benefits are paid and look at it for a real 10 years of revenue and benefits, it is a $2.5 trillion plan.

We can't even be honest enough with the American people that we tell them exactly what it is going to cost. But you would expect that out of a layaway plan, and, in fact, that is what we have in front of us.

Let me suggest to my colleagues that if you reform health care, you can have coverage expansion without additional taxpayer investment. You can't take the things that are broken in our system and actually increase their use, such as Medicaid, and expect at the end of the day you are going to be able to save money, provide a better level of care; more importantly, that you are going to have a population that gets the benefits everybody else does: a medical home, preventive care, chronic disease

management. It doesn't happen in Medicaid today. It will not happen when you increase the rolls of Medicaid. It will only happen when you reform health care, and this bill does not do it.

I thank my colleague from Tennessee.

3:14 PM EST

Bob Corker, R-TN

Mr. CORKER. Our colleague from North Carolina has worked extensively on this issue. I think we have a couple Senators who have some business off the floor that is very important. I think Senator Barrasso may be one of those, and I think Senator Johanns is in the same boat. I know as a physician, the Senator actually knows something about health care.

3:14 PM EST

John A. Barrasso M.D., R-WY

Mr. BARRASSO. Twenty-five years taking care of families and the people of Wyoming. I have taken care of people on Medicaid and Medicare. We heard from Senator Burr about North Carolina and Medicaid as well as Medicare and I have concerns about both. I take care of all patients, regardless of their ability to pay. So what we know right now is that the Mayo Clinic--and the Mayo Clinic in Rochester, MN, has been held up in the Senate by our colleagues. It has been held up by the President

of the United States as the model for what we should try to get to do in America for health care. The Mayo Clinic has now told Medicare and Medicaid patients they are not welcome. It has put out the sign: No vacancies for you. It is astonishing. It is hard to believe the Mayo Clinic would say: No thank you, we don't want you, but they have done that.

3:15 PM EST

Bob Corker, R-TN

Mr. CORKER. So I guess if you had Medicaid, it is kind of like, in many cases, you have something that is not usable; is that correct? I know Senator Alexander has spoken to an analogy in the past in that regard, but it makes it pretty difficult if you are a Medicaid recipient.

3:16 PM EST

John A. Barrasso M.D., R-WY

Mr. BARRASSO. As the senior Senator from Tennessee said, it is like having a bus ticket when no bus is coming. Others commented in the paper that it is like putting more people into a sinking ship.

Why would the renowned Mayo Clinic not want to see these patients? They are sending out letters saying if you are from these surrounding States--Wyoming and others in the Midwest and the Rocky Mountain West send many patients there--you cannot do it. The Mayo Clinic is able to provide the kind of care they do because they take very few Medicaid patients, they take very few Medicare patients, and they take people who have insurance. That is why we know premiums go up when more people are on Medicaid.

There are actually two hospitals in Rochester, MN--Mayo Clinic, where 5 percent of their patients are on Medicaid. At the neighbor hospital in the same community, it is 29 percent of their patients.

The hospitals in Tennessee cannot take everybody out of town. We have to take care of those people. When reimbursement is so low by the Federal Government, which is the biggest deadbeat payer in the world when it comes to health care--the deadbeat Federal Government pays so little, the Mayo Clinic wants nothing to do with them. That is why they came out against these proposals.

Harvard Medical School gave these proposals a failing grade and said people who support these are collectively in denial, because they know we are looking at a health care bill that will raise the cost of care, to be paid for by raising taxes and cutting Medicare for seniors. Our seniors on Medicare cannot even get into the Mayo Clinic. It is fascinating. Mayo set up a branch in Arizona. They say they will no longer accept Medicare for patients seeking primary care at its facility in Arizona:

We don't want them. No vacancies for you. If you want to come in, you have to pay additional fees--a $250 annual fee plus anywhere from $174 to $400 a visit if you are on Medicare.

3:18 PM EST

Bob Corker, R-TN

Mr. CORKER. I assume that by the Reid plan taking $464 billion out of Medicare savings and not using that money to deal with this huge doc fix issue--the fact that physicians are going to have a 23-percent cut in a year, they are not dealing with that. I know it costs about $247 billion to keep them whole. I assume that would keep many physicians, such as the Senator's former colleagues from--it would cause them to drop Medicare recipients, is that correct?

(Mr. LEVIN assumed the Chair.)

3:18 PM EST

John A. Barrasso M.D., R-WY

Mr. BARRASSO. It will absolutely prevent new Medicare and Medicaid patients from getting in. The Medicare cuts will prevent doctors from taking new patients and may cause them to drop others. The concerns are so large, and the concerns aren't just for the doctors. I am concerned for the people in Wyoming, who depend upon Medicare for health care. I know the Senator is concerned for them in Tennessee. How will they get the care they need? More people are coming of Medicare age every day.

This big bill, this monstrosity, will cut close to $500 billion from people who depend on Medicare for their care. The American people--those watching--need this care. But this takes it away to start a whole new government program. It is not fixing the program that is going broke already.

So the hard reality is--and I think the spokesperson for the Mayo Clinic said it well. She said that ``it simply is the reality of the health care business and how we are going to be able to continue our mission when these payments are so far below what it costs to provide the care.''

You are not even talking about staying open, keeping the doors open, breaking even. The reimbursements are so far below what it even costs the Mayo Clinic--the model being held up by Senators on the other side of the aisle--so far below what it costs them to provide care. So as we look at this and say how can we take care of and help the people of America get health care, quality care, what we need to do is be aimed at driving down the cost of care. This means an increase of the cost of care

and premiums. They are going to do it by raising taxes, and everybody will be affected. The Senator from North Carolina, a State with an incredible background in technology and advances in medical devices--anything that taxes them will be passed on to everybody, regardless of income level. Every patient in America will suffer. The Mayo Clinic--the world-renowned Mayo Clinic, where anybody in America would like to go for their care--I heard

the Senator from Tennessee say, in addition to what the Senator from North Carolina said, that people in his State want to have the same level of care you would have. We would all want that. The Mayo Clinic says if you are on Medicare or Medicaid, like many of the other States, don't come here, because we cannot afford to have you, because Washington--the biggest deadbeat payer of all time--isn't paying enough to keep our doors open.

3:22 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. I thank Senator Corker on behalf of not only myself [Page: S11938]

but the folks back home in Nebraska for giving me a few minutes today, and I also thank Dr. Barrasso. When he talks, I want to listen. I am so tempted to yield my time to him because he is so knowledgeable in this area. I do have a few things I want to say.

It occurs to me that after the vote tonight, what we should do is declare a recess for 2 weeks. We should take this bill out across our States and listen to the people. We should listen to the doctors, like Dr. Barrasso, who are on the front lines every day. We should listen to the nurses and hospital administrators and say: What do you think? I think we would get an earful.

I did four townhall meetings during the short recess around Veterans Day on health care issues. I have been all over the State of Nebraska. Let me tell you a story--and every single Senator can tell this same story. I visited a small hospital in our State, the critical access hospital--and Dr. Barrasso is familiar with these. Under Federal law, these hospitals are 25 beds or under. They are in our small communities, not only in Nebraska but all across America. They have no margin for

error, because all they do is hospital services. They don't have an exercise program or whatever. It is hospital care they provide. I asked the same questions to those doctors and administrators. I would say: Let me ask you, first, could you run this hospital and keep it open on Medicaid reimbursements? It was 100 percent unanimous: We would go broke.

I asked a second question: Could you keep this hospital open on Medicaid and Medicare reimbursements? It was 100 percent unanimous. They say: No, we would go broke.

What does this bill do? It expands Medicaid. Fifteen million people will be added to Medicaid--the largest single expansion in Medicaid in the program's history. Nearly half of the reduction of the uninsured in this bill is due to moving people onto Medicaid, a program that if you had to live on those reimbursements, and you were a critical access hospital, you would close your doors. That is shocking to me. Who were they listening to when they wrote this bill? Why can't we take these staff people,

who have been holed up in the majority leader's office for 6 weeks, to Nebraska or Wyoming or Oklahoma or Tennessee or Texas? It makes no sense to me.

I came here saying I was going to work to solve real problems for real people. We say that a lot out there. Let me give you a real people perspective about my State. Again, every Senator can tell this story. I was in a beautiful little community hospital--a critical access hospital, with 25 beds or less--in Valentine, NE, in a beautiful part of our State along the northern tier. It is a beautiful area, the Niobrara River Valley. There are great people there. It is off the interstate. It is a

beautiful part of our country. Pick up a Nebraska map, because when I say this--if you look at the map, it will bring home what I am talking about. Between Chadron, NE, in the northwest part of the State, and O'Neill, NE, closer to the north central part of the State, lies Valentine. That little hospital in Valentine is the only hospital in that northern area that is providing deliveries for babies.

When you pass this bill and you expand Medicaid that they can't live on, and the reimbursement rates are disastrous for them--if you mess around with that hospital's ability to deliver babies, you have a crisis in the northern part of my State. You can tell that story over and over.

I wanted to talk about this last thing, and I will do it quickly, because other colleagues want to speak. As a former Governor, I dealt with Medicaid to try to balance the budget. I was the Governor in Nebraska post-9/11, when our economy and the Nation's economy tanked. We had to cut budgets over and over. My State of Nebraska just finished a special session. They cut about $300 million from the State budget. Four hundred people, the Associated Press reported, will lose their jobs because of

these very difficult budget decisions.

Here is the point I want to make: When this is fully in effect, we will drop into the States--my State included--billions of dollars worth of unfunded mandates for Medicaid--billions of dollars in a program where already 35 to 40 percent of our doctors cannot afford to take Medicaid patients, and they are saying: We would go broke if we had to. We are adding insult to injury by telling our Governors they have to figure out that in addition to the historic problems they are having with their budgets,

they have to deal with an unfunded mandate. In a moment of candor, one of my colleagues who worked on this for years said something when I asked: Why Medicaid? It is so problematic. Why all these millions on Medicaid? In a moment of candor he said to me: Because it makes the score look better.

3:28 PM EST

Bob Corker, R-TN

Mr. CORKER. Yes, it is the cheapest route for us and the most expensive way for the States. This has been mostly about moving money around. I have not seen a lot in here that has a lot to do with reform. I appreciate the comments about Medicaid and what it will do to your State. After having been a Governor, I know that Dr. Coburn, the Senator from Oklahoma, is here, and we have the Senator from Texas, who has been highly involved in every health care meeting we have had. Senator Hatch

helped create SCHIP years ago. I think he knows that in this bill not only is there an unfunded mandate for Medicaid, not only are there taxes and Ponzi schemes, such as the CLASS Act, that have been put together, it doesn't fund an existing program such as SCHIP. That is another huge burden of $40 billion or $50 billion. I don't know if Senator Alexander wants to speak to that. I thank Senator Johanns for being here. I know he has a meeting off the floor.

3:29 PM EST

John Cornyn, R-TX

Mr. CORNYN. I express my gratitude to the Senator from Tennessee for leading this important discussion on Medicaid. If I can pull back for a moment, I think it is important because this is such a complex subject, as we can see from this 2,074-page bill. We need to define our terms. Medicaid, obviously, is a program for low-income people, shared by our State and Federal Governments. Medicare is for seniors, paid for entirely by the Federal trust fund, $38 trillion in unfunded federal liabilities

to two entitlement programs, both of which are in terrible financial shape. Rather than make this better, this bill makes it worse. I will describe very quickly how in my State of Texas. I have watched on C-SPAN and on the floor Senators come here and say tonight we are having merely a procedural vote on whether to proceed to the debate.

I thought we had been having a debate about health care reform for the last year or so. I point out that under the Senate rules, we will not be able to change one period, one comma, one sentence, one part of this bill unless we can get 60 votes to do so. So the increase in premiums, the taxes on small businesses and the middle class, the cuts in Medicare, this expansion of Medicaid--all of these are a fait accompli unless 60 Senators vote to change it. That is under the rules of the Senate.

It is not true, in my humble opinion, that people can come in here and say: We are going to vote yes to proceed tonight at 8 o'clock, but it doesn't make any difference, the debate is just beginning. Not so.

I again thank the Senator from Tennessee for raising this concern. Both of our Tennessee colleagues have been in the forefront of discussing this issue.

I think this is shameful. The expansion of Medicaid in this bill to cover 60 million Americans is shameful. It consigns people to a health care gulag which they cannot get out of, where they get bad outcomes in terms of their health care, where they cannot find doctors who will treat them at the low rates paid for by Medicaid, and it bankrupts our States.

The Medicaid officials in Texas have told me, after their preliminary review of this 2,074-page bill, it will cost Texas taxpayers, in addition to their Federal liability, $20 billion over the next 10 years.

Our friends who have been Governors have told us, as Governors and as State legislators, they have to make terribly hard choices. But when the Federal Government imposes an unfunded mandate on the States to pick up $20 billion over the next 10 years, what does that do to our ability to do other things, such as law enforcement, higher education, and the like? It shoves those to the side because the Federal [Page: S11939]

Government is going to jam this down the States'

throats--another unfunded mandate--and it disrupts those States, as the Senator says, that are operating on balanced budgets. They do not have the luxury of printing money like the Federal Government.

3:33 PM EST

Bob Corker, R-TN

Mr. CORKER. Mr. President, did the Senator from Texas see this weekend where college students in California were having public protests about the huge increase in tuition out there? Yet here we are getting ready to pass something that is going to drive that up even more because the State of California will have to cover more Medicaid recipients without the money being provided. So this is going to exacerbate that situation. I don't know if the Senator saw it this weekend.

3:33 PM EST

John Cornyn, R-TX

Mr. CORNYN. The Senator is correct. It is a 32-percent increase in fees and tuition, and that is in California alone, which is bankrupt already. This is the direct result of the irresponsibility coming out of Washington, DC, forcing more costs on them.

I know there are other colleagues who want to talk about this topic, and I want to have this continued conversation. I think this is a good format for parsing what is in this bill.

Let me mention one anecdote in Dallas, TX. If you are a Medicaid recipient, or a low-income child or beneficiary in Dallas, TX, only 38.6 percent of the doctors will see a new Medicaid patient--38.6 percent. In other words, 61 percent will have restricted access to Medicaid because, as the Senator from Tennessee and the Senator from Wyoming pointed out, it only pays about 72 percent of what a private insurance policy would cover.

Mr. President, 85 percent of Americans have private insurance, and they pretty much like what they have. They think it costs too much, and we agree. We want to help them bring down that cost. But we have these safety net programs which, frankly, do a lousy job. They promise coverage, but they deny access because of low reimbursement rates.

Let me give an anecdote of what this means to 6-year-old Ruth Guerra in Dallas, TX. I took this article from the Dallas Morning News, dated June 3. It says:

When Ruth Guerra, 6, tries to write, holding the pencil puts just enough pressure on her left pinky to make it bleed. With her condition, if she falls down while playing or a classmate accidentally brushes against her, she bleeds.

Last week [her mother] Sandra Ramirez ..... took time off from her hourly job at the Dollar General after another one of Ruth's bleeding episodes.

Unfortunately, because she qualifies for Medicaid--and while people in Washington say: Isn't it great; we are going to give 60 million people Medicaid--what it means for Ruth Guerra is that she has to wait 6 months to get an appointment with a doctor who will actually see her. That is what I mean when I say this bill consigns 60 million people to a health care gulag they cannot get out of.

I agree with the Senator from Tennessee. We need to provide the American people with choices that Members of Congress have, among an array of choices. What this does with the mandates, with the force-feeding Medicaid on people such as Ruth Guerra and on the States, along with the huge budget deficits that are going to come from it is shameful.

3:36 PM EST

Bob Corker, R-TN

Mr. CORKER. I thank the Senator for his contributions, being down here on a Saturday on a very important issue. I know Senator Coburn is here. Senator Alexander is here. I don't know what order they may want to speak. It looks like it is Dr. Coburn.

Again, each Monday, typically in his State, he is actually seeing patients. He knows something about Medicaid. He knows something about health care. Many of the reforms he put forth would give people a choice, low-income citizens a choice like we have. But, instead, this bill confines them to Medicaid. I know he is going to talk about that.

I thank the doctor very much for being here.

3:37 PM EST

Tom Coburn, R-OK

Mr. COBURN. Mr. President, I thank Senator Corker.

I have had the distinct pleasure of delivering over 2,500 babies for Medicaid insurance and taking care of their children. These are wonderful folks. I didn't do any differential between Medicaid and private insurance in my practice, but most of my colleagues did.

The heartbreaking part about Medicaid is that when you have a sick child who needs a specialist, you cannot get one. You just cannot get one. You say: Why can't you? Do they not care? Yes, they care. But you know what. Because of the Medicaid reimbursement for pediatric subspecialities--pediatric cardiologists, pediatric oncologists, pediatric hematologists--there are not any.

We only have two pediatric cardiologists in the city of Tulsa serving 1.9 million people. Try to get an appointment for a Medicaid patient there. I can hardly get a regular one. How did that happen? The reason we have a shortage of pediatric subspecialities is directly related to the Medicaid system in this country because the reimbursement is so low that you cannot afford to have a high percentage of Medicaid patients in your practice and still pay your bills.

So what consequently has happened is doctors do not go into pediatrics, and then they do not go into the subspecialities of pediatrics. So I end up having 8-month-old children seen by adult cardiologists or adult hematologists because there is no available doctor to see them because we have created a system through the substandard reimbursement of Medicaid that has directed people coming out of medical school away from that speciality.

As a matter of fact, last year, if you take all the

medical students who graduated from medical college, whether it is osteopaths or allopaths, M.D.s or D.O.s, 1 in 50 went into primary care. That is general internal medicine, family practice, or pediatrics, only 1 in 50.

We have 50 million baby boomers going to hit Medicare in the next 7 1/2 years, and we are not going to have the primary care doctors there to take care of them. The reason is because through government programs, we have incentivized doctors not to do primary care. Consequently, we don't get there.

The other point I will tell you is that if you look at perinatal mortality rates in our population across the country, it is, No. 1, directly related more to poverty than it is to anything else. But the second most important factor is that if you are in Medicaid, you are twice as likely to have a perinatal mortality event--in other words, your child dies after childbirth--than if you are in private insurance. It doesn't matter what your culture is. If you are poor, but you have private insurance,

the likelihood your baby is going to do better is greater.

Think about that: a promise we are going to give you care, but the result of the care is going to be less good. We are going to give you care, but it is not as good care, and it is not available care. We are going to make you wait in line, but we are going to call it care.

Care delayed is care denied. Let me say that again. Care delayed is care denied. If, in fact, you have a problem that needs attention, and you cannot get what you need, it does not matter what Medicaid does if you cannot get treatment.

If you look at the subspecialities in Medicaid, 65 percent of them do not see Medicaid patients. We have about 40 percent in primary care who will not see a Medicaid patient. We have about 65 percent of the specialities, because there is such a shortage in the specialities, that what we are saying is we are going to have 60 million people in a system that says: You get care, but guess what. It is not available; you are on Medicaid.

Senator Wyden did offer a plan, I say to Senator Corker, that would put every Medicaid patient in this country, except dual eligibles, into private insurance. So did we with the Patients' Choice Act, the first bill introduced on our side of the aisle. We take the stigma off saying you have a low-paying plan, and we give them the same kind of insurance we have right here in this body. By doing it, we save the States $1 trillion over the next 10 years. Think about that.

But that isn't nearly as important as we have a major increase in the positive outcomes for Medicaid patients. You cannot talk about Medicaid without talking about Indian health care because as you add up Medicaid to Medicare to TRICARE to VA to Indian health care, when you add all that up, the government is running 61 percent of our health care right now. No wonder we are in trouble.

I do not deny there are big problems with the insurance industry. I do not [Page: S11940]

deny we need a Patients' Bill of Rights that protects people's rights and their interests. I do not deny we need transparency in the insurance industry both on price and quality. I do not deny anything.

The question we ought to ask is, if we are going to truly reform health care, are we going to allow everybody, when they say they have health care, no matter where they get it, to have an equal shot at getting equal care?

You see, this bill does not do that. This bill puts Medicaid patients in jail and says: If you happen to be lucky enough, the lucky 60 percent to get into the line, you will be OK. And if you need a subspecialty, if you happen to be part of the lucky 35 percent, you will be OK. But everybody else is in jail. You are in monopoly jail. We are promising--the government--to do that.

A final point--and then I will yield so others can talk--is the idea that my State--Texas is a big State. It is our southern neighbor. They sometimes have a better football team than we do. They certainly did this year. We are about one-eighth the size of Texas in terms of population. We cannot afford $2.8 billion over the next 10 years, I say to Senator Cornyn. We are going to say we are going to cover 15 million people and some of those will be in Oklahoma. We cannot afford it.

What we can afford is to insure them if we make true changes in care, if we truly change and incentivize preventive care, management of chronic disease--if we truly reform health care. These bills do not reform health care. What they do is grow government.

They are not going to change outcomes, other than except they are going to limit what you can and cannot do through cost-effective comparativeness.

As we look at this bill, what we need to do is think about those we are going to promise something we are not going to deliver. We are going to call it a system, but they are not going to have it available.

I thank Senator Corker for leading this discussion, and I yield.

3:46 PM EST

Bob Corker, R-TN

Mr. CORKER. I thank Dr. Coburn. As I listen to him, I realize we have a health care reform bill before us where half the money, $460 billion, is taken from a program that is insolvent. Instead of making it more solvent--a program that would take $38.6 trillion in the bank today, earning Treasury rates to make it solvent--it is a pretty big number--we are taking $ 1/2 trillion out of that program to leverage a new entitlement. The reform we are getting out of that is we are moving half

the folks into a program that not a person in this body would want to be a part of; is that correct?

3:46 PM EST

Bob Corker, R-TN

Mr. CORKER. That is not the kind of health care reform I thought we were going to be doing. I am shocked. As a matter of fact, as I said many times, I don't think there is a person on the other side of the aisle who would vote for this bill if you and I offered it; do you think that?

3:47 PM EST

Tom Coburn, R-OK

Mr. COBURN. Probably not. But the Senator sparks one question. Think about this, and I have experienced this as a physician.

I care for patients and they lose their job, they have a financial catastrophe, and all of a sudden they become dependent on Medicaid. We continue to see those patients. But do you know what normally happens? You lose your insurance, you loss your job, you come on hard times and go on Medicaid. You can't go back to the doctor you had before because they are not taking new Medicaid patients. So somebody you have been with for 15 years, all of a sudden you can't get back in because they are not

going to pay enough for them to care for you. It is a discriminatory system that says we will send you down the line.

That doesn't mean there are not truly caring physicians in this country, but it has to be said, outside of pediatrics, if you want to look at quality parameters, the Medicaid population ends up going to the less-qualified, the less-experienced, the less-good-outcome physicians in this country.

3:48 PM EST

Bob Corker, R-TN

Mr. CORKER. I thank the doctor. It is so good to hear from somebody who has dealt, year after year, with Medicaid recipients with his compassion.

Senator Hatch from Utah, I don't think there is a person in this body on this side of the aisle who has spent more time trying to make sure the poor children of our country have health care. No one has done that. I know he is here to speak today about this huge Medicaid expansion. I thank the Senator for the leadership he has shown in this body for years, ensuring that young children in this country have appropriate health care.

3:48 PM EST

Orrin Hatch, R-UT

Mr. HATCH. I thank my colleague for leading out here, talking about this very important issue. You and your senior colleague from Tennessee are great Senators and mean a lot to all of us.

It is funny to me that the people in this body don't listen to the only two doctors in the body, and both of them are excellent physicians. Both of them are concerned about people. Both of them make such cogent arguments in the field of health care. I think we have had a very good argument by Senator Coburn, from Oklahoma--one of our two doctors in the Senate.

Senator Barrasso is an orthopedist, a specialist. He has come here to fight for the causes he believes to be right. He knows what is trying to be put off on America today is not right.

Our States are facing a historic deficit of more than $200 billion right now. Yes; that is what our States are facing right now without this bill. One of the biggest drivers behind this is the Medicaid Program, which takes up an increasing share of our States' budgets across the country.

The Senate bill, which is nothing more than a 2,074-page takeover by Washington of our health care system, calls for the biggest Medicaid expansion ever--133 percent of the Federal poverty level. That is 150 percent in the House bill, if we pass that monstrosity.

My home State of Utah only allows Medicaid coverage of up to 133 percent of the Federal poverty level for infants, children under the age of 5, and pregnant women. Other categories of citizens are, however, covered at different levels. For example, nonworking parents are only covered up to 48 percent of the Federal poverty level.

This bill will now massively expand the level of Medicaid coverage to 133 percent for everyone. Who is going to pay for that? Our colleagues say the Federal Government will. What are they going to pay for it with? We are running the Federal Government right into bankruptcy. It is ultimately going to be the responsibility of the States and the States can't do it. Think of New York, New Jersey, California, just to mention three. Let's not forget that the House has already passed a Medicaid expansion

of 150 percent of the Federal poverty level. The Congressional Budget Office estimates this massive entitlement expansion will cost States an additional $25 billion over the next 10 years.

You heard me right, $25 billion more. That is over the next 10 years.

However, if history has taught us anything about the way things work in Washington, I believe this number is actually a huge underestimation and the real impact on our States will be much higher. I would like to read the following excerpt from a letter sent to me by Governor Herbert, our Governor in the great State of Utah, and what this Medicaid expansion would mean for my State. It is a quote. This is what my Governor has to say:

As I am sure you know, Utah, like most other states, is suffering from the negative impacts of nationwide recession. As we prepare the state's fiscal year 2011 budget, we face continued cuts to agency budgets and reduced government services on top of painful reductions made last year. The unfunded mandate of a forced Medicaid expansion will only exacerbate an already dire situation. If required to increase our Medicaid program as envisioned in Washington, Utah, and most every other state, will

be forced to find the money to do so through other means. This will require states to either raise taxes or continue to cut budgets in areas currently suffering from a lack of funding, such as public and higher education.

We are seeing a real life example of this in California right now. Faced with a mounting State budget crises, we recently saw that the State-run University of California system had to hike its tuition rates by 32 percent--32 percent!

I don't know about anyone else, but I will not allow this to happen in my home State of Utah just because Washington thinks it is a good idea to keep expanding government programs on the back of our States.

Here is the reality that our States are facing: [Page: S11941]

Unemployment rates rose in 29 States in October. A significant number of States are facing unemployment rates much, much higher than our national rate of 10.2 percent--the highest in 26 years: Michigan, 15.2 percent; Nevada, 13 percent; Rhode Island, 12.9 percent; California, 12.5 percent. In fact, California, Florida, Delaware and Washington, DC, posted their highest unemployment rates since 1976.

The last thing we need right now is for Washington to impose more liability on the states.

This alone should be a reason enough for every Senator to stop and rethink their decision about letting this ``tax and spend'' bill move forward.

But I have to tell you, I know what is behind all this. Ever since I have been here, there has been a push to have more and more people moved into Medicaid. Why is that? Because if they can push more and more people into Medicaid, then ultimately we will have a single-payer system--in other words, socialized medicine in this country, where the government will control everything. That is what is behind a lot of this bill.

I have to tell you, what bothered me an awful lot about this bill is that even the CBO Director, whom I find to be an honorable, honest man, Dr. Elmendorf, he said that if we go to a government plan--which is a hallmark of what our friends on the other side want to do--then you could have almost 10 million people going into that plan. However, if you look at the Lewin Group study, they say if you go to a government plan, we could have 119.1 million people going into the new plan.

What is it going to be, the 10 million or the 119.1 million? I guarantee it is going to be a lot closer to the 119.1 million than it will be to the 10 million.

Our friends on the other side started criticizing the Lewin Group after this report. They have quoted them for years before this report. Now that they don't agree with our colleagues on the other side, they think it will only be 10 million. Don't kid yourselves. If you had to choose between the 10 and the 119 million, you know doggone well it will be closer to the 119.

If we move millions of more people over from private insurance into government health care, I can't tell you the pressure that will be on America, the pressure that will be on the health care professionals.

We heard from one of the great doctors in this body, whom we ought to listen to, that we can't get the primary care people to take care of people now on Medicaid, let alone adding millions more under this expansion.

I thank my colleague from Tennessee for his leadership on this. I am happy to be here to say a few things about it because I have spent a lifetime working on health care issues. Before I ever got here, I actually tried medical liability and defense cases, defending doctors, nurses, hospitals, health care providers. I know what these costs are. They are just beginning to explode.

If this bill passes, it is going to be an explosion of health care costs such as we never dreamed possible.

I am very concerned about this. It is all driven by a desire to get, right here in Washington, control over all of our health care. If we do that, we deserve the problems we are going to have.

I thank my colleagues for the great work they are doing.

3:57 PM EST

Bob Corker, R-TN

Mr. CORKER. I thank the Senator very much for coming. No one in this body knows more about what is happening in public programs than he. We heard for the last 55 minutes from the Senators from Texas, Oklahoma, Wyoming, Utah, North Carolina, Nebraska. I can't think of a better person to close us out this afternoon than the distinguished Senator from Tennessee. I am fortunate to serve with this Senator. He was a Governor, an education Secretary. He knows what he is talking about. I am proud the

senior Senator from Tennessee is going to close us out on what I think has been an outstanding hour on the floor.

3:58 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. Mr. President,

for those who are watching, Republican Senators are reading through the bill, reading the bill in its entirety. It is kind of like reading the entire New Testament in Greek. It is better to have somebody help interpret it. We have been talking about page 396, title II, subtitle A, section 2001, which expands Medicaid. We have heard eloquent statements about how moving 15 million low-income Americans into a program called Medicaid, which is a medical ghetto, is not health care reform. We have

also heard Senator after Senator say what right do we have to expand Medicaid and tell the States that you are going to pay for it. What kind of arrogance do we have to say that to States that are in their worst fiscal condition since the Depression?

The Reid bill requires states to expand Medicaid eligibility to cover all persons under 133 percent of poverty, which means those earning about $14,000 per year for an individual and about $29,000 per year for a family. Individuals who are not otherwise covered by an employer-sponsored insurance would not be eligible for tax credits. In effect, every American below 133 percent of poverty would be locked into Medicaid which is like confining them to a medical ghetto. With this bill we are on path

to expand the largest ``public option'' we already have, Medicaid, and it could bankrupt the States, because they will be paying for it. As the former Governor of Tennessee, I do not see how Tennessee can pay for their part of the Medicaid expansion included in Senator Reid's health care bill without a new income tax, or seriously damaging higher education by raising tuition like California just did, or both.

I am opposed to this expansion of Medicaid, which, according to the CBO, would cost States an additional $25 billion, and add 15 million people to the Medicaid Program. This would be the largest single expansion of Medicaid in the program's history. Why? Because nearly half of the reduction of the uninsured in the Reid health care bill is due to people moving into the government-run program that is Medicaid.

Expanding Medicaid to cover uninsured individuals is a terrible vehicle for health care reform, because dumping this many more people into that program will increase problems for beneficiaries getting access to care and for maintaining quality. Plus the program is already riddled with fraud and abuse; this would just invite more of that. Most Governors are struggling with Medicaid in its current form, and they agree that expansion is a bad idea. This includes Democratic Governors.

Tennessee's Medicaid Program is called TennCare. The Tennessean from Thursday printed an article that reports how ``People covered by TennCare may face new limits on their coverage and reductions in their benefits next year, under a plan unveiled Wednesday to help slice state spending.'' The article continues, ``The limits are meant to help TennCare, the State's Medicaid program for the poor, pregnant women and children, meet Govenor Phil Bredesen's goal of reducing spending by most State agencies

by as much as 9 percent as the State deals with a shortfall in tax receipts that could reach as much as $1.5 billion over the next two fiscal years.''

If the Reid health care bill is passed, TennCare might introduce a $10,000 annual cap on hospital coverage for the 1.2 million enrollees. Additionally, they might also eliminate coverage for occupational, speech and physical therapy, and limit enrollees to no more than 15 outpatient procedures and 15 lab procedures in a year. This past Sunday, the Tennessean ran another story titled, ``Bredesen faces painful choices as TN begins budget triage'' which states ``there is no quarrel with the general

position that Tennessee State Government faces a grim situation'' and the Governor anticipates that roughly $750 million in cuts will be needed for the next fiscal year. To make matters worse ``state tax collections are already $101.3 million less than assumed when this year's budget was enacted.''

Another article from the Tennessean reported that the State ``might release as many as 4,000 non-violent felons, possibly even including people convicted of drug dealing or robbery, under a plan outlined Monday by the Department of Corrections to deal with the state's budget crisis,'' and Tennessee is not alone in its budget crisis. Even though many States are going through budget crises much like Tennessee, Senator Reid has proposed to as even more costs onto these States. Earlier this

month, the National Governors Association released a fiscal survey of the States and an accompanying release, ``The State Fiscal Situation: The Lost Decade.''

That report said:

[Page: S11942]

The recent economic downturn started in December 2007 and likely ended in August or September 2009, making it one of the deepest and longest since the Great Depression.

It went on to say:

Medicaid spending, which is about 22 percent of state budgets, averaged 7.9 percent growth in FY 2009, its highest rate since the end of the last downturn six years ago. Medicaid enrollment is also spiking, with projected growth of 6.6 percent in FY 2010 compared with 5.4 percent in 2009.

We don't yet have an estimate from Tennessee of how much Senator Reid's bill will cost the state, but we expect it to be in the ballpark of what the Senate Finance bill would have cost, which according to Governor Bredesen would have cost an additional $735 million over 5 years. Tennessee can't afford to get a $735 million bill from Washington. Not only is it wrong to ask states to pay for expanding this program, but I think it is wrong to dump low-income Americans into a government-run

program that is failing.

Medicaid is a program that, if given the choice, none of us would join. A 2002 Medicare Payment Advisory Committee survey found that ``approximately 40 percent of physicians restricted access for Medicaid patients,'' meaning they won't take new Medicaid patients, because reimbursement rates are so low. Only about half of U.S. physicians accept new Medicaid patients, and yet this is how the majority leader proposes we cover the uninsured.

Why is there such an access problem for people on Medicaid? It is because Medicaid reimbursement rates to doctors and hospitals are so low. Medicare pays 80 percent of what the private insurers pay and Medicaid pays about 72 percent of what Medicare pays. Which means if you are a doctor or a clinic, or a hospital, you get paid about 60 percent for serving a Medicaid patient versus one of us who has his or her private health care. You can see why this spells trouble, and the Senate bill does nothing

to fix this problem. In fact, by dumping 15 million more people into the program it will only make things worse. Who would want to be one of those 15 million people?

In addition to access problems, the quality of care for Medicaid patients is significantly lower than those with private insurance, and even those with no insurance. According to a survey by the National Hospital Ambulatory Medical Care, Medicaid patients visit the emergency room at nearly twice the rate of uninsured patients, and a 2007 study published in the Journal of the American Medical Association found that patients enrolled in Medicaid were less likely to achieve good blood pressure control,

receive breast cancer screening, or have timely prenatal care than similar patients enrolled in private plans. Another study of cancer patient outcomes found that even after adjusting for patients who became eligible as a result of their cancer diagnosis, Medicaid patients have significantly lower survival rates than non-Medicaid patients.

The final example I will give today of why dumping 15 million more people into Medicaid is such a bad idea comes from the Government Accountability Office, GAO. The GAO has determined that the program is plagued by fraud and abuse. In 2009, the GAO labeled Medicaid as a ``high-risk'' program, finding $32.7 billion in improper payments in 2007 alone. That is 10 percent of the program's total spending.

As a former Governor, I am particularly concerned about the impact and expansion of Medicaid would have on the State budgets and the resulting squeeze on higher education spending. When a governor looks at his budget and sees the things he has to pay for like elementary and secondary education, prisons, roads, and Medicaid. Then a Governor looks at the things they want to spend money on like higher education and a Governor, knowing they have to balance their budgets every year, can't spend money

he or she doesn't have, so something has to give, and it's usually higher education. As I noted earlier, the New York Times reported Friday that the University of California Board of Regents will raise undergraduate fees 32 percent by next fall to make up for steep cuts in state funding.

The article goes on to report that ``The University of California now receives only half as much support from the state, per student, as it did in 1990. Even with the higher student fees, the system needs a $913 million increase in state financing next year to avoid further [budget] cuts.''

From 2000 to 2006, spending by State governments on Medicaid has risen 62.6 percent, because of that higher Medicaid spending; higher education has only seen an increase of 17.1 percent over the same time period. As a result, tuition at a public 4 year university has risen an average of 63.4 percent. So Congress passes a generous Medicaid benefit, and the governors have to pay the bills. Then the governor has to say to our college students: your turn, pay up. Expanding Medicaid is exactly the

opposite of real health care reform.

Senator Corker, you were the chief financial officer of the State of Tennessee. You were the mayor of Chattanooga. How would you like it if someone in Washington passes a program and sends you the bill?

3:59 PM EST

Bob Corker, R-TN

Mr. CORKER. I would be losing a lot of sleep right now. I know people all across the country who have to act responsibly, unlike us, are losing sleep over what we are getting ready to do to States across the country.

Is the Senator finished? Is that the point?

3:59 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. The Governor of Tennessee, who is a Democratic Governor, has estimated that the cost to our State of this bill, of moving 15 million Americans into this medical ghetto, is about $800 million over 5 years. In my view, finding that much money would seriously damage higher education, raise tuition in Tennessee like California's, which just went up, or require us to enact a new State income tax, or all of those things at once.

I yield the floor.

4:00 PM EST

Chuck Schumer, D-NY

Mr. SCHUMER. Mr. President, today we stand at a crossroad. We can continue to turn a blind eye to the very real, very dangerous threat burgeoning health care costs pose to our economic future or we can choose the path to restoring economic opportunity in this country by tackling what my dear friend, Ted Kennedy, called the ``great unfinished business of our society.''

As so often is the case at any major crossroads in our history, embarking on what we all know is the right path is difficult. Indeed, this is the single most difficult undertaking I have ever seen in my 30-year career as a legislator. But my colleagues and I know what has to be done. Tonight is only one step down the road. There will be more procedural hurdles, more disagreements, more pressure from our opponents, more television ads, and many amendments. But I have no doubt we will pass this

bill.

There have been many attempts over many decades in many Congresses to reform health care. This time, moral and economic necessity will guide us over the finish line. It is unacceptable that in this country--the wealthiest, greatest country in the world--there are Americans who are forced to choose between their health care and rent, between their health care and food, between their health care and an education. But there are. And there are too many of them, and that must change.

Consider these facts: Health care costs are out of control. Premiums for New York families have doubled in the last decade. Premiums have risen far in excess of inflation while median income has remained stagnant. Costs have risen so much that more than 20 million Americans have skipped a doctor's visit for no reason other than cost and 23 million Americans have premiums so high they consume $1 out of every $8 earned. Health care costs now account for a staggering 16 percent of our GDP, far more

than any other industrialized country in the world. For every dollar a small business in the United States spends on health care, its foreign competitors spend a mere 63 cents. Yet the health care of the U.S. workforce lags behind all other industrialized countries. Plain and simple, [Page: S11943]

our small businesses will no longer be able to compete unless we act to reform health care.

Even among those Americans fortunate enough to have coverage, nearly 88 million don't have health care they can rely on. That is half of all Americans age 18 to 64 and their families. And 46 million of these Americans have a serious preexisting condition that has made it harder or more expensive for them to get coverage. In addition, 37 million of these Americans had a gap in their coverage during the last year.

Our health care system is holding our economy hostage. The entrepreneur in Binghamton who does not take a chance, who does not leave a job to start his own firm because he is afraid of losing his family's health care; the college graduate in Oswego, days away from losing her parents' coverage, takes a job because it provides health care, even though that health care eats up a quarter of her paycheck--each of these individuals who limit their potential because they are concerned about their health

care should inspire action among all of us.

Passing this bill is an economic imperative. The broken system we have is not only a burden on the present, it is a tax on the future. Every day we do not act to fix the health care system is a day that handcuffs our economy. It drains it of productive workers who do not treat illness. It drains businesses of money they could otherwise use to innovate and outperform their foreign competitors, and it drains it of savings and wealth that every American should have in retirement as a reward for

a lifetime of hard work.

Inaction is not an option. The consequences of failure are simply too high. Premiums will climb higher, benefits will erode further, businesses will buckle under the cost of insurance, and Medicare will go bankrupt. Yet our Republican colleagues would rather see us fail. At every turn, they have obstructed our path with procedural delays, with calculated misinformation, and sometimes with outright falsehood. I am amazed they are against a government health care plan, but they want to protect

Medicare. Medicare is a government health care plan. You can't have it both ways.

Yet when Democrats move to protect consumers from insurance company abuses, Republicans fight to allow these companies to drop, deny, or limit coverage for the people who need it most. When Democrats tackle waste, fraud, and abuse in our health care system, Republicans cry foul to preserve the status quo. When Democrats fight to protect and strengthen Medicare for future generations, Republicans try to weaken it.

Tonight, there is no question what path our Republicans will take. They will follow the map handed to them by the big insurance companies--protecting industry profits, defending unfair practices, and ignoring the threat rising health care costs pose to America's economic future. They will continue to speak with two tongues against government health care and for Medicare. You can't have it both ways.

Our Republican colleagues will not stand in our way. The road ahead is not a smooth one, but the wind is now at our backs. The American people want reform, and we will have the votes to finally deliver it to them. Sure, changes will be made to improve the bill as we move forward, but we will pass this bill. We will finish this great, unfinished business.

I yield the floor.

4:07 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. Mr. President, as the Senator from New York has so eloquently stated, the time for health care reform is now. We cannot afford to wait any longer. We can't afford to wait, for the middle class.

There are a lot of numbers that get thrown out in the debate, but I think we can say it pretty simply by just using three numbers. Those numbers are 6, 12, and 24. What do those numbers mean? Ten years ago, the average family in this country paid $6,000 for their health insurance. Now they are paying $12,000. That is an average. I know of one small business in northern Minnesota, a backpack company, paying $24,000 for a family of four. One guy started a company with five employees. He now has

15--a growing business. He is paying $24,000. The average right now is $12,000 for a family of four. Where is it headed if we don't bend the cost curve for middle-class families--$24,000 average, little towns all over America, $24,000, 10 years from now. That is not the kind of stability the middle class needs.

The middle class needs to know, people I know all over my State need to know that if their kid gets sick, they still can have health care coverage; that if their kid goes to college and they want to keep them on their policy, they can still do that. That is what we are talking about when we talk about stability.

The other piece of this reform effort that is so important, coming from Minnesota, a State with high-quality, highly efficient care, is the cost issue, that we begin the long journey of reforming our Medicare cost so that we actually promote the kind of high-quality care we see in my State at places such as the Mayo Clinic and we promote the

kind of efficient care we need to see.

My favorite example is in Pennsylvania, the Geisinger Clinic. They had diabetic patients. They decided it was not going that well. The patients didn't feel that good about their treatment, and the quality they wanted was costing too much. They tried something else. For routine cases, they said they will see nurses and see them more often. The more difficult cases went to endocrinologists, and they reviewed the routine patients' records. Higher quality care, happier patients, better care, lower

costs--$200 per patient per month--that is what happened. They got less money for that higher quality care, less money. That is what we are talking about. We want to use those kinds of models so we get higher quality care for America at a more efficient rate.

Some of my colleagues across the aisle have been using the name of the Mayo Clinic in vain. This matters to me because I come from Minnesota. It is the home of the Mayo Clinic. The minority has suggested that the Mayo Clinic doesn't want any part of this bill. They have said the Mayo Clinic wants nothing to do with this bill. They have said the Mayo Clinic--and this is an exact quote from the Senator from Wyoming--``is no longer taking Medicare or Medicaid patients.''

Let me set the record straight. Like anyone in this country, the Mayo Clinic is looking at this bill. They like some provisions, and they don't like others. They have specifically said they support the creation of accountable care organizations, bundling of payments, the creation of an independent commission to evaluate Medicare solvency, which is in the Senate bill, the MedPAC idea. They are supportive of these issues because right now it is becoming harder and harder for them to cope with the

current Medicare payment system.

This allegation that they are no longer taking these patients is completely incorrect. They made a decision not to take about 80 patients a year from the State of Nebraska because they weren't getting paid. They are still taking all Medicare-Medicaid patients from Minnesota and the contiguous States. This is not a small amount. Forty percent of Mayo patients are on Medicare. Six percent--I wrote this on the back of an envelope driving in with one of their chief doctors, so you know it is accurate,

unlike the ``facts'' we are hearing over there. Forty percent of their patients are on Medicare, 6 percent on Medicaid, 46 percent are on Medicare or Medicaid. Sixty percent of their business is from Medicare or Medicaid.

It is just false. But what is true is that they want to see reform. They want to see reform of the Medicare and Medicaid system. They want to have it based on quality, not on quantity. That is why they support the quality index I sponsored, along with Senator Cantwell of Washington.

Just putting your head in the sand and hiding behind the stacking of that bill--by the way, we had a three-page bill with the Bush TARP plan, that didn't work out that well when there were no accountability measures in that. That is not going to bring us the [Page: S11944]

kind of health care reform the Mayo Clinic wants to see for the rest of this country.

I heard a lot in Minnesota from small businesses. Small businesses are paying 20 percent more than big businesses for their health care right now. Why should employees of little businesses, which are really the entrepreneurial engine of our States and the Nation, why should they have to pay 20 percent more than people who work for big businesses? This reform effort allows them to pool their numbers, allows them to join together so they can buy private insurance off an exchange with the same kind

of numbers you have at a major corporation.

I know the Senator from Maryland has been very devoted to the idea of helping small businesses.

I ask Senator Cardin about this specific issue. How does the Senator see this as helping small businesses in Maryland and helping the middle class in his State?

4:14 PM EST

Ben Cardin, D-MD

Mr. CARDIN. Let me thank Senator Klobuchar for setting the record straight as it relates to the Mayo Clinic. It is interesting, I have had conversations with people at Johns Hopkins University, the University of Maryland Medical Center. I hear the same thing. They desperately want to see health care reform. The cost issues are beyond their ability to maintain the excellence of our health care system. We have to get health care costs under control.

If I might point out, I was listening to my colleagues on the other side give every reason why we should not move forward with the debate, saying: Don't worry, things will be OK. Those were the same arguments they made 15 years ago, which was the last opportunity we had to debate comprehensive health care reform. They blocked it from being on the floor of the Senate 15 years ago.

What has happened in the last 15 years, after they said: Don't worry about it. Everything will be OK. Just keep on with our current system of protecting the private insurance companies. They will do a great job.

In the last 15 years, we have seen health care costs go up, $912 billion, almost a three-time increase.

We have seen the per capita cost of health care go from $3,400 to $8,100. We have seen that share of our economy in the last 15 years go from 13 percent of our economy to over 17 percent of our economy. We need to act.

One more number I want to give because it affects Mayo Clinic and affects Johns Hopkins because in many cases they are the provider of last resort, where no one else will give care. Also, the number of the uninsured has increased since 1993 from 39 million to 46 million.

The legislation that is being brought forward by our vote later today will reduce the number of uninsured by 31 million. Mr. President, 98 percent of Americans will be covered by health insurance with this bill. It reduces the growth rate of health care costs in America. It provides an affordable option for every American. This is a critically important bill.

The Senator mentioned small companies. I am glad the Senator did because small companies are the ones that are most discriminated against today in our health care system. They pay 20 percent more for the same coverage as a larger company. They do not have options. They do not have a lot of choices about who they can get to insure them. Not only is the cost so high, the annual increases are unpredictable. How do you run a business, if you are a small business owner, not knowing whether your health

care cost is going to go up by 10 percent, 20 percent, or 40 percent in the following year? You cannot.

As the Senator knows, we have had small businesses come before us and tell us they are going to have to decide to eliminate their health care. In one case, we had a small business owner who said: Look, I am going to have to give up my business and start to work for a larger company because I can't afford the health care.

We are at a crisis. I do not understand my colleagues on the other side saying they do not even want to have a debate on this issue, they do not even want to vote so we can take up this issue. Instead, they want to protect the private insurance companies and let them continue to make these profits, continue to cause real problems for our consumers.

I have letter after letter from people who are confronting the problems of private insurance today, where they are denying coverage based on preexisting conditions or not covering a specific drug under their policies. There is no effective way to challenge private insurance companies today. This bill will give the consumers of America a chance against our private insurance companies.

4:17 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. Mr. President, if the Senator would yield, I see the Senator from Delaware is in the Chamber. Both the Senator from Maryland and the Senator from Delaware serve on the Judiciary Committee, and we have had several hearings in that committee about an issue people do not always think about that hurts the middle class, and that is the money that is being sucked down the fraud tube. Medicare fraud is $60 billion a year, I think.

4:18 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. Mr. President, $220 billion. This bill will give us the tools. I know I wish to add even more to it on this subject, to go after that money, so that money can go back to help the middle class afford health care.

I yield to the Senator from Delaware.

4:18 PM EST

Ted Kaufman, D-DE

Mr. KAUFMAN. That is absolutely right. What we are going to do is increase the number of whistleblowers, people who will see health care fraud and report it. We are going to get more prosecutors. We are going to get more FBI people. We are going to get more people to make sure we bring this health care fraud down. That is part of this bill.

But I do not understand--to follow up on what the Senator from Maryland said--how can you say you do not want to debate the bill, when you look at the fact that the alternative is our present health care system, which is totally, completely broke? How can you say you do not want to do it? You say you are fiscally responsible. How can you say you are fiscally responsible when you are not going to do anything about Medicare and Medicaid health costs and the cost of health benefits in this country?

As we have said many times before on the floor, my State is one of the worst cases; that is, in 2016, a family of four making $50,000 a year would be paying $29,000 in health care premiums. They cannot afford $29,000 in health care premiums. So what is going to happen? They are going to have the equivalent of half what they have today. If they can afford $12,000 or $13,000, they are going to have half the program.

I heard my colleagues on the other side talking about rationing. What is going to happen to these people when they are getting half as much health care from these health care companies? And the health care companies are the ones that decide what procedures you can have, when you can have them, and those kinds of decisions. When people have their health care insurance cut by this amount, you have to worry about whether they are going to be able to get the things they need.

Of course, Medicare and Medicaid prices are going through the roof. It is going to bankrupt the country. In 6 or 7 years, Medicare and Medicaid costs will cost more than everything else in the Federal Government. So how you can talk about----

4:20 PM EST

Ben Cardin, D-MD

Mr. CARDIN. On the Medicare issue, during the last hour we heard all these people, who for a long time have been trying to privatize Medicare and reduce the program, now saying that Medicare is going to be in jeopardy if this bill moves forward. It is very interesting. The AARP gets it right when it says:

The new Senate bill makes improvements to the Medicare program by creating a new annual wellness benefit, providing free preventive benefits, and--most notably for AARP members--reducing drug costs for seniors who fall into the dreaded Medicare doughnut hole, a costly gap in prescription drug coverage.

This bill strengthens our health care system, strengthens Medicare for the future, and that is what is going to be critically important to our seniors.

I thank my colleague.

4:20 PM EST

Ted Kaufman, D-DE

Mr. KAUFMAN. I think that is absolutely right. Right now, medical bankruptcies are 60 percent of U.S. personal [Page: S11945]

bankruptcies--a rate 1 1/2 times what it was 6 years ago--because of medical bills. The thing that is striking about this is, 75 percent of the families entering bankruptcy because of medical bills actually have health insurance. Two-thirds of all Americans filing for bankruptcy because of medical bills already have health insurance. We cannot

stop that unless we change the system and give people more insurance and give them better insurance and make sure you cannot be denied for preexisting conditions and make sure--the killer--once you get sick--it is bizarre. You get sick, and then the health insurance company comes in and cuts off your health insurance. No wonder so many people are going into bankruptcy.

4:21 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. If the Senator would yield, I see the Senator from Massachusetts is in the Chamber, who I think has firsthand knowledge of the importance of this bill, having taken the seat once held by our dear friend Senator Kennedy, who worked so hard to get this bill done, to get health care to the people of his State.

I say to the Senator, maybe he would want to talk about what this would mean to the people of Massachusetts.

4:22 PM EST

Paul G. Kirk Jr., D-MA

Mr. KIRK. I thank the Senator.

I thank Senator Klobuchar for her leadership, as we approach the important moment on voting on a motion to proceed with this debate.

I was appointed by the Governor of the Commonwealth basically in conformity with Senator Kennedy's wishes. He knew how divided this body was over the important health care legislation and the importance of 60 votes so we could proceed to debate the merits of this bill. I am honored and humbled to be standing at his desk, to be one voice and one vote from Massachusetts.

It is a historic moment, and it is a poignant moment. As I reflect on my experience on his staff, as Senator Kaufman was on Senator Biden's staff at that time, my experience began 40 years ago under the leadership of

Senator Kennedy. That was the time he first spoke about the need for national health insurance that would be affordable and accessible to every single American--in hearing after hearing, in speeches on the Senate floor, and in field hearings throughout America, prodding, listening, leading.

I can only reflect on how proud he would be of his colleagues and the leadership of Senator Reid and Senator Dodd, Senator Harkin, Senator Baucus, all his colleagues who are now uniting in this moment of history to do for the American people what they have waited for for several decades, even since the first utterance of this important health insurance coverage by former President Harry Truman.

Having read through this bill and knowing how proud Senator Kennedy would be of this legislation, I will tell you why he would be. If you look through the bill, what does it do? It saves money. It controls costs. It reduces the Nation's deficit. It stimulates competition. It expands coverage. It strengthens Medicare. It attacks fraud, waste, and abuse. It increases transparency. It eliminates patient discrimination. It promotes flexibility and innovation. It rewards quality and value--not quantity

and volume--of health care. It provides affordable, quality health care choices for individuals, families, and small businesses across America.

It introduces, through Senator Kennedy's leadership, a provision which provides long-term services for the elderly and the disabled.

4:25 PM EST

Paul G. Kirk Jr., D-MA

Mr. KIRK. Before I do, I say to the Senator from Maryland, there is one large, major question. If this bill promises to do all these things, for the life of me, I cannot understand how 1 of the 100 of us could go home for Thanksgiving and be able to explain to middle-class families, who are stretched and looking for health security and financial stability, that he or she would not vote even to debate the merits of this legislation.

4:26 PM EST

Ben Cardin, D-MD

Mr. CARDIN. I was going to comment, listening to the Senator, at the desk that was Senator Kennedy's desk, how proud he would be of the statements the Senator is making here this evening. Senator Kennedy was our champion for middle-income families in America. He understood they needed a voice in the Senate, and he was their strong, passionate voice.

This bill speaks to middle-income families. It is what Senator Kennedy fought his whole career for here in the Senate, to do something that would help middle-income families.

As the Senator points out, we need to bring down the cost of health care. Health care costs are rising three times faster than wages. Senator Kennedy understood better than any of us that Americans are falling farther and farther behind because of the health care issues, because of health care costs. Private insurance companies can make lots of money if health care costs go up. They are not losing. It is the middle-income families who are getting hurt by the system.

He understood that small businesses could not survive unless we figured out a way to deal with the health care issues. And as to people on Medicare--most people on Medicare are from middle-income families. We need to protect Medicare for the future. That is why, again, I get very concerned when I hear what we have heard over the last hour in the discussions, because one of the principal reasons we need to bring this bill forward on the floor of the Senate tonight is to strengthen Medicare, to

make sure it is there for the future, to make sure it stays strong, and to make sure we expand benefits, as we do under this bill.

I thank the Senator because those of us who have heard Senator Kennedy speak on the floor of the Senate know how sorely missed he is here, and we are proud you are representing that vote here on the floor of the Senate tonight.

4:27 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. Mr. President, if the Senator would yield, I also see the Senator from Rhode Island in the Chamber. Rhode Island is a State that has one of the highest unemployment rates right now in the country, and it certainly is a State that would welcome this kind of reform. And also on the issue we have been talking about, Medicare, the Senator from Rhode Island has long fought for seniors.

As to Medicare, as has been pointed out, if we do nothing, it is going to go in the red by 2017. The seniors I know who are 65 want to live to be 95 and still have Medicare. People who are in their fifties want to make sure Medicare is there for them when they are 65. That is why it is so important we make these smart reforms, to raise the quality of the care, and to make sure we preserve and save Medicare. And that is what this bill is about.

I yield to the Senator from Rhode Island.

4:28 PM EST

Jack Reed, D-RI

Mr. REED. Mr. President, I thank the Senator from Minnesota. I want to add my comments to that of the Senator from Maryland and the Senator from Delaware to commend the new Senator from Massachusetts. He not only carries on the great work of Ted Kennedy, but he does it with the same passion and eloquence.

What struck me in this legislation--and reminiscent of Senator Kennedy--is that this legislation will provide real help to real people. It is about solutions, not slogans.

Let me illuminate, if I may. Premium relief. What is troubling so many middle-class families? They are too wealthy to qualify for direct public assistance in terms of the Medicaid Program, but they are not wealthy enough to pay for insurance.

This legislation will cap family outlays on medical insurance premiums. Families making under $88,000 will pay no more than 10 percent of their income on premiums. They will be given direct assistance through the tax system. There will be a rebate. So people now, rather than staring at 20 percent, 15 percent, 18 percent increases, will at least know there is a cap. And perhaps if we do our work well enough, the whole system will begin to reduce below the 10-percent mark, and everyone will benefit.

It is also notable that real families worry about many things. They worry about educating their children. They want them to be educated, but they also recognize as full-time students in higher education, they can stay on the family health care plan. It is interesting to note that decisions made about education are tied into health care, and also, in fact, as to where you work, if you should keep your job you do not like because you have health [Page: S11946]

care

or go on,

whether you strike out to start a new business because you have this brilliant idea or stay in your current position because there is health care there. But what this bill does, again, is provide real help for real people and allows families to keep their children on their health care plan until they are 26 years old.

It also reforms dramatically the insurance system. Again, we listen to many of the complaints: Oh, we don't want a government-run health care system; we don't want bureaucrats telling us what to do. The irony, of course, as you mentioned, and Senator Schumer did, too, is that one of the most popular health care programs in this country is Medicare, which is government run. One of the other most popular health care programs in this country is run through the Veterans' Administration,

which is a government agency. The least popular programs are private health insurance, where everyone has complaints--doctors, patients, providers. This legislation will prevent lifetime limits that insurance companies dictate. It will also do many other things.

So let me conclude because I appreciate very much--and if the time allows, I have a question for the Senator from Massachusetts. But this is a bill that when you move past all of the rhetorical smokescreens--because, frankly, most of our colleagues on the other side don't want to do anything. They didn't want to do it in 1993 and 1994; they didn't want to do it in 1933 and 1935; and they still don't want to do it--this legislation helps real people with solutions not slogans about nationalization

and bureaucrats.

4:32 PM EST

Ted Kaufman, D-DE

Mr. KAUFMAN. I was presiding yesterday for I don't know how many hours. When you listen to what is said on the Senate floor by the other side, they are talking about a model where there is no competition. Any tax on an insurance company is going to be passed on to the consumer. What kind of a business--I don't know anybody in business who, if they get an increase in cost, they just pass it on to the consumer. Right? I mean, we have a law of supply and demand the last time I checked. But every

single one got up and talked about the cost and said this is going to hurt the consumer. It is not going to hurt the insurance companies because they are just going to pass it on to us. The reason they are going to pass it on to us is kind of obvious.

Here is a list, a small list, that lists all the States in America and how much of their insurance is tied up in two or less companies. Do you know what you have to do? You have to get down to No. 40, Oregon, because the first 39 States on this list, two insurance companies make up over 50 percent of the market in their State. How can you have competition when you have so much of the business tied up in just one entity?

The way you can tell there is not competition? You don't have to have an advanced degree in economics to figure out there is no competition. How do you know there is no competition? Every January, my premiums go up. The only other thing I know that I get that goes up every January is my cable bill, right? There is no competition in cable. You either take cable or you don't. They say there is competition. So every year, whether it is January, February, or March my cable bill goes up. And every

year, just like clockwork, my health insurance premiums go up. So clearly, there is not competition.

That is why a public option is so important. We have to have a public option so there is competition not only in the top 39 States where one firm has over 50 percent--two firms have over 50 percent of the business--but in all 50 States.

That is what this bill does. It is amazing to think on the other side, the support they have for competition, and I believe they do and I know them and I respect them and they all are concerned about competition--except every once in a while they kind of turn a blind eye to the fact of how powerful competition is. Competition is valuable and powerful in keeping costs down and increasing benefits and quality of care--only when there is actually competition. So we are going to have to have competition.

This bill will actually do it.

4:34 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. If the Senator will yield, I think we have been joined by the Senator from North Carolina, who is a member of the HELP Committee and I know has a background in business and understands a little bit about competition.

So how does she see this as being a problem? I know in the State of the Senator from Maryland there is limited competition, and in a number of our States one or two providers--Minnesota is an exception, but one or two providers dominate the market, jacking up the prices.

The Senator from North Carolina.

4:35 PM EST

Kay R Hagan, D-NC

Mrs. HAGAN. I think one of the key points is the fact that this bill is going to eliminate discrimination based on gender and preexisting conditions. I have two children right now who are in their midtwenties. My daughter is paying more per month for health insurance than her brother. Yet it is the exact same policy. The same with preexisting conditions. How many people do we know who have a condition such as diabetes or asthma, or a woman who has had a C-section who is, therefore, denied from

getting health insurance? We have to be sure we correct this, and that is what this bill does.

Let me give a couple of examples. So many people in North Carolina I have heard from have some of these situations. Recently, I got an e-mail from a family in Greensboro. It is a working family. The husband has Graves disease, which is a treatable condition, but he can't obtain health insurance because of this condition. Without health insurance, his life is gravely in danger. He repeatedly uses the emergency room for care.

To make matters worse, he has a 2-year-old son who has hemophilia and has to be taken to the emergency room every time he bumps his head, which sometimes can cost, for a 2-day supply of medicine, $4,600. The family makes too much money to qualify for Medicaid and, obviously, with these preexisting conditions, health insurance is way out of reach for them. It is heartbreaking for this family. What the father has decided to do is to purchase life insurance instead of trying to get health insurance,

and he is 29 years old.

4:36 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. If the Senator will yield, I think what the people will be shocked to find out is that I think in eight States domestic abuse is actually a preexisting condition. You talk about gender discrimination. If a woman is a victim of domestic abuse, she will basically not be able to get certain insurance policies. Is that right?

4:37 PM EST

Ben Cardin, D-MD

Mr. CARDIN. If the Senator will yield for a moment, as Senator Klobuchar pointed out, if you don't have competition--and Senator Kaufman said the same thing--if you don't have competition, what is your choice? You are going to have to pay the premium.

There was a Washington Post article written about a street in Gaithersburg. Gaithersburg is a growing suburban community not far from here, certainly middle-class families. They think they are doing fairly well. It talked about one street in Gaithersburg, and they gave half a dozen stories about people--real stories--about people having problems with our current system. They talk about Patty, who has private insurance and thought she was in good shape. She talks about having to search a book

in order to find out what doctor she could go to to stay in the network because it is too expensive to go out of network, and then she hits her deductible and finds that her fees and copayments come in fast and strange, making it unaffordable for her with her current insurance coverage. She has no other choice. That is the only insurance she can get.

Two doors down the road is Chuck who needs oxygen, needs certain medicines. He had to fight with his insurance company to get the prescription drug covered. He got the prescription drug covered, only to find out the nurse who administered the drug was not covered, and it cost $400--another problem with a private insurance company.

Across the courtyard, Will and Sarah, they have

insurance today. They are going to lose it because he [Page: S11947]

just lost his job, and he has no prospect for being able to afford insurance.

The last one is Martha. This is a very interesting one. Martha went to the emergency room for delivery of her child. She needed an epidural. She made sure she went to a hospital that was in-network because she wanted to make sure it was covered. Guess what. That anesthesiologist she had no control over was not in-network and she had to pay all that extra money. Again, no choice. She had no choice in the system. There is no competition.

I know we have Senator Kirk here who is our newest Member. Perhaps the Senator could tell us what he is hearing from Massachusetts. He is a new Member here. I don't know whether he is getting the same stories of what is happening in his State.

4:39 PM EST

Paul G. Kirk Jr., D-MA

Mr. KIRK. Well, it is exactly the same story, with one exception, I would say to the Senator from Maryland, which is that 3 years ago, Massachusetts adopted its own health reform. Now, 97 percent of the people in Massachusetts are covered with health insurance.

As you have said and as the Senator from Rhode Island has said, the best illustrations of the need for health reform are the individuals, the real people. So I will tell my colleagues a story about a young lady. She is a waitress, a 24-year-old girl. Her name is Jessica Wheeler from Somerville, MA. She is a waitress and works part time as an intern. She had dreams of graduate school, but she was concerned about health insurance. We have an exchange in Massachusetts not dissimilar to what is being

offered in this legislation where there is increased competition from private insurers and others. She applied to the exchange and was found eligible and enrolled and took out an insurance plan.

Shortly after, she was stricken gravely ill with organ failure and was hospitalized for an extended period of time. She was made well. She has to take a pill every day in order to keep up with her condition, but her coverage was complete. She has applied now to graduate school, and although she probably has her tuition issues stretching her means and so forth, she is free of the concern and need of expensive health care bills; otherwise, she would have been without. So it is just another illustration.

Just one other point on competition that keeps coming back and back, I ask myself: Why do middle-class families save their hard-earned money to buy health insurance? Obviously, the answer is so that they will have coverage if they get sick. Without competition, I will tell you what is going on. Insurance companies--now get this--are denying coverage because people are sick or they say: Well, you reached a certain limit, and we didn't realize you were going to get that sick, so we dropped the

coverage.

4:42 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. If the Senator could yield, I have exactly the same kind of example where someone wants to buy coverage, they are willing to pay for some coverage, but they can't. They basically are cut out because they are sick.

This is one of the saddest letters. We just got this from Cheryl from Bemidji, MN. She says:

I am writing to you because I just got off the phone with my daughter Mickey. At first I couldn't understand her because she was sobbing so hard. Her husband had just been told by his boss that they wouldn't be carrying health insurance on their employees any longer. They are a small company in northern Minnesota and it was costing them $13,000 a month. For her, for my daughter, this is a matter of life and death. She has cystic fibrosis. Because it is a preexisting condition, the insurance companies

won't touch her unless it is under a group plan such as the one her husband just lost.

She says:

You need to stand and be my voice, be Mickey's voice. Mickey is a fighter, but she can't keep fighting a system that is so against her. Mickey has already lived longer than any of the doctors expected. I want her to live to see her 5-year-old son become President one day.

That is from a mom in Bemidji, MN.

So I will just ask my colleagues, how can we continue to go down this path where hardworking families--a man who has a job, who is working for a small business, gets cut off from his insurance, and because his wife has cystic fibrosis, they aren't going to be able to afford insurance.

The Senator from Delaware.

4:44 PM EST

Ted Kaufman, D-DE

Mr. KAUFMAN. I think the reason we use these examples so much is because certain words kind of roll off your lips; words such as ``preexisting condition.''

Here is an example involving Angela in Dover, and she is a bartender, not a waitress. Her income is from tips. She has no health insurance through her employer. She became pregnant. She tried to find private health insurance, but she was declined coverage because pregnancy was considered a preexisting condition.

Now, just do a visual for a minute. This woman has been living off of tips. She is about to have a baby, and there is nowhere she can go to get health insurance. She applied for Medicaid to find prenatal care for herself and her baby, was denied coverage because she earned $200 more than the monthly income limit. I mean, just picture this now, if you were in this situation. She called organizations and clinics and was unable to find a payment plan she could afford.

Midway through her pregnancy, Angela decided to cut back her work hours so she could qualify for Medicaid. She worked all 9 months of her pregnancy and delivered the baby on May 27. The Medicaid coverage she got was especially crucial because she had complications with hyperthyroidism and was able to get the necessary prescriptions to control her condition.

OK. Do we have the picture? How would we like to see ourselves with our spouses or our kids with this kind of a decision? The sad part of the story, as if it is not sad enough, is that Angela was so anxious to ensure that everything possible was done for a healthy baby and the system threw up roadblocks. Pregnancy should not be considered a preexisting condition.

People in this country who are pregnant should not have to worry, in addition to going through the trauma of being pregnant for 9 months and the baby being healthy and all the fears you have and on top of that fear they may go into bankruptcy because they cannot afford to pay for the doctor bills for their baby. This is real stark to me.

We are going to vote tonight on cloture so we can move to a bill that will, once and for all, make sure Angela Austin and all the women similar to her who have the ``preexisting condition'' of pregnancy will only have to worry about their baby and what is going to happen to her and not worry about what she is going to do when the child is 2 and she is in bankruptcy, because so many people are going into bankruptcy.

4:46 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. Maybe the Senators can answer this. In these thousands of letters and calls we get from these people, they are asking us to be their voice. They don't want to say we are not going to debate this bill at all, that we are going to put it in a drawer and pretend it didn't exist.

4:47 PM EST

Ben Cardin, D-MD

Mr. CARDIN. That is the interesting point. These are all real stories, people who are being denied health care today because of arbitrary practices from private insurance companies or the way our system is currently organized.

The vote tonight is a pretty simple vote. If you think the current system is what you want, OK, I understand why you are voting against cloture. I understand that you say the status quo is fine; we don't even want to debate the issue; we don't care about the people who have been affected by the arbitrary actions of private insurance companies and saying that pregnancy and childbirth is a ``preexisting condition'' or when you are using over-the-counter drugs to keep your cholesterol under control

and the insurance company says that was a preexisting condition.

All we are saying tonight is: Is this worthy of debate on the floor of the Senate--a clear vote? Those who vote for cloture say this is worthy. The people who have written us these letters are entitled to have the Senate take up this issue. That is why we point out that there are numerous groups, including the American Medical Association, that say vote for cloture, let's have this debate before the American people.

4:48 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. Along those lines, before I yield to the Senator from Massachusetts, I started out talking about the cost issue. I wanted to put in the Record the statement of November 5, 2009, from the Mayo Clinic. There have been things said about their position. [Page: S11948]

My friends on the other side have said they ``don't want any part of this bill'' and they ``want nothing to do with it.'' Those are exact quotes. They said they ``are not taking Medicare

and Medicaid patients anymore.''

Those are exact quotes. They are all incorrect. I will put this in the Record. It is dated November 5, 2009. ``Points of Agreement and Divergence.'' They say:

We are encouraged by much--including provisions to pay for value in health care, an insurance exchange, individual mandate, subsidies for people to achieve coverage, and pilot projects on accountable care organizations and bundling of payments.

To be fair, they also say they are ``concerned about other areas including a public option that is based on Medicare rates. .....''

As you know, the options in the House and Senate bills are not based on Medicare rates but negotiated rates. They are concerned about the long timeline for implementation of value provisions, as I am. They are concerned about across-the-board cuts for providers. They neither endorse nor support the bill. To say they don't want any part of the bill is false.

I ask unanimous consent that this material be printed in the Record.

There being no objection, the material was ordered to be printed in the RECORD, as follows:

A Perspective on Current Health Reform Issues From Mayo Clinic

REFORM BILLS: POINTS OF AGREEMENT AND DIVERGENCE

As the House and Senate prepare to bring their final bills to their respective floors, Mayo Clinic would like to highlight the areas of agreement and divergence in the bills and our positions on health care reform. We are encouraged by much--including provisions to pay for value in health care, an insurance exchange, individual mandate, subsidies for people to achieve coverage, and pilot projects on accountable care organizations and bundling of payments.

At this juncture, Mayo Clinic will neither endorse nor oppose entire bills in the House or Senate, but will continue to point out provisions that we think move the country toward patient-centered health care and areas where we have concerns.

While many provisions in the bill are aligned with our recommendations, Mayo Clinic remains concerned about other areas including a public option that is based on Medicare rates, the long timeline for implementation of pay for value provisions and across the board cuts to providers.

It is critically important that we accelerate the timeline to adjust the Medicare payment system to pay for value in order to truly bend the cost curve--especially in light of the growing number of baby boomers reaching retirement age.

These payment reform provisions should not lag behind expanding coverage to more Americans. In any event, we must focus on ensuring the financial viability of health care for the long term to ensure that patients have access to quality care across the country.

SUPPORT HOUSE IOM STUDY OF HIGH VALUE CARE AND GEOGRAPHIC VARIATION

Mayo Clinic supports the provision that was added to the House bill that will charge the Institute of Medicine to study and design new payment methodologies to build value and address geographic variation into the Medicare payment system. The proposal is consistent with Mayo Clinic's focus on creating a mechanism to better define value, measure it, and create new payment methodologies that reward it.

Most of us, as patients or family members, don't stop to think that our doctors and hospitals are generally paid more for doing more tests and procedures--whether or not we need it. Take for example, the story of a patient eventually seen here at Mayo Clinic:

An older gentleman went to an emergency room because he fainted. A CT scan of the heart was done and showed calcification. Urgent heart catheterization was recommended and then bypass surgery was performed. Later, when a stress test was done, an abnormality was found and a second heart catheterization showed a complication--one bypass was blocked. Stents were placed in the heart artery where the

bypass was blocked. However, the fainting spells continued. With his issue unresolved, the patient came to Mayo Clinic, where we conducted a lengthy assessment by a team of physicians. It was determined that all he needed was an adjustment of his medications. In the end, the tests, stents, and surgery performed at the other facility were not needed, did nothing to help the patient, but were paid for by Medicare. On the other side, the additional office time spent at Mayo to fully assess patient's

situation and ensure proper diagnosis and treatment was not covered by Medicare.

Doctors and hospitals are usually paid more for doing more tests, visits, hospital admissions, and surgeries rather than spending time with the patient and assessing their individual needs. What if instead, the system rewarded doctors and hospitals for spending time with patients, for doing a procedure successfully, for the fact that you leave the hospital without a fall or infection, and for providing excellent service to you while you were under their care.

SUPPORT CANTWELL AMENDMENT TO INCENTIVIZE VALUE IN MEDICARE

We support a similar provision in the Senate Finance Committee bill introduced by Sen. Cantwell that will help move Medicare in the direction of paying for value by creating a value modifier for physician payments that will create incentives around value in the Medicare physician payment formula.

INSURANCE REFORM THAT GIVES ACCESS TO ALL

We believe coverage can be achieved without creating or expanding a government-run, price-controlled, Medicare-like insurance model. A public option that employs a true negotiated rate process is better than a system based on Medicare rates. However, we are concerned that the exchange could be opened to large employers, which could result in a large shift from private to public insurance plans.

We support reforms to the current insurance system that eliminate pre-existing condition exclusions, and create an individual mandate where individuals can purchase private insurance in various ways:

Through employers,

On the individual market,

Through co-operatives, or

Through an exchange model like the Federal Employees Health Benefit Plan (FEHBP).

We also believe that the government should help people afford the insurance through sliding scale subsidies as needed.

ENCOURAGED BY ACCOUNTABLE CARE ORGANIZATION PILOT PROJECT

Mayo Clinic is encouraged by provisions in the House and Senate bills that allow groups of providers who voluntarily meet certain statutory criteria, including quality measurements, to be recognized as Accountable Care Organizations (ACOs) and to be eligible to share in the cost-savings they achieve for the Medicare program. Both houses propose to start an ACO pilot program January 1, 2012.

Mayo Clinic believes that under this approach, a group of physicians would be responsible for quality and overall annual Medicare spending for their patients. Different

payment models could be tested. For example, physicians would be paid FFS rates, less a withhold, and then receive bonuses for meeting resources use and quality targets over the course of a year. Options should include creating virtual accountable care organizations based on physician-hospital referral relationships. Such an approach would create incentives for physicians and hospitals to work together to provide better value care.

BUNDLING PAYMENTS CAN HELP CONTAIN COSTS

Both the House and Senate bills have provisions to test a system of bundling payments for Medicare Parts A and B. We are pleased with the pilot projects on Medicare payment bundling. However, we would like to see a more aggressive implementation timetable--not one that starts in 2014 or later, but finishes by 2014--so that we can see more immediate financial results for the Medicare system.

To realize cost savings quickly, Mayo Clinic believes Medicare should start bundled payments for high-cost hospital episodes such as total knee replacement, heart attack, and lumbar disc herniation. Over time, bundled payments could be considered for some chronic conditions as well. The bundled payment should include hospitalization (Part A), physician (Part B) and post-acute care (nursing home, home health care, etc.) services. The outcome would be defined as reasonably attainable improvement

in health status in the safest, most cost-effective way and would cover the entire episode of care through the patient's return to function.

The goal is to reduce practice variation and focus on an outcome-based goal. Such a reformed payment model would encourage improved coordination of care among physicians, hospitals and nursing homes, and it would encourage utilization of nursing and other non-physician caregivers.

CMS INNOVATION CENTER TO ENHANCE QUALITY, IMPROVE PATIENT SAFETY

Mayo Clinic also supports the proposal in the Senate Finance Committee bill that calls for the HHS Secretary to create an Innovation Center within the CMS. The Innovation Center will be authorized to test, evaluate, and expand different payment structures and methodologies which aim to foster patient-centered care, improve quality, and slow the rate of Medicare cost growth. The provision calls for promoting improved quality and reduced cost by developing a collaborative of high-quality, low-cost

health care institutions. The collaborative would develop best practices and proven care methods in improved quality and efficiency, as well as assist other health care institutions on how best to employ such best practices and proven care methods.

INDEPENDENT COMMISSION TO EXTEND MEDICARE SOLVENCY

The Senate Finance Committee proposal includes a provision to establish a 15-member Independent Medicare Commission to develop and submit proposals to Congress aimed at extending the Medicare program's solvency and improving its quality. Each year, beginning in 2013, the Medicare Actuary's Office would make projections about [Page: S11949]

whether Medicare's per-capita spending growth rate in two years will exceed a targeted rate. In years when Medicare costs are

projected to be unsustainable, the Commission's proposals will take effect unless Congress passes an alternative measure.

Mayo Clinic believes that this commission can insulate many health care decisions from direct political influence in Congress while still being accountable to Congress. We also believe that the commission should have the authority to change the health care payment system with the goal to move away from fee-for-service medicine and toward paying for team-based, coordinated care.

In addition to payment reform, the commission could serve as a trusted national data aggregator, making performance and pricing information publically available so that stakeholders can identify best practices and high performers.

This perspective is written by Jeffrey O. Korsmo, Executive Director, Mayo Clinic Health Policy Center; and Bruce Kelly, Director of Government Relations, Mayo Clinic.

4:49 PM EST

Paul G. Kirk Jr., D-MA

Mr. KIRK. I know time is running short. I want to say one thing about this. We have heard talk about the status quo. Make no mistake, this is a situation with respect to--we assume when we hear the words ``status quo'' that things will remain as they are.

In the area of health care and health insurance, things are not going to remain where they are. The status quo is not the status quo. We either move forward or we fall back. If we don't address or at least debate the merits of the bill and don't move it forward, we all know what is going to happen. The figures are there. The average family premium, which is now over $13,000, in 2016 will double to $24,000. That is not the status quo. That is falling back. Similarly, the number of uninsured will

rise from 47 million today to 54 million in 2014. That is not the status quo. That is falling back. Fourteen-thousand people will continue to be dropped from coverage each day. That is not the status quo. That is falling back. I could go on.

There is a reason this bill needs to be debated. It is because the average middle-class working family deserves and needs health care security and financial stability. This bill will bring them that. At least I hope that the Members of the Senate--all 100--would say that, on the merits, this bill and this need should be debated.

4:52 PM EST

Kay R Hagan, D-NC

Mrs. HAGAN. Yes. A lot of what we have been talking about are people who don't have health insurance and who want it enhanced because of preexisting conditions. We have people who are sick and stuck with health insurance.

I received an e-mail from a young North Carolinian who works for AmeriCorps. She was the valedictorian of her high school class. She suffers from a brain abscess. Her illness has put her into debt for the rest of her life. She has health insurance, but it ran out when she hit a $50,000 cap. Her bills far exceed the cap. It is sinking her entire family into debt. She is sick and stuck.

How many people do we know who have a spouse or themselves who have health insurance, and they are working, but they cannot switch jobs because they would lose their health insurance? I have a good friend whose husband has cancer. She wants to change jobs, but she cannot do it because of the condition of her husband. Once again, people are sick and they are stuck. We have to be sure we can have a debate, that we can move forward on health care reform so we can help people.

4:52 PM EST

Ted Kaufman, D-DE

Mr. KAUFMAN. We are all concerned about the economy. Even with health care reform, I think for every Senator I talk to on both sides of the aisle, their biggest problem is getting people back to work again and getting the economy moving. It is truly tragic when you think so many people are losing their jobs. Under our present system, the way it is structured, when you lose your job, you not only lose the money coming in to you, you lose your health insurance. You lose your self-respect because

we are all judged on where we work. That is how people judge us.

As has been said, the longest walk is the walk home to tell your spouse and your kids that you lost your job. The irony of ironies and the thing that makes this so incredible is that you don't just lose your job and self-respect, you lose your health care insurance.

We have a system, and we have to change the system so these people out their right now can maintain their health care insurance and care for their children and their families, as they and everybody in their families go through this very traumatic experience.

4:54 PM EST

Ben Cardin, D-MD

Mr. CARDIN. We are running out of time, with only a few more minutes left. I want the people in Maryland and of the Nation to understand what this vote means. We are going to bring an amendment to the floor of the Senate for debate. Any Senator will be able to offer an amendment to how we should advance health care. The Senator from Massachusetts is absolutely correct. We are either going to continue to see our health care system with more people being denied coverage, with the costs escalating

much faster than our economic growth, with businesses having to decide to terminate plans--that is what is going to happen--or we can take up health care reform and try to rein in the practices of private insurance companies and provide a way where every American can get access to affordable health care. That is why the American Cancer Society Cancer Action Network says:

The American Cancer Society Cancer Action Network urges all Senators to vote in favor of allowing critical health care legislation introduced by Senator Harry Reid this week to be debated on the Senate floor. With thousands of cancer patients being denied coverage, charged excessive premiums, and facing exorbitant out-of-pocket costs, it is urgent that the Senate take action now, not later, to protect and extend health coverage to millions of Americans in need.

Last week, Cynthia and Eric Cathcart were here in the Senate. They are two people who are self-employed. They cannot even get an insurance policy to cover their family. They have to have two separate policies, with two deductibles and two premiums, and they cannot afford it. We must take up this issue for the Cathcarts and the millions of Americans who cannot make it under this current system. Middle-income families are depending upon us tonight.

4:56 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. There is a lot of talk about Medicare and our seniors and what this bill does. Think of the woman I talked about who is a fighter, as her mom says, but she cannot keep fighting a system that is so against her. As you pointed out, the advantage of this bill is, it gives our seniors a better playing field with the drug companies paying for their drugs in the doughnut hole. Also, it is my understanding that AARP wants to advance the bill. Certainly, AARP has stood up for seniors for

years and years and years. They know we need to preserve Medicare and keep it safe.

Can the Senator comment on AARP?

4:56 PM EST

Ben Cardin, D-MD

Mr. CARDIN. AARP not only wants us to advance the bill; they support the bill. They believe this bill will improve the Medicare system, make it stronger, and provide additional benefits, particularly in reducing the dread Medicare doughnut hole. They want the Members of the Senate to vote to allow this bill to come to the floor.

4:57 PM EST

Amy Klobuchar, D-MN

Ms. KLOBUCHAR. Maybe we should end with the Senator from Massachusetts, the home State of Ted Kennedy, having the last word of this very interesting colloquy, in which we heard from the Senators from North Carolina, Rhode Island, and Maryland.

4:57 PM EST

Paul G. Kirk Jr., D-MA

Mr. KIRK. I thank the Senator. I am honored to be a Senator in this body. Back home, they think I am the 60th vote. I would like to believe we would have a more enlightened full body and that 60 would be a number we would pass through.

The American people are looking forward to debate on this issue. I think they believe they deserve many of the aspects that are contained in the bill. On behalf of my constituents in Massachusetts and those who, for so many years, revered and loved and elected and reelected Senator Kennedy--I think they all, as we do, have him in our minds and hearts tonight, and we hope we can advance this bill to the American people, knowing his spirit and years of work are a reminder of our obligation.

I hope we will have a successful vote this evening. That will provide an opportunity for the American people to [Page: S11950]

hear a debate and perhaps allow corrections by whatever amendments may be needed, so we proceed, keeping in mind, as is true in all legislation, we cannot let the perfect be the enemy of the good. The good is something our people have been waiting for, for decades. The time is now. Let the debate begin.

I thank the Chair and yield the floor.

4:59 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. I came to the floor early so I could listen to what my Democratic friends have had to say. I found it quite enlightening, and I have a few comments with respect to it.

They have been debating vigorously against the status quo. They have been giving us examples, heart-tugging, real-life examples of people who are finding difficult problems in the situation as it now exists--as if the debate were between the status quo and doing something.

The debate is between the solution that has been offered by the majority leader and other solutions, which people on this side of the aisle have been trying to bring forward through the entire time and have not been allowed to come forward.

We recognize that things need to be done to fix problems with respect to the health care situation. We realize the legislation we have been living with for all these years needs to be amended. We have been unable to get any of our ideas to come forward. Now we are told there is such urgency to deal with the status quo that we must pass this bill, and we must pass it virtually without amendment.

I would like to point out, as I have done before, if there is such urgency with respect to the challenges we have in health care, why do we wait until 2014 to have those changes come? We have heard all these examples coming on the Democratic side of the aisle of people who have terrible problems under their health care plan. We must act, we must act immediately, and the act will be to say to all of these people: We will solve your problem in 2014. We will delay all of these reforms we are talking

about until 2014.

I made that point the other day, and the Senator from Maryland said, no, some parts of this bill will begin immediately. And he is exactly right. The parts of the bill that would begin immediately are the taxes. We will start taking in money in 2010 if this bill passes. The annual pharmaceutical manufacturers fee would drive up the price of everybody's drugs, an annual nondeductible $2.3 billion fee. That will begin in 2010. The medical device manufacturers fee, another $2 billion, will begin

in 2010. The medical insurance provider fee, that will begin in 2010. The cosmetic surgery fee, that will begin in 2010. In 2011, there will be a limit on contributions and in 2013 a high-cost insurance excise tax. All the taxes are front-loaded, but all of the reforms they promise this bill will bring

to all of the people whose stories they told us will not take place until 2014. The status for them will remain quo. For all of these attacks on the status quo, the one change we will get is they will start charging the taxes but they will not start delivering any kind of health care reform until 2014.

Why are we delaying until 2014? Not because they do not think people need it but because they realize that if they start spending at the same time they start taxing, the score they will get out of the Congressional Budget Office will point out the true cost of this bill. And it is the true cost of this bill that is the kind of thing we need to be debating and talking about rather than listing story after story. My State is full of them, and I am just as sympathetic as anybody of people who have

problems with the present health care system. That is a false debate.

We all realize, all 100 of us realize that something has to be done to make the health care system better. This is not, should we do nothing; this is a debate about what should be done. The proposal we have from the majority leader is not the answer to the problems we face.

5:03 PM EST

Jon Kyl, R-AZ

Mr. KYL. Mr. President, I wonder if I may interrupt to ask, when the Senator said this is not the approach, the approach taken by the Democratic leader, among other things, because of the cost of it--my colleague from Arizona is here, and I think no one takes second place in this body to him in carefully looking at the cost of every bill we have on this floor. He frequently proposes amendments to reduce the cost of the bills.

I wonder if my colleague from Arizona agrees with my colleague from Utah and is aware of the respected columnist David Broder who wrote in today's Washington Post--actually, it is for publication tomorrow--a column, the title of which is ``A Budget Buster in the Making.''

5:04 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, I say to my colleague, not only is David Broder's column this morning important, but he is probably the most respected columnist in America. He talks about it in far more eloquent terms than I can.

I ask my friend from Arizona--a very unusual event happened today. The majority leader, I guess proceeding on the concept, the age-old tried tactic of ``shoot the messenger,'' came to the floor of the Senate and excoriated David Broder, of all people, probably the most respected columnist. I might say, Mr. Broder from time to time has written an article or two or more that has been critical of me, but he always had my respect. For the majority leader, who cannot rebut the facts in David Broder's

column, to come to the floor and excoriate one of the most respected columnists in America is remarkable.

One of the things, I say to my friend from Utah, is that I do not think Americans really understand the scam that is going on here of beginning to collect taxes. Tax increases and Medicare cuts of approximately $1 trillion begin 40 days from now. In other words, on the first of January, according to this plan, Americans will begin experiencing cuts in Medicare and increases in taxes, 40 days from now. But then it will be 208 weeks and 1,460 days before any benefits from the legislation come about.

Tell me, isn't that like a couple goes to buy a house and they say: OK, you can have the house for X amount. And by the way, you have to start making the payments now and for the next 4 years before you can move into the house. Is there anybody who would agree that is nothing but a scam on the American people? I do not think the American people truly understand the reason why--and why would they do that? To disguise the real cost of this $2.5 trillion bill. That is why they do it. I think Bernie

Madoff went to jail for this kind of behavior.

5:07 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. I say to my friend from Arizona, he reminds me of a real-life experience of a husband who at Christmastime came back to his wife and presented her with a brilliant Christmas present that she had not been expecting. She said to her husband: How could we afford this because the only amount we had in our Christmas budget was--pick a number--$200, and this is obviously worth more than $200.

He said: Oh, don't worry about it. I paid $200 for it.

She said: How in the world did you get $200?

He said: The department store agreed to take the other $1,000 in payments later on.

That is exactly what is happening here. We are making a downpayment and telling ourselves that the total cost is covered as outlined by the Congressional Budget Office.

5:08 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Again, it is so important that we read this hernia-inducing bill, that we understand the details of it. Specifically in these cuts, which are going to take place in 40 days--40 days from now; Happy New Year, America--in 40 days, it will cut $135 billion from hospitals, it will cut $120 billion from 11 million seniors on Medicare Advantage.

I would like to pause there for a moment. Senator Kyl and I represent the State of Arizona. We have thousands and thousands--and I am going to get the number before this debate is over--of seniors who are on Medicare Advantage. They are going to cut out the Medicare Advantage Program and tell the American people that if you like your insurance policy you have, you can keep it? How does that work? Then [Page: S11951]

there is $15 billion going to be cut from

nursing homes, $40 billion from home health agencies, and $8 billion is going to be cut from hospice care--my God, hospice care, $8 billion.

Here we are telling the American people that we are going to fix health care in America, and the way we are going to pay for the massive government takeover of health care is through cuts. It is terrible on its face, but does anybody really believe these cuts are going to take place? Does anybody really believe the doctors are going to be cut $247 billion in the next 10 years? Does anybody believe we are going to cut $247 billion--or whatever it is--from Medicare? We are not. Why are we not?

Because we are a loving, caring nation. We are not going to tell our seniors that they are not going to receive a high quality of Medicare.

Of course, this latest mammogram incident where a board, not unlike the one that is envisioned in this bill, said that women over 40 should not have mammograms--by the way, I have a close friend, Carly Fiorina, who has just recovered from chemotherapy. What would her situation be today if she had not had a mammogram? Women all over America are rising up about it. If you think that is bad, wait until you get this legislation.

By the way, while my friends are standing, I would like to say please sit down, I have shocking news. The three Senators we were worried about--the Senator from Louisiana, the Senator from Arkansas, and the Senator from Nebraska--shocking news. They are going to vote for this bill to move forward. That was an issue of tremendous speculation with the media. I certainly did not know that with all the protestations we had from those three Senators that, by golly, they were thinking long and hard.

Guess what. So, OK.

5:11 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. I say to my friend from Arizona, and then I will yield to my friend from Tennessee, Senator McCain

just asked a question: Does anybody really believe these cuts will take place?

I share with him an experience I had driving home from the Senate just this week. I was listening to the radio, and the first story on the radio was this vote coming up. The Senate is going to vote at 8 o'clock on Saturday. The second story was that the House of Representatives just passed a doc fix of $200 billion. So we already have action by the House of Representatives proving that the comment by Senator McCain is exactly right. Before this bill even gets passed, they are reversing

the cuts over in the House of Representatives. Senator Reid tried to do it here before we got to this bill, and we voted him down. So the House is going to take care of it, and they will ping-pong the bill over here.

There is no question that these cuts will not take place.

My friend from Tennessee wishes to comment.

5:12 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. Mr. President, I see the Republican leadership in the Chamber. It seems as if every other word we hear coming from the other side is that this vote tonight is historic. I agree, it is historic. But I think my view of why it is historic is a little different from their view.

I wonder if my colleagues would not agree with me that this bill is historic in its arrogance? It is historic in its arrogance to think that we in Congress are wise enough to take this entire complex health care system, that serves 300 million Americans and is 16 percent of our economy, and think we can write a 2,074-page bill and be wise enough to change it all at once. It is historic in its arrogance by dumping 15 million low-income Americans into a medical ghetto called Medicaid, which none

of us or any of our families would ever want to be a part of for our health care. It is historic in its arrogance by sending the States, that are going broke, a big chunk of the bill for what we have just done. It is historic in its arrogance because it tells Americans that the bill costs $849 billion and then thinks we are not smart enough to read the print and figure out that the real cost is $2.5 trillion when it actually is implemented. It is historic in

its arrogance by telling us that paying for reimbursement for physicians is not an important part of a health care bill. It is historic in its arrogance because it cuts and taxes grandma's Medicare, which according to the trustees will be broke by 2015 to 2017, and then spends it on somebody else other than grandma. The bill is arrogant because its telling us it will reduce premiums for most Americans, when, in fact, it increases premiums for most Americans.

So People say: Where is the Republican health care bill? My answer to that is, don't expect Senator McConnell to come rolling in here with a wheelbarrow with a 2,074-page budget-busting, debt-ridden, arrogant piece of legislation because that is not what we believe in.

What we need to do as a Congress is re-earn the trust of the American people by setting a clear goal of reducing health care costs, showing some humility, and starting to move step by step in that direction. I hope during this hour that we have a chance to talk about the specific steps to reduce health care costs that we Republicans have offered day after day to no avail.

5:17 PM EST

Mitch McConnell, R-KY

Mr. McCONNELL. I certainly share the views of Senator McCain that letting these cuts stand is not likely. On the other hand, the President of the United States said he would veto any measure seeking to reverse these cuts. So we have a Hobson's choice: Either the cuts will occur in which case seniors will be devastated or they will not occur, as the Senator from Arizona has pointed out, and the deficit will balloon further.

5:18 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Did the majority leader happen to notice that the AARP has now endorsed this bill? It has endorsed a bill that will cut people, 300,000 of them in my State, from their Medicare Advantage Program, that would cut $15 billion from nursing homes, that would cut $8 billion from hospices, and that AARP, which, by the way, I understand gets some $60-some million out of this deal--I say to the senior citizens in my State: Take your AARP membership card, cut it in half, and send it

back to AARP because they have betrayed you.

5:19 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. If I could make the comment, Mr. President, among the people who do not believe these changes would not occur is CBO itself. CBO itself agrees this is smoke and mirrors. They do it in very polite language, but let me share with you the language. They say:

These longer-term calculations assume that the provisions are enacted and remain unchanged throughout the next 2 decades, which is often not the case for major legislation.

[Page: S11952]

That is about as gentle a way as CBO can put it. They don't believe this thing is going to stand without these kinds of changes. Yes, they have come forward because their computers say: You put the numbers in this way, this is the result you get. But human beings are saying that is not what is going to happen over the next two decades.

5:19 PM EST

Jon Kyl, R-AZ

Mr. KYL. If my colleague will yield, Broder, in his column as to this estimate of budget deficit, he says it depends upon two big gambles.

Will future Congresses actually impose the assumed $420 billion cuts to Medicare, Medicaid and other Federal health care programs? They never have.

5:20 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Also, I would like to follow up on what the Senator from Tennessee has said because, particularly from some quarters on the other side of the aisle, we have been attacked: Where is the Republican plan?

A very important article was written by Robert Samuelson in the Washington Post on November 16--again, one of the most respected economists in America.

I don't lay off these opinions of my own on them, but the fact is, when you have highly respected people like Robert Samuelson, one of the most respected economists in America, I quote from his column--the title is ``Obama Care, Buy Now, Pay Later.'' That is the title of it. He says--which I think is directly in consonance with what the Senator from Tennessee said:

[A] prudent society would embark on long-term policies to control health costs, reduce government spending and curb massive future deficits.

Then he goes on to say:

So what do they do? Just the opposite. Their far-reaching overhaul of the health care system--which Congress is halfway toward enacting--would almost certainly make matters worse. It would create new, open-ended medical entitlements that threaten higher deficits and do little to suppress surging health costs. The disconnect between what President Obama says and what he's doing is so glaring that most people could not abide it.

That is strong language from an economist. I think what the Senator from Tennessee is saying, and what we are trying to say is, let's go forward. Let's have malpractice reform. That is nowhere in this monstrosity. Why don't we encourage health savings accounts and expand them? Why don't we let people go across State lines to get health insurance policies of their choice? Why don't we reward wellness and fitness? There is a long list of amendments, of fixes to the long-term costs of health care

that we could control, that we could enact tomorrow on a bipartisan basis. They do not add to the deficit. In fact, what they do is control health care costs, which is what is wrong with health care in America.

The quality of health care in America is outstanding. It is the cost. We could be working together step by step, as the Senator from Tennessee says, with a long list. I am sure he will add to them the ones I just gave out to control health care costs in America. We stand willing to do it.

After this bill fails, because the American people overwhelmingly are beginning--it may pass the Senate. It may pass the House. It will not pass.

Then why don't we sit down together for a change, Republicans and Democrats, and move step by step to fix the health care problems in America?

5:23 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. The Senator from Arizona is exactly right.

There is no Senator in the Chamber who has a better record of working across party lines on bipartisan steps in the right direction than the Senator from Arizona. But going to Mr. Samuelson's comment--I was talking to a businessman this morning.

I said: If you had a problem in your company, would the first thing you would do is to tear the whole company down and start over again? Or if the football team had lost two or three games, would you blow up the stadium and run everybody off? No, that is not the way you do it.

The person I was talking to said: What I would do, I would identify the problem, I would test the solution, I would phase it in, and I would make sure we can afford it.

The American people know that. I think they are sitting up there looking at us saying: What are these guys doing? Two-hundred-fifty million of us have health care policies, 85 percent. We would like for the rest of America to have that opportunity too. But we know we can't afford that until we get the costs down.

Why don't we do as the Senator from Arizona suggested, let's move step by step in the right direction to re-earn the trust of the American people by reducing costs?

He said: Why haven't we done that? One of those steps is to allow small businesses to pool their resources and purchase a health plan, which the Congressional Budget Office has said would allow nearly 1 million more employees of small businesses to be covered. Their rates would be lower than they are paying today. It would save $1.4 million of Medicaid. This is what the Congressional Budget Office said. So it would reduce costs, increase insurance coverage, and lower premiums. The reason we are

not considering it is because when we brought it up, the Democrats said no. They filibustered it. They didn't come across the aisle and say that is a pretty good idea; let's put that together with two or three of ours, and we will reduce costs.

I say to Senator Bennett of Utah, you have founded a company. You have run a company. If you were having a problem with the cost of a product or some other fundamental problem, is the first thing you would do, is to think you were wise enough to tear the whole thing down and start over again? Or if you called in a consultant and he recommended that to you, what would you say to him?

5:25 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. Obviously, I would not respond in the way the folks across the aisle have responded to this health care crisis. The example the Senator has given is a valid one. That is not how you deal with it.

The other point I would make is that if I had a serious problem that was causing difficulty for the survival of the

company, I would not put the solution off for 4 years while I raised prices on the existing products to try to pay for it. I would try to do what I could to get the fix upfront as soon as possible.

As both Senators have pointed out, we Republicans have fixes that could start now and don't have to wait until 2014 in order to get a good CBO score.

5:26 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Along those lines, again, about this Madoff-type budgetary procedure, I am not that good at math. I am sure the Senator from Tennessee is. Help me out.

We have $1 trillion that they want to make in offsets, right, in this 10-year plan. If you started the program at the same time that you enacted the savings, that would be $1 trillion, right? That would be $2.5 trillion. So the deficit, if you used correct accounting procedures--in other words, you bring in the benefits at the same time you start paying for it--you would end up with a $1.5 trillion deficit to the budget? Does that make sense?

5:27 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. It sounds right to me. It is another part of the arrogance of this bill, which is to say we are not smart enough to figure it out. The majority is saying the 10-year cost of the bill is $849 billion, but it doesn't start counting until the fifth year, and Senator Reid thinks the American people are not smart enough to figure that out. That is part of the arrogance of the bill.

5:27 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. I point out the CBO makes the same point at these 10 years. Again, quoting the CBO letter, talking about the 10 years following, when you have the full 10 years of expenditures instead of just 5 or 6 years of expenditure, it says:

Under the legislation federal outlays for health care would increase during the 2010-2019 period, as would the federal budgetary commitment to health care.

So those who are saying this is going to be a saving to the government and you are going to turn the cost of health care--turn the cost curve with respect to health care down, the CBO has said: No, that is not the case. The Federal commitment would go up in those years.

Again, by delaying the implementation of the expenditure while implementing immediately the implementation of the revenue, they are creating the kind of financial chicanery that, as Senator McCain has said, put Bernie Madoff in jail. [Page: S11953]

5:29 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Could I bring up another issue to the Senator from Tennessee and the Senator from Arizona and Utah. A New York Times article this week stated: ``Drug Makers Raise Prices in Face of Health Care Reform.''

Even as drugmakers promise to support Washington's health care overhaul by shaving $8 billion a year off the Nation's drug costs after the legislation takes effect, the industry has been raising its prices at the fastest rate in years.

In the last year, the industry has raised the wholesale price of brand-name prescription drugs by about 9 percent, according to industry analysts. That would add more than $10 billion to the nation's drug bill, which is on track to exceed $300 billion this year. By at least one analysis, it is the highest annual rate of inflation for drug prices since 1992.

So the moral of the story is, you lie down with dogs and you get fleas. So they cut a deal with the administration to cut drug costs, and guess what. With inflation zero, no inflation, they have decided to raise costs by more than 8 percent. Oh, the Consumer Price Index has fallen by 1.3 percent. The Consumer Price Index has fallen by 1.3 percent, and the prescription drugs have increased in cost by 9 percent.

What does this do to seniors? Seniors are not going to get a COLA in Social Security this year because the consumer price index has fallen--which is the indicator as to whether cost of living adjustments are given to Social Security recipients. So what does the drug industry do? Without inflation, they raise the cost of prescription drugs by some 9 percent at a time when Americans are hurting more than ever. Shame on the drug industry. Shame on those people, and shame on the administration for

cutting a deal with them.

5:31 PM EST

Jon Kyl, R-AZ

Mr. KYL. Mr. President, I see our other colleague from Utah here. I know that during Finance Committee deliberations, he was directly involved in one of the conversations about the drug costs and also has been working on his own ideas for alternative approaches to some of these problems. I will ask a question and then if my colleague from Utah, Senator Hatch, may like to comment further, we would invite that.

Is it the case that the Joint Committee on Taxation, which reported to the Finance Committee, and the Congressional Budget Office both said that not only would the increased taxes on the pharmaceutical industry, the medical device industry, and the insurance industry be passed on to consumers in the form of higher premiums but that overall under the legislation that is before us, for the average family as compared to what prices are today, insurance premiums would actually go up and this was

one of the two major reasons, the other being mandated benefits?

5:32 PM EST

Orrin Hatch, R-UT

Mr. HATCH. The Senator is absolutely right. They even said the premiums of the so-called government plan would be higher than private sector insurance premiums. It is incredible.

I have enjoyed the comments by the distinguished Senators from Arizona, Utah, and Tennessee. If you look at what they are trying to do, they are going to throw out a system that 85 percent of the American people feel is basically OK, because they have not taken care of the 15 percent who don't have insurance. But when you deduct the 6 million people who work for companies that provide insurance but they don't take it--they would rather have the money--and you take out the 11 million people who

basically qualify for Medicaid or SCHIP but are not enrolled, and you deduct those who earn over $75,000 a year and can afford their own insurance, and then you take the illegal aliens, the documented workers and undocumented workers, you basically come down to 17 million people who need and deserve our help. We are going to throw the whole system out for 85 percent of the people when we could, through subsidization, help those who deserve help.

It doesn't make sense. What are they thinking over there? I hope it is not that they want to take us to socialism or to Europeanize us, when Europe is trying to get away from Europeanization.

We are rapidly approaching one of the most important votes for all of us in the Senate. This is bigger than any of us, our parties or our ideologies. This is about the future of the greatest Nation in the history of the world. It is about your children and my children. It is about your grandchildren, my grandchildren. Elaine and I have three great-grandchildren and two more on the way. It is about giving the future generation the same opportunities and same sense of pride. It is about every American's

way of life.

Every American business will be subject to this. Look at that thing, a 2,074-page edict from Washington. I am going to spend my time before this historic vote to highlight some very important numbers. Every Member of this Chamber should understand what they are voting to advance. Make no mistake, our actions today will not be without consequences. History and future generations will judge us by what we do here today.

Zero is the number of provisions prohibiting the rationing of health care, not one word prohibiting the rationing of health care. All you have to do is look at some of the things that happened this week and you start to worry about it. How about this? Zero is the number of government-run entitlement programs that are financially sound over the long term. Consider these important numbers: 10.2 percent national unemployment rate, the highest in 26 years; 70, the total number of government programs

authorized by this bill, 70 new programs at a time when we are going into fiscal insolvency; 1,697 times the Secretary of Health and Human Services is given authority to determine or define provisions in this bill. We are turning the whole thing over to the bureaucrats here in Washington. More numbers: 2,074 total pages of this bill--look at that--2010, the year Americans start paying higher taxes to support this bill. My colleague from Utah and my colleagues from Arizona and Tennessee have brought that out in no

uncertain terms. The year when this bill actually starts is 2014, most of the major provisions of this bill. Some of them don't even begin until 2015. The number $6.8 million is the cost to taxpayers per word in this bill; $8 billion is the total amount of new

taxes on Americans who do not buy Washington-defined health care; $465 billion in cuts in Medicare at a time when Medicare faces a $38 trillion unfunded liability to finance more government spending; $494 billion is the total amount of new taxes in this bill.

If you think that is all, I think you have something coming here. According to the Budget Committee, using CBO figures, $2.5 trillion is the real cost of this bill over a 10-year period. Our total national debt will be $12 trillion. These numbers are facts and they are indisputable.

Let me finish by reading an excerpt from a fellow Utahn from Provo who is worried about what this bill will do to our country.

I am writing out of deep concern over the increasing expansion of government. I moved here from Germany 20 years ago. I love America because it is free--free-er than Germany in that I have the freedom to choose among other things how I want to insure my family (we have six children). I'm all for affordable health insurance which requires affordable health care. I am self employed and have been hit hard by the economy. There is a good chance that we would actually benefit from [this bill]. Business

has been so bad that we would qualify for free school lunches if we asked for it. But I don't want more government handouts. I don't want the government telling me what kind of insurance I need to have. I don't want the government telling me what services

I can receive when I need them. I don't want them taking an ever greater part of my income to help finance government programs such as the ``public option'' and the army of government employees it will take to administer such a program. I do not want more

government. I want less. A lot less.

These people from Germany have been living in our country as citizens for 20 years. They know what it was like to have their type of a system. I think we ought to pay attention to that humble person who, in spite of the travails they have, don't want this big, massive government program to become law.

5:39 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, I thank both Senators from Utah for their thoughtful comments and significant involvement. I wish to return to the issue of what we need to do. I say that because criticism has been leveled at this side of the aisle that we have no plan; therefore, since we have no plan, we should embrace this. The fact is, we have had plans. We have had proposals. We have tried to get them listened to. They range from medical malpractice reform to other free market cost reduction

measures that add competition [Page: S11954]

and quality to the health care system. Our objective is affordability and availability.

I want to talk with the Senator from Tennessee about the issue of medical malpractice reform. Here is a huge piece of legislation. Yet I ask my friend from Tennessee, is there any measure in this bill we have been able to detect so far--we have been able to detect $100 million in additional Medicaid benefits for the State of Louisiana, but we haven't been able to determine all of the aspects of this bill. On the issue of medical malpractice reform, physician after physician in America says they

have to practice defensive medicine for fear of finding themselves in court. Why is it that we have literally no addressing of an issue that could significantly reduce cost?

As I recall, the CBO said that medical malpractice reform could reduce direct medical costs by some $54 billion over 10 years. There are other estimates that say if we added in the cost of the practice of defensive medicine over prescription medicines and drugs because of fear of finding themselves in court, this could be as much as $200 billion. Yet there is not one significant addressing of the issue of medical malpractice in this legislation. I think that is a testimony to the influence of

the American trial lawyers association.

5:42 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. Mr. President, I would say to the Senator from Arizona, that is a part of the problem. But I think of it a little different way. There has been a lot of talk this week about medical care availability for women in America. In Tennessee, in 45 of our 95 counties, there are no OB/GYN doctors. So pregnant women in Tennessee in those counties have to drive 50, 60, 70 or 80 miles for prenatal health care. They might have to check into a hotel for a few days in a big city in order to

have their baby.

5:43 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Could I add, the mirror opposite of that is the State of Texas which was hemorrhaging medical doctors and care providers and then, after they enacted a very modest malpractice reform, there was a flood of physicians returning to the State of Texas. Isn't that the case?

5:43 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. That is exactly right. In fact, a number of us have offered to the Senate, as a part of the way we would go about reducing health care costs, basically adopting the same kind of provisions they did in Texas which still leaves anyone who is hurt, a complete right to recover from that injury, but makes a major change in the availability of doctors to that patient. And in the case of Tennessee, we were talking about OB/GYN doctors to women who are about to have babies. The Senator

from Arizona said that would save at least $54 billion over 10 years. No one doubts that reform of medical malpractice, junk lawsuits against doctors, would reduce costs. The point we are trying to make here is, instead of that historically arrogant 2,074-page bill that presumes we know enough to change every aspect of

health care in America, why don't we re-earn the trust of the American people, who have lost a lot of confidence in those of us in Washington, and start taking steps in the right direction to reduce cost? We could do it by adopting our legislation to reduce unwarranted medical malpractice suits. That would be one step.

5:44 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Could I revisit with the Senator an issue we talked about a little earlier and with my friend from Utah as well. This is the recent spate of publicity concerning a recommendation that women wait until 50 years of age before--I see our physician Dr. Barrasso is here also--getting routine mammograms. That ignited a firestorm throughout America and story after story of women who have experienced breast cancer who state categorically that if they hadn't gotten the mammogram

when they did, it is possible they would not be alive today.

Now that is a nice academic discussion. But I would ask--maybe Dr. Barrasso would answer it--isn't that the kind of advisory board this legislation could put into law; that those kinds of mandates could come down, which could literally jeopardize the health and lives of Americans?

5:46 PM EST

John A. Barrasso M.D., R-WY

Mr. BARRASSO. Mr. President, I would say to my colleague and friend from Arizona, this type of legislation would have cost my wife her life. She is a breast cancer survivor, diagnosed by a routine screening mammogram. She was in her forties when that mammogram was performed. She went through the testing and had the operation. In that age, in her forties, she already had the breast cancer spread from her breast to one of the lymph nodes. It was a screening mammogram that saved her life. She has

had three operations, two bouts of chemotherapy. As a result, she is a survivor--6 years later.

But this piece of legislation says: No, no, do not worry about it. There is not going to be any denial of care. There is not going to be anything like that. But if you turn to page 1,150, it talks specifically about this preventative task force, specifically saying when they make their recommendations there is going to be money that taxpayers are going to pay to tell people what those recommendations are. Then, if you go to page 1,190, it says that if it is not approved, they will deny payment

for that service--deny payment. It does not say they might.

5:47 PM EST

Jon Kyl, R-AZ

Mr. KYL. Mr. President, I went back to my office and got the exact pages our doctor colleague has just been talking about--page 1,189 and page 1,190 of the actual bill. My colleague from Arizona asked the question--this entity, this U.S. Preventive Services Task Force; the entity that made the recommendations with regard to mammograms is it possible their recommendations could be used to deny coverage or reduce payments or deny payments?

Well, here is the exact language, if my colleagues would like to hear it. The Secretary of HHS is, of course, the person who implements this. It is not the task force. The task force makes the recommendations, and then the Secretary of HHS issues the regulations. Quoting:

Notwithstanding any other provision of this title, effective beginning on January 1, 2010,--

That is just a couple months from now--

if the Secretary determines appropriate, the Secretary may--

(1) modify--

(A) the coverage of any preventive service described ..... to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force. .....

So there you have modifying the coverage. Then, secondly, as my colleague was just reading:

(2) provide that no payment shall be made under this title for a preventive service described in subparagraph (A) of such section that has not received a grade of A, B, C, or I by such Task Force.

In other words, they make the recommendation, and they say this does not meet our standards, so she can say, therefore, we are not going to pay for it.

That is taking the recommendations of this task force and translating it into the rationing of health care. This is how rationing begins.

5:49 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. Mr. President, if I could share with Senators this statistic. We hear a lot of talk about everybody has to be covered. We talk about the United Kingdom, where they have a plan where everybody is covered. The cancer survivor rate for women with breast cancer in the United Kingdom, after diagnosis, is 57 percent. The cancer survivor rate in the United States, where we have people who are not covered, is 67 percent. I do not think we want to move in the direction of bringing that rate

down.

5:49 PM EST

John A. Barrasso M.D., R-WY

Mr. BARRASSO. The reasons for that are they are not doing early enough screening, and even once they are able to find the cancer in Great Britain, how long do they have to wait in line until they actually receive the surgery? The delay of care is the denial of care, and that is what is going to happen under this bill.

I see my colleague from Idaho standing as well because he is familiar with this situation. But I look at this and see the numbers. They said: Well, we don't want to cover this service because it would only save 1 life out of 1,900 women in their forties. Well, in my case, that 1 life out of 1,900 was my wife Bobbi.

I know the Senator from Idaho wants to get involved in this discussion.

Senator Risch.

5:50 PM EST

Jim Risch, R-ID

Mr. RISCH. Mr. President, as you read these pages, most of it is incomprehensible. But, interestingly enough, [Page: S11955]

the point made by the good Senator from Arizona about the ability of the U.S. Government to cut off health care to people is stated so clearly on page 1,189 of the bill. The title of the provision is ``Authority to Modify or Eliminate Coverage of Certain Preventive Services.'' How much clearer can it be? This bill gives authority to the group

that was identified to modify or eliminate coverage of certain preventive services.

Had this bill been in effect in the last week when the recommendations came out on mammograms, American women would be denied coverage for mammograms in the time period that was identified by this group. This is absolutely clear on this. This is just the beginning of the kind of health care rationing you are going to see under this bill. Americans are frightened, and they should be. Health care rationing is coming to America if this bill is passed.

5:52 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. Mr. President, I would like to share another statistic in this whole circumstance that I think we need to focus on because, back to the Broder column Senator McCain talked about, we are talking about the amount of expenditures and the creation of a new entitlement.

Let's go back to the debate on the budget. We got the numbers that said the projected revenue for fiscal year 2009 was $2.2 trillion. The entitlement spending for 2009 was $2.2 trillion. That means everything we have done in government--our embassies overseas, our military, the national parks, education, whatever it is--absolutely everything in 2009, other than entitlement spending, had to be borrowed money.

What are we doing with this bill? We are going to increase entitlement spending. We are going to increase the role of government that this Congress or future Congresses have no direct control over through the appropriations process. I have been chairman of an appropriations subcommittee. The amount we have control over in the Ag Subcommittee is about $17 billion. The total bill was $80 billion. The rest of that $80 billion was off-limits to the Appropriations Subcommittee because it was on autopilot

as entitlement spending.

The entitlement spending for farm subsidies is small potatoes, to use a farm subsidy word, compared to the entitlement spending for health care. So facing the kinds of deficits we are facing, facing the runaway entitlement spending we have, the largest portion of which is entitlement spending for health care, what are we being told to do? Increase the entitlement spending for health care and put future Congresses in an even deeper financial bind by taking even more of the total portion of the

Federal budget that is outside the appropriations process and putting it on autopilot. That is the issue we must keep in mind as we look at this whole circumstance.

5:54 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, I thank the Senator.

Could I go back, again, and reemphasize with my colleagues and the American people what is very odious about the bill that is before us; that is, the Madoff-style budget gimmickry associated with this legislation. In 40 days--in 40 days--tax increases and Medicare cuts of approximately $1 trillion will begin--in 40 days. That is 6 weeks from now. But any benefits that would accrue from this legislation would begin in 208 weeks--1,460 days.

So why in the world would we approve--and, obviously, we know why it is done. It is to make the budget look better, when it is deception being perpetrated on the American people because we are not telling them the true cost. We are not telling the truth because, if the benefits

started at the same time the taxes started, it would be a $2.5 trillion deficit over 10 years.

It is unfair to the American people, who are going to have to foot the bill for this massive piece of legislation--it is unfair to them to tell them they are going to have to start paying the taxes and footing the bill for it and only 4 years later would any benefits come to them. I think that is a really wrong thing to do to the American people.

Do you know what. The American people are beginning to figure it out. Mr. President, 51 to 35, the American people do not want this. The American people do not want an increase in the deficit. They want the spending stopped, and they are figuring it out. I am afraid my friends on the other side of the aisle may have underestimated the intelligence of the American people.

5:56 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. Mr. President, I would like to thank the Senators from Arizona, Utah, and Idaho. Reading that big bill is very hard to do. So for those who are watching, what we have been trying to do--as Senator McCain and Senator Kyl just did--is take specific provisions and discuss them and interpret them.

We have done that with the higher premiums. We have done that with the higher taxes that the bill will require. We have done that with the Medicare cuts. Earlier today we had an hour discussion, led by Senator Corker, that discussed how the bill would send the costs for Medicaid expansion to States.

We have talked now about what we would do if this bill were to fail, which we hope it does. We think this bill is historic in its arrogance--arrogance that we could turn over this whole system, that we think the American people cannot figure out that the bill costs $2.5 trillion, instead of the $849 billion, as advertised.

What we propose is, we move step by step in the direction of cutting health care costs for individuals and for our government. We have proposed legislation that would reduce junk lawsuits, combat waste, fraud, and abuse, allow small businesses to pool resources to purchase insurance, allow Americans to purchase health insurance across State lines, expand health savings accounts, and promote wellness and prevention.

5:58 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. Mr. President, I wish to make the point, again, following up on what the Senator from Tennessee has had to say, that the argument we are hearing from the other side is a false argument when they say it is either this bill or the status quo and the Republicans have nothing to offer.

We have been offering proposals all along. I have been immersed in this for 3 1/2 years, cosponsoring, with my Democratic friends, ideas on the way to go forward. Those proposals were not even allowed to be considered in committee. The 2,000 pages we see before us were written without a single Republican knowing where the room was, let alone being in the room. Then we are told: But you stand for the status quo, and the status quo is unacceptable.

I repeat what I said earlier: The way this bill is constructed, the status will remain quo until 2014, as far as benefits are concerned, but the taxes will start immediately. But we all know the revenue that comes from those taxes will not be held in trust to pay for the benefits in 2014. They will go for other things, to pay for the $1.4 trillion deficit we have this year. Then, in 2014, when the expenses start, the money will all have been spent that had been brought in, in the 4 years previously,

and, as the CBO says, there will be change.

I yield the floor.

6:00 PM EST

Debbie Stabenow, D-MI

Ms. STABENOW. Mr. President, it is my pleasure and honor this evening to be here to strongly support this motion, this historic motion to proceed to a historic debate about whether we, as America, the greatest country in the world, are going to make sure all Americans have access to affordable health care insurance.

This is something that has been debated for 100 years. Now we have the opportunity, with the House having passed their version, to move forward to this debate where we will have lots of opportunity to offer amendments and to debate honest differences in policy. But in the end, I believe confidently that we will come together to move forward to pass legislation that will save lives, that will save money for the American people, that will protect Medicare, and that will stop insurance abuses happening

for families every single day.

I have come to the floor so many times to talk about health insurance reform, as has the distinguished Presiding Officer from Rhode Island. I wish to take just a moment to say thank you to a few people because, as the Presiding Officer knows, we would literally not have this opportunity today if it were not for Senator Harry Reid, [Page: S11956]

our distinguished majority leader. He is a quiet, smart, determined, focused leader who has listened to everyone,

who has looked at the work products from the Finance Committee and the HELP Committee and brought together a combined bill that is the best of both. He is going to give us the opportunity to continue to debate and improve it on the floor before final passage. So I thank Senator Reid. I know he is passionate about his State of Nevada, and that is his No. 1 love after family, but I think No. 2 is the Senate and the ability to lead and get things done, and I thank him.

I thank Senator Baucus for his incredible leadership on the Finance Committee; Senator Dodd for his leadership and stewardship in bringing the HELP Committee through with their legislation; Senator Harkin, Senator Wyden, and Senator Bennett, who is on the floor. We are not agreeing on the movement forward on this bill, but there have been 2 years of working on health care that I appreciate, and their efforts together to work on health care.

I thank Senator Snowe. I don't know if she is going to be with us this evening, but her courageous vote on the Finance Committee is something we desperately appreciate. I know she is going to continue to provide input, and I am hopeful she will be with us on the final vote because her input and her knowledge have been extremely important in this process.

I also thank the memory of a very important Senator named Ted Kennedy, who I know is here in spirit, for 40 years of dedication to this cause.

Finally, I thank President Obama. If not for his vision, we would not be here today. For 8 years under a former President, we did not have the opportunity to get here to this place. We did not have the opportunity to be able to end insurance abuses and truly protect Medicare for the future, to put forward health care reform, to save lives, and to save money. I also thank President Obama for understanding that health care is also about jobs and that we have too many people in this country today

who are losing their job, and with that they are losing their health insurance. So it is impossible to talk about health care reform without also talking about jobs because for most families they are connected and one and the same.

I have spoken on the floor so many times on health care cost and access. Frankly, health care is something that brought me to public service 30 years ago; when I was 5, I just want to say that for the record. I led an effort in our community to keep a nursing home open in Okemos, MI, and ever since then have been fighting to get to this debate, to get to this point in terms of affordable health insurance for all Americans.

So tonight, after this vote, we start the real debate. This bill provides a framework for every American to find affordable insurance. Is it everything I would do if I was writing it by myself? Of course not. Every Member can say the same thing. But the Democratic process is coming together with the best ideas and negotiating and doing the best we can to be able to solve as much as we can in the best way possible. I am going to continue to work to make health care truly affordable and will be

sponsoring and cosponsoring amendments as we move forward to improve on what I believe is a very good bill. I am confident that at the end, again, we will pass legislation that saves lives, that saves money, that protects Medicare, and that stops insurance abuses.

When we first started this effort, I set up the Health Care People's Lobby on my Web site so that people could share their stories, how they felt about what we should be doing. Should we move forward and act? What should happen? What were their experiences with their health insurance and the companies that cover them now? I have heard so many stories. I wish to thank everyone--thousands of people--who has shared their story. I want to put a face on this debate and vote tonight by sharing just

a couple with you.

When we say saving lives, this is not just a slogan. We are talking about saving lives. Forty-five thousand people have the ultimate rationing every year because they can't find affordable insurance. As a consequence, they lose their lives--45,000 people in the greatest country in the world. We can do better than that, and that is what this bill is about.

I wish to share just one story of a young man, Joe, from Okemos, MI. He is a recent graduate of dental school. He worked very hard, was very bright. He was just between jobs after completing his residency, and we know how long and hard that is, to get to that point. He suddenly fell ill. This was only a few months ago. He called his mom. She urged him to go to the doctor, but because Joe didn't have insurance, he was worried about going to the doctor, so he didn't. He continued to feel worse.

His family finally got him to agree to go to the hospital, but by then it was too late. Joe died at age 27 of an aneurism--27 years old--because in America, he didn't have insurance and was afraid he couldn't afford it if he went to a doctor.

This is about saving lives. This is about saving money for businesses that are trying to keep the doors open, that may provide insurance now but are at a point where either the jobs go or they have to stop providing insurance. So people come in, and the owner says: I want to keep you working, but we are not going to be able to have health care for you anymore.

This is about the fact that our country is spending twice as much as any other country on health care and yet sometimes having outcomes that are far worse than we would like to see as it relates to other countries. We are 29th in the world in the number of babies who make it through the first year of life. Of all of the insurance companies a woman can choose from if she goes into the private individual insurance market--59 percent don't provide maternity care, basic care, prenatal care, care

for mom and baby during the first year. So that is going to change because of the values we bring to this.

We are going to protect Medicare. Folks don't have to believe us. There is a lot of debate about what is happening in Medicare. I am very proud to say we have received a very strong letter from the AARP supporting a ``yes'' vote this evening to move forward on this debate, and that is critically important for us.

Let me share from the Web site of AARP what they say--the champions for seniors in this country; what they say, not what we say--about what is being done in health care reform.

On their Web site:

Myth: Health care reform will hurt Medicare.

Fact: None of the health care reform proposals being considered by Congress would cut Medicare benefits or increase your out-of-pocket costs for Medicare services.

Fact: Health care reform will lower prescription drug costs for people in the Medicare Part D coverage gap or doughnut hole so they can better afford the drugs they need.

Fact: Rather than weaken Medicare, health care reform will strengthen the financial status of the Medicare program.

That is why AARP has written a letter urging us all to vote yes on the motion this evening we will be voting on, because we are strengthening Medicare for the future.

Then let me speak to the question of insurance reforms because the reality is that the majority of people have insurance. The majority of us so far have insurance through our employer, and we hope that as we bring down the costs and save money, that, in fact, we will be able to make sure people are going to be able to continue to have the coverage they are paying for today. So we are talking about insurance abuses and stopping those insurance abuses.

I wish to share a couple of stories from individuals who have found themselves in a very difficult situation. I realize my time has come to an end, so I will be brief, but I do want to share just a couple of stories in conclusion.

From the newspaper recently: Benjamin French, a young boy in Michigan, was born with his right arm missing below the elbow. In his 12 years, he has been fitted with seven prostheses. His most recent replacement will cost nearly $30,000, and his doctor says he will soon grow out of it. He is a 12-year-old who is growing up, so as he gets an artificial arm, it has to be replaced periodically to be able to grow with him. But according to his insurance company, the boy is ineligible for future coverage

of prosthetic devices because he has already spent his lifetime maximum benefit. That is going [Page: S11957]

to stop. We are going to eliminate those lifetime caps that get in the way of a 12-year-old being able to have the artificial arm he needs as he grows up so he can lead a normal life.

I wish to share one other story, and that is from Glen from Sterling Heights. He is 62 years old. He got laid off in December. It doesn't look as if he will be called back. He writes:

I am too young for Medicare. I have preexisting conditions, so nobody wants to insure me. If I get sick before I can get Medicare, my savings and everything else will be wiped out. This is not the way I pictured retirement was going to be. I raised four children, got them through school, and married; paid taxes and did what I thought was the right and moral thing to do. I didn't create this mess, but I am sure paying for it.

He did the right and moral thing, and that is what we are being asked to do on behalf of the American people.

Vote to move forward tonight. Vote for the debate. Doing nothing is not an option when we are losing jobs, people are losing lives; when we are losing the capacity of the country to be able to provide the health care for our families that we need to provide. It is our turn tonight to vote yes on proceeding to a debate that I believe, working together, will result in legislation on health care that will save lives, save money, protect Medicare, and stop insurance abuses.

Thank you, Mr. President. I yield the floor.

6:15 PM EST

Bob Menendez, D-NJ

Mr. MENENDEZ. Mr. President, for many months the voices of opposition to any health care reform have been loud and clear. They have been shouting at townhall meetings and heard in debates in this Chamber. All too often, we have heard shrill voices raised in anger from those who are either misinformed or who would choose the status quo that benefits insurers at the expense of families. For too long those voices have gone unanswered.

The Patient Protection and Affordable Care Act we are about to consider is our answer. It is loud and it is clear. It is thoughtful and historic. Once again, like so many other pieces of landmark legislation in the last century, it is a product of this side of the aisle.

Those who have chosen to block any attempt at health care reform this year are on the wrong side of history, just as those who came before them had one response to every landmark piece of legislation for the last 80 years. Their response has been a resounding ``no.'' They told us that it is not good for business, that it is socialism, that it stifles free market forces, and that it is too much and it goes too far.

We have heard the same fear mongering and innuendo since the New Deal. There are those who raised the specter of socialism then and said no to Social Security. They said no to unemployment insurance when President Roosevelt proposed it as part of the Social Security Act. They said no when John Kennedy and Lyndon Johnson fought for Medicare. They said no to the Civil Rights Act. They said no to the Voting Rights Act. They said no to the Clean Air and Clean Water Acts. They said no to jobs programs.

They said no to increasing unemployment insurance, when people needed it the most. They said no to government oversight of polluters who poison our land with toxic waste, and then they said no to cleaning it up. They have been on the wrong side of history for almost a century on every major piece of legislation that has leveled the playing field for average Americans. They are on the wrong side of history once again.

All we hear from the other side of the aisle is the dim echo of the past, with no plan for the future. Americans are tired of the naysayers, tired of the shrill voices of no, when so much is at stake. It is time to say yes, time to say yes to stopping greedy insurance companies from standing between doctor and patients, time to say yes to ending medical decisions based on risk management and the bottom line rather than on saving people's lives.

This historic legislation, like so many other pieces of legislation debated on this floor, is about people--their lives, their hopes, their health, and their dreams for a better life for themselves and their families. We can be proud of this legislation. I know that when the dust settles and the provisions of this bill become clear, America will be proud of it as well.

This landmark reform legislation includes State-based exchanges creating a fair, open, and competitive marketplace for affordable health care coverage. It includes an amendment I proposed for long-overdue consumer protections for emergency services without having to call your health care provider and get a prior authorization. It requires insurance plans to provide behavioral health treatments, such as those for children who face the challenges of autism, as part of the minimum benefit standards.

It encourages investments in youth therapies to prevent, diagnose, and treat acute and chronic disease. There is a tax credit for innovative biotechnology research. It ensures that minor children qualify as exchange-eligible and provides for the availability of child-only

health insurance coverage in the exchanges. It stops insurance companies from denying coverage for some preexisting condition, some preexisting health status, or gender. It ends the medical benefits shell game that insurers have played with people's lives.

As soon as this bill passes and the President signs it into law, 1.3 million seniors in New Jersey will receive free preventive care, such as colonoscopies or any other recommended preventive service; 227,000 New Jersey seniors will have their brand-name drug costs in Medicare Part D cut in half; 854,000 New Jerseyans will qualify for tax credits to help them buy health insurance and ease the burden of premiums, deductibles, and copayments; 107,000 small businesses in New Jersey could get a small

business tax credit--up to 50 percent of premium. Health care reform will end the hidden tax that gets passed along with the $1.1 billion spent on uncompensated care in New Jersey. It will provide portability, security, and choice through the health insurance exchange for 1.5 million New Jersey residents who don't have health insurance at all.

The bottom line is that Senator Reid's merged bill helps New Jersey and America. It is fair, balanced, and fixes a badly broken system. It is truly a historic piece of legislation and will be remembered as such. Yet there are all those who will stand against all of it, those who will stand firmly on the wrong side of history once again, those who will use every legislative tactic to stop this legislation as they tried to stop Social Security and Medicare. I am afraid history is about

to repeat itself.

We have seen that the truth has been a victim on the Senate floor today. We listened to some of the most dire predictions, some of the most incredible statements, with figures thrown out there that are astronomical, simply not true, and in defiance of what the nonpartisan CBO said, which we all depend on--Democrats and Republicans. They said this bill actually cuts the deficit by $130 billion in the first 10 years and $650 billion in the second 10 years.

In the face of a health care system that seems to work only for health insurers--certainly not for average Americans--one must ask what, if any, health care reform are my friends on the other side for. What were their predecessors for when Americans were standing in bread lines and needed unemployment insurance? What were they for when they voted against Medicare? What are our Republican colleagues for now? They seem to be for one thing only: protecting the status quo, leaving health care just

the way it is, letting insurers make medical decisions, letting insurers collect premiums and then find creative ways to deny coverage.

On the other hand, this bill represents the change America voted for. But as we have seen, change does not come easily. You have to work for it. You have to fight for it. Sometimes, in the face of the naysayers and fear mongers, you need more than the truth, common sense, and even a good plan; you need to fight for what you know is the right thing to do for every American, not the few, not the powerful and the well-connected but everyone.

At the heart of it, this vote we will cast tonight is about change. We can see how hard real, honest, commonsense change is. We must ask ourselves: Do we continue to be the agents of change or do we stand with the status quo that discriminates against [Page: S11958]

hard-working Americans who are denied health coverage because of preexisting conditions? Do we continue to be agents of change or do we stand with the status quo and deny coverage to women when they are

pregnant? Do we continue to be agents of change, however hard it may be, or do we continue to deny millions of Americans access to quality, affordable care?

History calls on us to stand on rare occasions for what is fair and just and right for the American people. This is one of those occasions. It requires more than parliamentary maneuvers to slow the process. It requires more than voices raised under the banner of free market values at the expense of fundamental human values. It requires doing what is right for the American people. Only then will we find ourselves on the right side of history. That is what this vote is about.

Mr. President, I yield the floor.

6:15 PM EST

Bob Menendez, D-NJ

Mr. MENENDEZ. Mr. President, for many months the voices of opposition to any health care reform have been loud and clear. They have been shouting at townhall meetings and heard in debates in this Chamber. All too often, we have heard shrill voices raised in anger from those who are either misinformed or who would choose the status quo that benefits insurers at the expense of families. For too long those voices have gone unanswered.

The Patient Protection and Affordable Care Act we are about to consider is our answer. It is loud and it is clear. It is thoughtful and historic. Once again, like so many other pieces of landmark legislation in the last century, it is a product of this side of the aisle.

Those who have chosen to block any attempt at health care reform this year are on the wrong side of history, just as those who came before them had one response to every landmark piece of legislation for the last 80 years. Their response has been a resounding ``no.'' They told us that it is not good for business, that it is socialism, that it stifles free market forces, and that it is too much and it goes too far.

We have heard the same fear mongering and innuendo since the New Deal. There are those who raised the specter of socialism then and said no to Social Security. They said no to unemployment insurance when President Roosevelt proposed it as part of the Social Security Act. They said no when John Kennedy and Lyndon Johnson fought for Medicare. They said no to the Civil Rights Act. They said no to the Voting Rights Act. They said no to the Clean Air and Clean Water Acts. They said no to jobs programs.

They said no to increasing unemployment insurance, when people needed it the most. They said no to government oversight of polluters who poison our land with toxic waste, and then they said no to cleaning it up. They have been on the wrong side of history for almost a century on every major piece of legislation that has leveled the playing field for average Americans. They are on the wrong side of history once again.

All we hear from the other side of the aisle is the dim echo of the past, with no plan for the future. Americans are tired of the naysayers, tired of the shrill voices of no, when so much is at stake. It is time to say yes, time to say yes to stopping greedy insurance companies from standing between doctor and patients, time to say yes to ending medical decisions based on risk management and the bottom line rather than on saving people's lives.

This historic legislation, like so many other pieces of legislation debated on this floor, is about people--their lives, their hopes, their health, and their dreams for a better life for themselves and their families. We can be proud of this legislation. I know that when the dust settles and the provisions of this bill become clear, America will be proud of it as well.

This landmark reform legislation includes State-based exchanges creating a fair, open, and competitive marketplace for affordable health care coverage. It includes an amendment I proposed for long-overdue consumer protections for emergency services without having to call your health care provider and get a prior authorization. It requires insurance plans to provide behavioral health treatments, such as those for children who face the challenges of autism, as part of the minimum benefit standards.

It encourages investments in youth therapies to prevent, diagnose, and treat acute and chronic disease. There is a tax credit for innovative biotechnology research. It ensures that minor children qualify as exchange-eligible and provides for the availability of child-only

health insurance coverage in the exchanges. It stops insurance companies from denying coverage for some preexisting condition, some preexisting health status, or gender. It ends the medical benefits shell game that insurers have played with people's lives.

As soon as this bill passes and the President signs it into law, 1.3 million seniors in New Jersey will receive free preventive care, such as colonoscopies or any other recommended preventive service; 227,000 New Jersey seniors will have their brand-name drug costs in Medicare Part D cut in half; 854,000 New Jerseyans will qualify for tax credits to help them buy health insurance and ease the burden of premiums, deductibles, and copayments; 107,000 small businesses in New Jersey could get a small

business tax credit--up to 50 percent of premium. Health care reform will end the hidden tax that gets passed along with the $1.1 billion spent on uncompensated care in New Jersey. It will provide portability, security, and choice through the health insurance exchange for 1.5 million New Jersey residents who don't have health insurance at all.

The bottom line is that Senator Reid's merged bill helps New Jersey and America. It is fair, balanced, and fixes a badly broken system. It is truly a historic piece of legislation and will be remembered as such. Yet there are all those who will stand against all of it, those who will stand firmly on the wrong side of history once again, those who will use every legislative tactic to stop this legislation as they tried to stop Social Security and Medicare. I am afraid history is about

to repeat itself.

We have seen that the truth has been a victim on the Senate floor today. We listened to some of the most dire predictions, some of the most incredible statements, with figures thrown out there that are astronomical, simply not true, and in defiance of what the nonpartisan CBO said, which we all depend on--Democrats and Republicans. They said this bill actually cuts the deficit by $130 billion in the first 10 years and $650 billion in the second 10 years.

In the face of a health care system that seems to work only for health insurers--certainly not for average Americans--one must ask what, if any, health care reform are my friends on the other side for. What were their predecessors for when Americans were standing in bread lines and needed unemployment insurance? What were they for when they voted against Medicare? What are our Republican colleagues for now? They seem to be for one thing only: protecting the status quo, leaving health care just

the way it is, letting insurers make medical decisions, letting insurers collect premiums and then find creative ways to deny coverage.

On the other hand, this bill represents the change America voted for. But as we have seen, change does not come easily. You have to work for it. You have to fight for it. Sometimes, in the face of the naysayers and fear mongers, you need more than the truth, common sense, and even a good plan; you need to fight for what you know is the right thing to do for every American, not the few, not the powerful and the well-connected but everyone.

At the heart of it, this vote we will cast tonight is about change. We can see how hard real, honest, commonsense change is. We must ask ourselves: Do we continue to be the agents of change or do we stand with the status quo that discriminates against [Page: S11958]

hard-working Americans who are denied health coverage because of preexisting conditions? Do we continue to be agents of change or do we stand with the status quo and deny coverage to women when they are

pregnant? Do we continue to be agents of change, however hard it may be, or do we continue to deny millions of Americans access to quality, affordable care?

History calls on us to stand on rare occasions for what is fair and just and right for the American people. This is one of those occasions. It requires more than parliamentary maneuvers to slow the process. It requires more than voices raised under the banner of free market values at the expense of fundamental human values. It requires doing what is right for the American people. Only then will we find ourselves on the right side of history. That is what this vote is about.

Mr. President, I yield the floor.

6:25 PM EST

Tom Harkin, D-IA

Mr. HARKIN. Mr. President, I thank the Senator from New Jersey for his very strong and poignant statement. I listened to it all. I think he really summed it all up.

Let me add to that by saying we are at a momentous crossroads right now in the history of our country. We are at a time that likens itself to 1935, when this Congress passed the Social Security Act. It is like the time in 1965 when Congress passed Medicare. Both of them were giant steps forward in the health and economic security of the American people. But as much as they are part and parcel of our American life today, both Social Security and Medicare were bitterly opposed in this Senate by

conservatives who did not want to change. In fact, one conservative Republican Senator said that passing Social Security would put an ``end to the progress of our great country.'' They attacked Medicare as socialized medicine. As Senator Robert Taft said at that time,

``It is going to Sovietize America if we have Medicare. It is going to be a government takeover.'' Well, here they go again. They are unduly frightening people in this country. We saw it earlier with the death panels--all bogus. It was to instill fear in people.

It is hard to change, but the people of America voted last November overwhelmingly for Barack Obama and for Democrats in the House and Senate because they wanted to change the system. They knew we had to change.

People don't fear change. They know it is tough, but they don't fear it. They don't fear change in our health care system either. What people fear is keeping the present system. That is what I hear. They fear being denied coverage because they have a preexisting condition or one of their children has a preexisting condition and they will not be able to get health care coverage. That is what people fear. They fear they will be dropped from their policy because they have come down with cancer or

heart disease or some other chronic illness. They fear that if they have a serious illness, they will have to go into bankruptcy to pay the bills. Sixty-two percent of all the bankruptcies in this country are because of medical causes. Eighty percent of those are people who already had coverage. That is what people really fear.

Another reason I think conservative forces will fail this time is because they believe people who have good health insurance really lack compassion and they don't care about the 46 million other Americans who don't have it. I disagree. People care deeply about those 46 million Americans who don't have insurance. It is a national shame when children don't have access to a doctor.

It is unfortunate that our Republican friends are determined to prevent us from even debating and amending the bill. That is what the vote tonight is about. Republicans and the health insurance industry are joined at the hip, using the same talking points, same distortions, same cooked-up scare tactics.

All I can say is, since the Republicans' goal is to obstruct, obstruct, and obstruct, the people of this country are looking to us, to the Democrats, as they did in Social Security and as they did in Medicare, they are looking to us to move this country forward. So this is a call to arms for our caucus. I hate to put it in those kinds of partisan terms, but what can I do when every single Republican says they want to obstruct and stop this bill? It is now on us, the Democratic caucus, all 60

Members, to come here and stand strong for the American people. Now is not the time to go wobbly in the knees, I say to my friends in the Democratic caucus. Now is the time to stand strong, the time to come to the well at 8 o'clock tonight and move this country forward. It is time to say yes to the American people and no to these fears and unfounded allegations you will hear from the other side.

Now is the time to take the next step forward in the real progress of this country.

6:30 PM EST

Chuck Grassley, R-IA

Mr. GRASSLEY. Mr. President, on November 10, former President Clinton visited the Democratic Senate caucus. It has been widely reported that his message to Senate Democrats was that on health care reform, the worst thing to do is to do nothing.

With all due respect to the former President, that is simply wrong. Mr. Clinton, the worst thing we can do is pass this bill. This is not something I say lightly because there are serious problems with our health care system. There are important steps we need to take to fix the problems in our system. But the excesses of this bill appear willfully ignorant of what is going on outside health care. Those things deal with our economy. Those excesses make this bill far worse than doing nothing.

We are a nation facing challenging economic times. We have seen the auto industry go into bankruptcy. We have seen banks shutter their doors.

I want to refer to a chart of our national debt. The Federal debt has increased by $1.4 trillion since inauguration. This chart shows the growing amount of debt the Federal Government is taking on. The amount of increased debt added since the inauguration is $11,535 per household. The national debt now exceeds $12 trillion for the first time in history.

I wish to show a chart on Federal health spending. As this chart illustrates, this bill bends the Federal spending curve further upward by $160 billion over the next decade. The red area of this chart is that net additional Federal health spending, not according to this Senator but according to the nonpartisan Congressional Budget Office. Americans have rightly lost faith when in the face of the current economic crisis Congress thinks this $2.5 trillion restructuring of the health care system

happens to be a good idea.

Perhaps one of the biggest warning signs that this bill will saddle taxpayers with more spending and debt is the fact that the budget fail-safe mechanism was dropped from the bill behind closed doors in the Capitol where this bill was written--and I emphasize ``closed doors.'' The Grassley budget fail-safe mechanism was cut from the bill and lots of budget gimmicks were added.

Former Congressional Budget Office Director Douglas Holtz-Eakin wrote in yesterday's Wall Street Journal that this bill is ``fiscally dishonest'' and that it uses ``every budget gimmick and trick in the book ..... leave out inconvenient spending, back-load spending to disguise the true scale, front-load tax revenue, let inflation push up tax revenues, promise spending cuts to doctors and hospitals that have no record of materializing,'' and so on.

This bill is simply irresponsible. It is worse than doing nothing.

Let's talk about some of the excesses in the bill. It increases the size of government by a staggering $2.5 trillion when fully implemented. It imposes $ 1/2 trillion in new fees and taxes. Imposing these new fees and taxes as the economy is struggling to recover is worse than doing nothing. This $ 1/2 trillion in new taxes will hurt small businesses and destroy job creation. It breaks President Obama's campaign promise by increasing taxes on individuals and families making less than $250,000

per year. Adding insult to injury, these fees and taxes will also cause health care premiums to go up beginning next year. [Page: S11959]

But I don't want you to take my word for it. Both the nonpartisan Committee on Taxation and the Congressional Budget Office have confirmed these taxes and fees will be passed through to the consumers in the form of higher health insurance premiums, and these taxes and fees will start increasing premiums 4 years before most of the reforms in this bill take effect in 2014.

Let's take a look at what happens to Medicare and Medicaid in this bill. Both of these health care entitlement programs are already on perilous financial footing. Both are facing a financial meltdown. This bill adds to that burden.

First of all, the Medicare trust fund started going broke last year. In the year 2008, the Medicare Program began spending more out of the trust fund than was coming in. The Medicare trustees have been warning all of us for years that the trust fund is going broke. They now predict it will go broke right around the corner, about 2017. But rather than work to bridge Medicare's $37 trillion in unfunded liabilities, this bill cuts $ 1/2 trillion from that Medicare Program to fund yet another unsustainable

health care entitlement program.

Medicare has a major problem with physician payments that will cost more than $250 billion to fix. But this bill ignores that problem by pretending the problem does not exist. This bill would leave future Congresses virtually no way to restructure Medicare to do the doctors fix.

By diverting Medicare resources elsewhere and ignoring major problems such as that one, this bill does worse than nothing.

Then there is Medicaid. The Medicaid Program serves 59 million low-income children and families. It is our health care safety net and it, too, is on very shaky financial ground. The Government Accountability Office has reported to Congress that States are reaching a financial and budgetary crisis with Medicaid. Like Medicare, Medicaid is essentially going broke. The Government Accountability Office models predict that State spending on Medicaid will grow faster than State revenues for at least

the next 10 years.

Here is what the Government Accountability Office has said about this situation:

Since most State and local governments are required to balance their operating budgets, the declining fiscal conditions shown in our simulation suggest that, without intervention, these governments would need to make substantial policy changes to avoid growing fiscal imbalances.

But this bill does not fix this problem either. Here again, this bill makes the problem worse. This bill adds another $374 billion in spending to the Medicaid Program. It adds 15 million people to the rolls of the worst delivery system in health care. It increases State spending by $25 billion, and that happens to be a hidden tax increase because States will be forced to raise taxes to pay for this increased cost--another unfunded mandate. By dropping the equivalent of a 10,000-pound weight through

to our frayed Medicaid safety net, this bill does worse than nothing. This bill also compounds these long-term entitlement spending problems by creating yet another new entitlement program called the CLASS Act. This one is a voluntary Federal program for long-term care insurance.

I devoted several years of effort to improving long-term care support, particularly for the disabled and the elderly.

I understand the issues that supporters of the CLASS Act want to address. But the CLASS Act is simply not viable in its current form.

The CLASS Act is almost certain to attract people who are most likely to need it. This is known as adverse selection. That will cause premiums to increase and healthier people to drop out of the program. It is a classic insurance death spiral.

On November 13, the administration's own chief actuary confirmed this. The chief actuary issued a dire warning in a report on the CLASS Act in the House bill, which is virtually identical to the Senate version. Quoting the chief actuary:

There is a significant risk the problem of adverse selection would make the CLASS program unsustainable.

For the first 10 years, the CLASS Act saves money. It saves money at the beginning because it collects premiums before benefits start getting paid out. But some time afterwards, it starts to lose money. We all know what happens from there. It will become the taxpayers' responsibility to rescue the program as it fails. Look at financial struggles of Social Security. Look at Medicare. Look at Medicaid. Now go home and look at your children and grandchildren.

Creating an unsustainable CLASS Act is not a responsible thing to do for our children and grandchildren. By adding the ticking time bomb of yet another unfunded liability to our children and grandchildren through the CLASS Act, this bill, again, does worse than nothing.

Health care is one-sixth of the economy. The American people do not want a bill that makes the economy worse. The nonpartisan Congressional Budget Office, the Committee on Taxation, and even the Office of the Actuary of the U.S. Department of Health and Human Services have told us what the American people already knew: These massive partisan health care reform bills are going to make the problem worse when it comes to the cost of health insurance.

According to a September 22 letter from the Congressional Budget Office to Chairman Baucus about the Finance Committee bill, CBO wrote:

Premiums in new insurance exchanges would tend to be higher than the average premiums in the current law individual market.

So according to CBO, after these bills spend $1 trillion, many of the people struggling to afford their premiums today will actually end up paying more if this bill moves forward and is enacted. By increasing costs when people desperately need Congress to lower costs, this bill does worse than nothing.

It does not have to be this way. When the debate began last year, interested legislators of both parties set forth benchmarks that were no-brainers. Health care reform should lower the cost of premiums. It should make health care more affordable. It should do so without Medicare cuts that jeopardize access to care for seniors. It should do so without overloading the Medicaid safety net until it rips. It should do so without adding to the already unsustainable, unfunded liabilities by creating

yet another unsustainable entitlement program. It should have done all those things. That is what we intended to do when we started out.

Instead, this bill threatens the economic recovery. It is $ 1/2 trillion of new taxes hurting small business and destroying job creation. It calls for an even bigger and more unsustainable Federal budget. It adds to that burden with a massive new government-run health plan. It makes health care more unaffordable and lowers quality.

I know some people believe we should get on to the bill and try to fix it by amendment. But this 2,000-page bill has many more problems than can be fixed by amendment on the Senate floor.

If you want to improve it, it should be stopped right now and get back together where we were at one time. Democratic leaders and the White House have put together one extreme health care plan after another. After the bailouts for Wall Street and Detroit, a stimulus bill that led to the highest unemployment in 26 years, and the Fed shoveling money out the door without any accountability, this health care reform bill is the straw that broke the camel's back.

What Senate Republicans are trying to say tonight, with tonight's vote, is we don't support reform just for the sake of reform. Changes to the health care system must be responsible and not break the backs of the taxpayers and the job-creating engine in America, small business.

It doesn't make any sense to make major new unsustainable commitments to entitlement spending. Already, Medicare's solvency is in jeopardy and the Reid bill would make things worse for Medicare. Seniors are in a tough situation today with the way the economy has hit their retirement savings. We have to step back and remember it is not our money, it is their money. It is the taxpayers' money we are talking about--$2 1/2 trillion of taxpayers' dollars over the decade when this bill is fully implemented.

Generations of hard-working Americans will be forced to pay the costly [Page: S11960]

price for this bill if it moves forward. It is irresponsible for Democratic leaders to use their filibuster-proof majority in the Senate and their control of the House and the White House to push through such massive legislation, reshaping one-sixth of the American economy. The unintended consequences of this legislation could have a destabilizing effect at just the wrong time as

America's economy struggles to recover and working families are doing everything in their power just to hold on.

The late Senator Moynihan often warned about the perils of a majority party pushing through major bills and changes in a partisan way. It is a well-founded warning that Democratic leadership has not heeded--this time, at least. If a bill like this one cannot get support more broadly, then something is wrong with it.

Moreover, grassroots America has spoken out against this legislation. It is alarming how those voices have been disregarded by congressional leaders. President Andrew Jackson made it clear that our duty is to tune in to the common sense of the American people who sent us here. I quote President Jackson:

Our Government is founded upon the intelligence of the people. I, for one, do not despair of the republic. I have great confidence in the virtue of the great majority of the people, and I cannot fear the result.

Listen to what President Jackson said. Listen to the concerns of the people. They are telling us to reconsider this massive, complicated legislation and take a path that leads to less spending, less taxes, and less debt. Instead of continuing to mortgage the future of our children and grandchildren, we need to get back to basics. Congress should pass commonsense medical malpractice reform to stop wasting so much money on defensive medicine. Congress should empower consumers to shop around for

health care and lower costs with competition just like with other services the consumers buy. Congress should make market reforms that help small businesses and the self-employed have greater access to health insurance at an affordable rate.

These issues can be addressed without upending the entire health care system with the result of higher taxes, higher insurance premiums, and deficits and debts that will get in the way of the opportunity that results from the ingenuity and industry of the American people.

If we were sitting around a coffee shop in Springfield, IL, or Little Rock, AR, and we were discussing health care reform and I told them we are talking about a bill that is going to raise taxes, cut Medicare, raise premiums, and not do anything about costs, they would say that is not health care reform.

I encourage my colleagues to listen to the American people and to send this bill back to the drawing board.

I yield the floor.

6:51 PM EST

Mike Enzi, R-WY

Mr. ENZI. Mr. President, as morning broke over our Nation today, millions of Americans woke to a typical, crisp fall day. It seemed ordinary as shop-owners opened their local grocery stores; children filled soccer fields and families made preparations for Thanksgiving holiday. It seemed ordinary. But today is anything but ordinary in the life of our Nation.

We have all heard the phrase and repeated it so many times, that we have almost grown numb to it--America is facing the worst economic crisis since the Great Depression. Think about that for a minute. What that really means is that for every single legislator in this Senate, we are in unchartered territory.

We have never been here before and recent signs of a slow, unsteady and jobless recovery are troubling. And, the American people know it. In a survey from this past week, 82 percent of Americans said that our Nation's economic conditions are poor.

Consider the news reports from just yesterday that 14 percent of all mortgage loans--meaning 7.4 million households--were delinquent or in foreclosure in the last quarter. That is the highest number since the mortgage bankers industry began this survey in 1972.

Consider the unemployment rate--it reached a 26-year high of 10.2 percent in October. We lost 190,000 jobs in just the month of October alone. And, according to the Department of Labor's broadest measure, some 17.5 percent of Americans are without a job entirely or underemployed. We have shed 3.5 million jobs since January of this year and the average work-week is now down to 33 hours for the American worker.

It is against this backdrop that the Senate majority leader has chosen to bring up this health care bill. Health reform is a huge undertaking.

Every one of the 2,074 pages in this bill will have a dramatic impact on the health care of every American. I have to tell you, that is a bridge. This is a bigger problem than anyone can imagine because it will affect every single American. This bill represents a massive government intrusion into the medical care of every American.

Under this bill, the government will review every employer health insurance plan in the Nation to determine if it satisfies all of the government mandated benefit requirements. If it does not, the government will then tax many of those employers.

The government will also now determine whether it believes your health insurance costs too much. It will decide what benefits should be covered and what preventive services you should receive.

Earlier this week, the U.S. Preventive Services Task Force recommended that women under age 50 should not receive annual mammograms. Anyone who was concerned about this decision needs to understand that this bill empowers a task force just like that to determine which preventive services should be covered by every health plan in America.

As one of the only Members of the Senate to sit on both committees of health care jurisdiction, I understand the complexities at work in comprehensive health care legislation. And I understand that this bill gets it wrong.

Instead of taking a step-by-step approach to health reform, identifying consensus reforms where we can fix what is broken and leave what works, the majority leader has chosen a different approach. Without Republican support and without the approval of a growing majority of the American people, Senator Reid has chosen to shake nearly 20 percent of our economy in its foundation in attempting to jam through a strictly partisan bill.

This bill will increase our health care costs, do nothing to improve the quality of our care, it will increase our Nation's debt and deficit and it will harm our Nation's tenuous job market.

There is no credible study and there will be no serious, unbiased economist who will say that this bill will create jobs or strengthen our economy. And that is what the people in the most recent election said was mot important.

Recently, in an op-ed in the Wall Street Journal, the dean of Harvard Medical School Dr. Jeffrey Flier gave the current health reforms a ``failing grade.'' Dean Flier wrote about the reform bills being debated in Congress, that ``there are no provisions to substantively control the growth of costs or raise the quality of care. So the overall effort will fail to qualify as reform.''

Dean Flier went on to write:

In discussions with dozens of health care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it. Likewise, nearly all agree that the legislation would do little or nothing to improve quality or change health-care's dysfunctional delivery system.

I ask unanimous consent that this editorial be printed in its entirety in the RECORD at the conclusion of my statement.

6:57 PM EST

Mike Enzi, R-WY

Mr. ENZI. With ratings of failed reform like the dean of the Harvard Medical School, why are we talking about taking the time to tweak a failure of ideas so we can say we did something. We are not fooling the American people. The voices of August are still echoing and coming from a vast majority.

Other experts have weighed in on the provisions in the Reid bill and their potential impact on jobs. One such provision is the job-killing tax of $28 billion that will disproportionately fall on the backs of small business employers in the form of a

mandate on employers to [Page: S11961]

provide Washington government-approved insurance.

This job-killing tax has been studied by the non-partisan score keepers at the Congressional Budget Office as well as nationally recognized economists and health experts. These experts have said that the costs of this new tax will ultimately be paid by the American working men and women.

Businesses that cannot afford to provide health insurance will pass the costs of these new penalties on to their workers in the form of lower wages, reduced hours and jobs cut. Yes, this so-called health reform bill will threaten your jobs and if this vote is successful we will spend weeks debating this bill. And just like committee work so far, the majority will reject real solutions just like they have through the two amendment processes that have been merged to make this flawed bill.

According to one recent study by the Heritage Foundation, this new job-killing tax in the Reid bill will place more than 5 million low-income workers at risk of losing their jobs or having their hours reduced and an additional 10 million workers could see lower wages and reduced benefits. At a time of unprecedented economic peril, the majority has chosen to bring a bill to the Senate that will threaten our Nation's jobs and our economic growth.

This bill will also increase our Nation's growing debt and deficit. Currently, our Nation's debt is greater than $112 trillion and our deficit for fiscal year 2009 was greater than $1.4 trillion. As a percentage of the economy, our deficit is 10 percent of GDP--the highest it has been since the Second World War. Once again, we are not debating this bill in a vacuum. Rather, we are debating this bill at a time when our credit card is maxed out.

I worry about the country that I am leaving for my children and grandchildren. Our Nation is being buried under a mountain of debt, which poses a deadly threat to the future of our Nation.

The Federal Government will spend $1.4 trillion more than it receives in revenue this year. The government will make up that deficit by borrowing more money, mostly from China and other foreign governments.

These levels of debt are not sustainable and, our foreign creditors are beginning to recognize this fact. As our creditors grow more concerned about our ability to pay our debt obligations, the interest rates we pay will grow. That means that it will soon cost us considerably more to allow Washington to continue to borrow the money it needs to fund its current spending binge.

With our current and growing debt, Congress should be concerned. Think about it--our most fundamental duty as Members of Congress is to wisely manage the power of the purse for our Nation. The Framers wisely put in place a process of appropriations that would be annually checked by the representatives of the American people here in Washington.

In this bill we create yet another stream of mandatory spending in perpetuity--or until it runs out--that is not reviewed by Congress on an annual basis.

I remind my colleagues that our Federal deficit is nearly nine times the size of the deficit just 2 years ago. During the same 2-year period, our Nation lost 8 million private sector jobs. Our total Federal debt is now around 85 percent of GDP. According to David Walker, the former head of the Government Accountability Office, at the end of the fiscal year 2000, the Federal Government had about $20.4 trillion in total liabilities and commitments and unfunded promises for just Social Security

and Medicare. That number rose to $56.4 trillion at the end of fiscal year 2008. That is a 176-percent increase in only 8 years. By the end of this year, that number is expected to rise to $63 trillion. With these staggering statistics, it is astonishing we are even debating the creation of a new entitlement obligation forever.

A couple days ago, Majority Leader Reid stated that this bill will be deficit neutral, but you have to understand what that means. First, the true cost of this bill is hidden by implementing the massive middle-class tax increases and Medicare cuts in the first year and pushing the massive costs in health care subsidies out to the fifth year. Republican Leader McConnell referred to this gimmick as being akin to paying a mortgage for 4 years before actually moving into the house.

I wish to emphasize that a little bit. It is a gimmick. You collect the money to begin with, but you don't provide the benefits until further down the road. Then you say: We covered all those costs. But when you extend it on out, it will not continue to cover those costs. So disaster.

As the only accountant in the Senate, I am shocked to see that what would constitute as fraud in the accounting world seems to be reason to hold a press conference to do a hollow boast. The gimmicks in this bill are stunning, whether it comes to implementation of the tax on so-called Cadillac health plans or the increased taxes or the $464 billion in Medicare cuts--Medicare cuts. We are already having a problem with Medicare solvency. It is going to go broke. We are going to take $464 billion

from Medicare. Then we are going to form a special commission and this commission will be able to tell us, on an annual basis, where we can make cuts in Medicare so it doesn't go broke. But let's see, there is a deal with the hospitals that they are not going to be touched. There is a deal with the doctors that they will not

be touched; in fact, theirs is going to be increased. There is a deal with PhRMA where they will not be touched. Who does that leave? That means cutting benefits for seniors. They and home health care and nursing homes are the only places you can cut it, if you let those other people off the hook. That is what the bill does.

When it comes to the long-term care provisions in this bill that Budget Committee Chairman Conrad has referred to as a Ponzi scheme, you have to be a little bit worried. If Washington accounting had to come under the same laws as private business, the administration and Congress would be in jail. To attempt to claim the mantle of fiscal responsibility, the majority leader has jammed 10 pounds of entitlement spending into a 5-pound sack. Again, entitlement means the payments automatically

go on forever with no further review or constraint. That is not fiscal responsibility and the American people are not buying it. They know, evidently better than we do, what we are talking about.

A large majority of Americans believe their prescription drug costs will go up under this bill and that the cost of their premiums will go up. They are right. What the CBO score doesn't provide us with and can't provide us with is the cost of this bill to each and every one of us. But we know that cost will be great. The CBO evaluation says it is going to be paid for. Paid for? That is an evaluation of whether it is going to cost the government anything. It is not an evaluation of whether it

is going to cost the people anything. The only place to get that money is from the people or, in this case, also stealing it from Medicare. In order for this bill to reduce the deficit, the majority leader has to assume that the Medicare payments to physicians will be cut by 21 percent next year. He also has to assume these payments will be annually cut another 5 percent for the next 9 years.

In order for this bill to reduce the deficit, the majority leader also has to assume that more and more middle-class Americans will pay this new tax on high-cost health insurance plans. According to the Congressional Budget Office, 84 percent of the revenue collected by this new tax will come from Americans earning less than $200,000 in 2019. This reminds me of another tax which was originally intended to target just 155 individuals who made more than $200,000 and did not pay any income tax.

Today the alternative minimum tax now hits millions of middle-class Americans, and every year Congress has to enact legislation to prevent it from hitting millions more. This bill is drafted that same way. It will creep up there and catch everybody in increased taxes.

In order to believe that this bill will reduce the deficit, its sponsors must believe that future Congresses will allow millions of middle-class Americans to be subject to these new taxes. While the majority leader claims all these things will happen, the American public isn't fooled.

In this morning's Washington Post, the dean of Washington journalists, David Broder, not a politically conservative columnist and someone often [Page: S11962]

cited by the other side, pointed out that a recent survey found that less than one-fifth of the American people believe that health care reform will be deficit neutral over the next 10 years. By a 16-point margin, the majority in this poll said they opposed the legislation moving through Congress. Mr. Broder

called this legislation a ``budget-buster in the making.''

It is difficult to quantify the scope of this bill. I have heard some of my colleagues talk about how many years would elapse in 2 1/2 trillion seconds. I heard some of my colleagues talk about how many cars $2.5 trillion would buy or how many school districts it would fund or how many decades it would fund State budgets across America. I don't think people are understanding how comprehensive this bill is that entails 100 percent of the people. That is the difficulty we in the Gang of 6 had

coming to any conclusion because it is so big that as we get into one area and scratch the surface and find out what we don't know, it takes a lot of research time to get there to be able to make basic decisions. But it was easy to cram into a bill and say: This solves it, solves it for $1 trillion. We should never say $1 trillion because that sounds like one, and one is not a very big number.

It is $1,000 billion. We don't know what 1 billion is either, but 1 billion is 1,000 million. So we are talking about a lot of money here.

Perhaps the best way to quantify this bill is, it keeps me up nights and, more importantly, these issues we are debating keep our constituents up at night. I am sure everybody has been hearing from their constituents. We worry immensely about the cost and the obligations we are passing on to our children and grandchildren. Where is this bill taking our country, and will we have the courage in our time to preserve and protect our Nation's great strengths for future generations? These are the questions

that keep me up at night, and I know these concerns are shared on the other side of the aisle. I sense it in conversations I have had with the senior Senator from Delaware and the senior Senator from Nebraska. I sensed it in my work over the summer with the chairman of the Budget Committee. I know they share these concerns on the other side. That is why I believe passionately that we must defeat the motion to proceed on this bill.

I am sometimes an optimist, and I still hope we can start over and get to work on a bipartisan bill that has the trust and support of the American people. Any major piece of legislation that has gone through this body has done so in a bipartisan way. It has been necessary to get the confidence of the American people. They don't have confidence in Congress right now. This bill is not helping.

We say we are spending our children and grandchildren's money. Actually, we are doing that plus spending seniors' money. When you take that Medicare money, that is what you are doing. The seniors have figured it out. That is why it was so raucous in August and ever since. They have been concerned about their future and the promises made to them. We have a system that is going broke, and then we are going to take money from it. We ought to back up and make sure Medicare money goes to Medicare.

I know part of that is listed as fraud and abuse. I am always fascinated when government talks about fraud and abuse because we talk about it, but if we have known that these billions of dollars of fraud and abuse were out there, why haven't we been collecting that money? Once we turn it over to the government to do that, it is no longer needed. Well, it is needed to pay the bills, but it is no longer that much of a care because the paid-for has already been taken care of.

There ought to at least be a separate account set up that you have to actually collect the fraud and abuse money before you can spend it, but we are not going to do that.

Every senior can tell you some instances of fraud and abuse that they think are happening, and we have passed those on. I see some effort to collect that but not a lot.

As many of my colleagues know, before I came to the Senate, I was a small business owner. My wife and I owned three small shoestores in Wyoming and Montana. When I was showing someone a shoe and he or she said they didn't like it or couldn't afford it, I didn't try to give them a sales pitch. I knew it was time to try to find another shoe, one they liked and could afford. There is a lesson from this in this health care bill. The people of America are complaining, and we are showing them the shoe

we want to show them. They don't want to see that shoe. They said: We thought you were going to lower my costs. Every person out there thought they were going to have the benefit of reduced costs, and they are not seeing it in this bill. They wanted to help out other people, and some of that is in here, to a limited extent. But

that isn't the main thing that they expected to have happen from this. Small businesses out there are particularly hurting, and this will react on small businesses, those shoestores all over the United States, the grocery stores, the dry cleaners. This is even going to affect doctors. They are small businesses, for the most part.

So there is a lesson in this story when it comes to reforming health care. It is time to listen to the customers and find the alternative they expected, that they wanted, and they can afford.

Probably the biggest help to me in legislating has been the experience of working in a shoestore. The people tell you what they want, and they have told us what they want. We haven't listened. If you want to make the sale, you better listen. You better see how your inventory matches what they want. We haven't checked the inventory or we have said: We don't have anything in here that you need, but we have some things to take care of other people. That is not going to sell.

We have a big decision to make tonight. It will have a lasting effect on our country,

a lasting effect in that if the motion to proceed passes, we are going to debate it for a long time. A bill this size deserves a lot of time. It is necessary. And it is more comprehensive than we are going to be able to get into, no matter how long we debate it.

So the American people are going to be surprised at the time we waste when we could be solving jobs and the economy, which is their biggest concern at the present time.

Mr. President, I yield the floor.

Exhibit 1

Health ``Reform'' Gets a Failing Grade

(By Jeffrey S. Flier)

As the dean of Harvard Medical School I am frequently asked to comment on the health-reform debate. I'd give it a failing grade.

Instead of forthrightly dealing with the fundamental problems, discussion is dominated by rival factions struggling to enact or defeat President Barack Obama's agenda. The rhetoric on both sides is exaggerated and often deceptive. Those of us for whom the central issue is health--not politics--have been left in the lurch. And as controversy heads toward a conclusion in Washington, it appears that the people who favor the legislation are engaged in collective denial.

Our health-care system suffers from problems of cost, access and quality, and needs major reform. Tax policy drives employment-based insurance; this begets overinsurance and drives costs upward while creating inequities for the unemployed and self-employed. A regulatory morass limits innovation. And deep flaws in Medicare and Medicaid drive spending without optimizing care.

Speeches and news reports can lead you to believe that proposed congressional legislation would tackle the problems of cost, access and quality. But that's not true. The various bills do deal with access by expanding Medicaid and mandating subsidized insurance at substantial cost--and thus addresses an important social goal. However, there are no provisions to substantively control the growth of costs or raise the quality of care. So the overall effort will fail to qualify as reform.

In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it. Likewise, nearly all agree that the legislation would do little or nothing to improve quality or change health-care's dysfunctional delivery system. The system we have now promotes fragmented care and makes it more difficult than it should

be to assess outcomes and patient satisfaction. The true costs of health care are disguised, competition based on price and quality are almost impossible, and patients lose their ability to be the ultimate judges of value.

Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special [Page: S11963]

interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern.

In effect, while the legislation would enhance access to insurance, the trade-off would be an accelerated crisis of health-care costs and perpetuation of the current dysfunctional system--now with many more participants. This will make an eventual solution even more difficult. Ultimately, our capacity to innovate and develop new therapies would suffer most of all.

There are important lessons to be learned from recent experience with reform in Massachusetts. Here, insurance mandates similar to those proposed in the federal legislation succeeded in expanding coverage but--despite initial predictions--increased total spending.

A ``Special Commission on the Health Care Payment System'' recently declared that the Massachusetts healthcare payment system must be changed over the next five years, most likely to one involving ``capitated'' payments instead of the traditional fee-for-service system. Capitation means that newly created organizations of physicians and other health-care providers will be given limited dollars per patient for all of their care, allowing for shared savings if spending is below the targets. Unfortunately,

the details of this massive change--necessitated by skyrocketing costs and a desire to improve quality--are completely unspecified by the commission, although a new Massachusetts state bureaucracy clearly will be required.

Yet it's entirely unclear how such unspecified changes would impact physician practices and compensation, hospital organizations and their capacity to invest, and the ability of patients to receive the kind and quality of care they desire. Similar challenges would eventually confront the entire country on a more explosive scale if the current legislation becomes law.

Selling an uncertain and potentially unwelcome outcome such as this to the public would be a challenging task. It is easier to assert, confidently but disingenuously, that decreased costs and enhanced quality would result from the current legislation.

So the majority of our representatives may congratulate themselves on reducing the number of uninsured, while quietly understanding this can only be the first step of a multiyear process to more drastically change the organization and funding of health care in America. I have met many people for whom this strategy is conscious and explicit.

We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead.

7:17 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, a noted psychologist once said:

To be mature means to face, and not evade, [a] crisis. .....

Our health care system is in a crisis. This crisis has been decades in the making, and history has made clear that this crisis will not solve itself. It is time for us to face the crisis. It is time for Congress to show mature leadership. It is time for us to reform health care, once and for all.

For years now, we have prepared for this moment. The Finance Committee and the HELP Committee studied the issues thoroughly. We have held nearly 70 hearings, roundtables, and walk-throughs. We have studied this issue very thoroughly and exhaustively. We each produced a blueprint for reform--each committee--and we worked together with Leader Reid and President Obama to combine those blueprints into one solid plan. This week, tonight, we have brought that plan to the Senate floor. Tonight,

we seek to begin that momentous debate. Tonight, we seek, at last, to face the crisis.

We have a bill that will put Americans, patients, and their doctors back in control. We have a bill that will end harmful insurance industry practices. Under our bill, no longer will insurance companies be allowed to deny you health insurance. No longer will insurance companies be allowed to hike up rates for Americans with preexisting conditions, such as heart disease, cancer, or diabetes. No longer will health insurance companies be able to take away your health insurance or reduce benefits

when people get sick. Under our bill, no longer will insurance companies be able to limit the amount of health care you can use in a lifetime. No longer will insurance companies be able to put unreasonable limits on the amount of health care you can use in 1 year. If you pay

your bill, the insurance company must renew your coverage and provide your benefits. No longer will insurance companies be able to discriminate based on gender or health status. No longer will insurance companies be able to charge more for women or for people who are sick.

Our bill will also require insurance companies to disclose the share of premiums that goes to medical benefits. That is new and very important. No longer will insurance companies receive tax credits when they use their profits to provide excessive executive paychecks. [Page: S11964]

Our bill is fully paid for. It is fiscally responsible. It will lower health care costs, and it will reduce the Federal budget deficit.

According to the Congressional Budget Office, our bill will reduce the deficit by $130 billion in the first 10 years. Over the next decade, it will further reduce the deficit by about one-quarter of 1 percent of gross domestic product. That is hundreds of billions of dollars in deficit reduction.

As well, our bill will provide billions in tax cuts for American families and small businesses. Our bill will create new marketplaces called insurance exchanges. Individuals and small businesses will be able, quickly and easily, to view, compare, and buy health insurance plans.

Today, many Americans already receive quality health care coverage through their employers. Many are happy with their current insurance plans. This bill will not change that. We keep the best of our current health care system. People who are satisfied with their current health insurance coverage will be able to keep it. But too many others do not have access to insurance, to quality insurance. For too many, this system is broken.

Under our bill, new exchanges will provide one-stop shops where plans are presented in a simple, consistent format. Americans will be able to know exactly what they are buying. Insurance companies will have to compete on price and on quality, not on their ability to select the healthiest people or hide restrictions. Americans will be able to count on the health care coverage they buy. And tax credits will help to ensure all Americans can afford quality health insurance.

Small businesses will also have access to exchanges and tax credits. Through small business exchanges, these companies will be able to pool together to spread their risk, increase their leverage, and enhance their choice, just as big companies do.

Members of Congress will be required to buy their health insurance through the same exchanges that people in their own States use--exactly the same. No longer will there be a separate congressional health plan.

Our bill will strengthen Medicare. It will improve benefits for seniors. And it will help to ensure Medicare is sustainable for future generations. Our bill will cut costs, but it will not cut benefits. Our bill will increase Medicare benefits. Our bill will provide seniors with free preventive care and wellness checkups. It will improve care for seniors with chronic conditions. And it will provide a 50-percent discount on brand-name prescription drugs to help close the doughnut hole, the gap

in benefits in the Medicare prescription drug program.

Our plan is a good, commonsense answer to the crisis facing American families and businesses.

On this floor, here in the Senate, tonight, we have a historic opportunity to consider this plan. We have the chance to make it even better. We hope to have a full debate. But more important than the process or rhetoric, we have the opportunity, at last, to face the crisis. We have the opportunity to show mature leadership. At long last, we have the opportunity, the historic opportunity, to reform health care, once and for all. History is knocking on the door. Let's open it. Let's begin the debate

to improve this bill before us today and provide the service all Americans expect us to perform when they elect us to this office.

I yield the floor.

7:25 PM EST

Chris Dodd, D-CT

Mr. DODD. Mr. President, I rise in very strong support of this melded bill, drafted and put together by our distinguished leader, the Patient Protection and Affordable Care Act.

Before I begin with some brief remarks, let me extend my heartfelt thanks to our majority leader for his tireless work and thank Max Baucus of Montana for his tireless work and the members of the committees who have worked over the past many months to bring us to this moment.

Others this evening have spoken with great eloquence, in my view, about the provisions of this bill, what we hope to achieve for our fellow citizens with the adoption of this legislation.

I commend the Senate HELP Committee, which did such heroic work during the writing of our portion of the bill--my colleagues, Tom Harkin of Iowa, Barbara Mikulski of Maryland, Jeff Bingaman of New Mexico, Patty Murray of the State of Washington, and so many others.

I thank my Republican colleagues on that committee as well. While we did not end up with a bipartisan vote at the end of that very long process, we did end up adopting more than 160 amendments offered by my Republican colleagues to that bill, which I think strengthened the legislation, made it a better piece of legislation, and many of which are a part of this legislation this evening.

I also want to pause for a moment, if I can, to recognize a colleague who is here tonight only in spirit, Ted Kennedy. So much has been said and written about his lifelong quest to ensure that every American--every American--has decent health care. Tonight and in the days to come, we will pay him the highest compliment, as our colleague, by fulfilling that quest of achieving the goal all Americans aspire for; that is, a national health care plan that serves every one of our citizens.

I would like to speak briefly, if I could, to the American people who are at home this evening and I suspect are just tuning in to this debate.

This important vote will occur momentarily. Why does this issue and this debate matter? Why are we here on a Saturday evening? But then again, for that matter, why are you watching C-SPAN on a Saturday evening, I might add?

Well, for one thing, health care represents one-sixth of our economy and affects 100 percent, as we all know, of the population of this country. And it is true that skyrocketing health care costs are the single biggest threat to the financial future of our fellow citizens.

But the reason tonight's vote is so historic, beyond those last two points, is that never, ever before--never before--has this body, elected to serve the American people, confronted directly this simple truth: Nothing, absolutely nothing, matters more to you and to your family than the ability to get the health care you need, when you need it, from the doctor you choose, at the price you can afford.

Health care is our most basic need. Health care is the most basic commitment we should be willing to make to each other. No matter what your family finances, no matter what your hopes and dreams are, no matter who you are or where you live or what your job is in America, in our 21st century America, you should be able to get the care you need.

But for too many American families--perhaps your family, as you watch this tonight from your homes--health care has become your most basic fear. If you do not have health insurance, you go to bed every single night knowing that if you wake up sick or your child does, you might not be able to see that doctor or afford one if you can even find one. Even if you have health insurance, you are paying more and more in premiums and getting less and less coverage for your money.

Millions of you are seeing your premiums skyrocket. Yet you lie awake at night--millions do--wondering: What if I lose my job? What if I get sick and find out my policy does not cover the costs and the care I need--or, even worse, your insurance company cancels your policy altogether? What if you run out of benefits and have to pay out of your pocket? I wish I could say these fears are irrational fears, but they are not. There is nothing irrational about those fears. Insurance does not allow

you to be sure of anything these days.

Our system, all 100 of us here know, is broken. People are losing their homes because they get sick. People are dying because they cannot afford the cure. This is just not acceptable in our America. That is why we are here on a Saturday night.

If you have watched the news over the past few months, you have probably noticed there is a wide range of opinions on how we should fix things. And that is as it should be. We need all the good ideas we can get, and hopefully this debate will produce that.

But if you have also watched the debate in the Senate over the last 2 days, you have probably noticed something else as well. I don't believe a single person in this body has stood up at any point and said we are OK doing nothing at all. Therefore, in the weeks ahead we will have a full and open debate about every provision of this bill. [Page: S11965]

But tonight's vote is nothing more than a choice--a choice between doing something or doing nothing. I urge my colleagues this evening to join us, hopefully unanimously, to say we should do something. We should do something about this most basic right that all Americans deserve.

I yield the floor.

7:31 PM EST

Mitch McConnell, R-KY

Mr. McCONNELL. Mr. President, the Nation is watching the Senate tonight. The American people know how important this vote is. They have seen the bill the Democratic leaders want to impose upon them, and they want to know where the rest of us will stand.

This bill itself is a massive monument to bureaucracy and spending. But at its core it is quite simple. At a moment when more than 1 of 10 working Americans is looking for a job, at the time when the Chinese are lecturing us about our debt, this bill--this bill right here--costs $2 1/2 trillion the government doesn't have and cannot afford. It imposes punishing taxes on almost everyone. It raises health insurance premiums on the 85 percent of Americans who already have health insurance. And

if that were not bad enough, it slashes Medicare by $ 1/2 trillion. Anyone who votes aye tonight is voting for all of these things.

It is a fact: A vote in favor of proceeding to this bill is a vote in favor of adding to the tax burden of the American people in the midst of double-digit unemployment. A vote in favor of proceeding to this bill is a vote to raise health insurance premiums on people who were told--they were told--that they could expect their health insurance costs to go down. A vote in favor of proceeding to this bill is a vote in favor of deep cuts to Medicare for tens of millions of seniors who depend on it

totally. A vote to proceed to this bill is a vote to continue the completely out-of-control spending binge this Congress has been on all year. A vote in favor of this bill tells every American family sitting in a waiting room tonight, wondering when they will get to see

a doctor or how much it is going to cost: It is not our concern. Worst of all, a vote in favor of this bill is a vote in favor of the spending binge that is leading to a massive and unsustainable, long-term debt that will shackle our children to a future they can't afford.

That is what tonight's vote is all about. If it weren't, none of us would be here on a Saturday night with the Nation watching and waiting to see what we do. They are watching because they know that none of this--none of this--is inevitable.

All it takes is one vote--just one. The simple math is this: If there were one Democrat, just one of our friends on the other side of the aisle, just one who would say no tonight, none of this would happen. The voices of the American people would be heard. We have seen all the surveys. We know how they feel. If one Democrat were to say no tonight, he would be saying no to the premium increases, no to the tax cuts, no to the Medicare cuts--just one on the other side of the aisle. Then we could

start over with a commonsense, step-by-step approach to fix the problem that got us here in the first place, and that is that health care costs too much.

That is the sad irony of this whole debate. The problem that got us here is that health care costs are out of control. Yet the neutral, nonpartisan Congressional Budget Office, the scorekeeper around here, says under this bill--this massive bill--health care costs are actually going to go up, not down, and the American people thought that is what this whole debate was about in the first place. So 2,074 pages and trillions of dollars later--2,074 pages and trillions of dollars later--this bill

doesn't even meet the basic goal the American people had in mind in what they thought this debate was all about--to lower costs. This bill will actually make the situation worse, and now we are about to vote on it.

We have heard some Senators come to the floor today and say that they oppose this bill, but they don't want to stop the debate. They oppose the bill, but they don't want to stop the debate. Nobody is suggesting we stop the debate. No one. Not a single Senator on this side of the aisle have I heard suggest that we stop the debate. But if we don't stop this bill tonight, the only debate we will be having--the only debate we will be having--is about higher premiums, not savings for the American

people; higher taxes instead of lower costs, and cuts to Medicare rather than improving seniors' care. That is what the debate will be about.

The American people and 40 of us in this room sitting on this side of the aisle are not asking to end the debate. That is not what we have in mind, to end the debate. What we want to do is change the debate--not end it, change it--because once we get on this bill, ladies and gentlemen, the basic dimensions will not change. The basic dimensions will not change.

So I ask: Why should we consider a bill we already know the American people oppose? This is not anything anybody is in doubt about. The American people think if you don't like this bill, you have an obligation to try to stop it, and that opportunity will come at 8 o'clock.

I am sure this won't come as a surprise to any Member of the Senate, but it is going to take 60 votes to change this bill. That means the bill as introduced--this bill we are looking at right here--will fundamentally be the bill we will be asked to pass sometime in the future. That is a fact.

After tonight's vote we will all go home and face our constituents. We will have to tell them how we voted on raising their premiums, raising their taxes, and cutting their Medicare. For some of us, that is not going to be a very easy conversation, but it doesn't have to be that way. If you want to lower costs and premiums, then we can work together step by step and pass the commonsense reforms the American people have been asking for all along.

We can end junk lawsuits against doctors and hospitals which drive up costs. We can encourage healthy choices such as prevention and wellness programs which hold down costs. We can lower costs by letting consumers buy coverage across State lines. We can allow small businesses to band together to get lower insurance rates. And certainly we can address the rampant--absolutely rampant--waste, fraud, and abuse that drives up costs. All of those, my colleagues, are changes worth making.

The American people are looking at the Senate tonight. They are hoping we say no to this bill so we can start on a better plan that fixes the problem the American people care about most, and that is cost. They want us to start over. There is nothing about this massive bill they like. They want us to start over. They want us to address their real concerns. All it would take, Mr. President and my colleagues, is one Member of the other side of the aisle--just one--to give us an opportunity not to

end the debate but to change the debate in the direction the American people would like us to go.

I yield the floor.

7:44 PM EST

Harry Reid, D-NV

Mr. REID. Mr. President, my dear friend, the Republican leader, has had since Wednesday to read this bill. Obviously he hasn't done so because the facts he is talking about do not exist except in the minds of a few people who don't understand this legislation.

For 200 years we have styled ourselves the world's greatest deliberative body. Deliberation necessarily implies discussion and great issues, necessarily requires great debate. Today we vote on whether to even discuss one of the greatest issues of our generation; indeed, one of the greatest issues this body has ever faced: whether this Nation will finally guarantee its people the right to live free from fear of illness and death which can be prevented by decent health care for all. In the coming

weeks, we will finally put people, not insurance companies, in charge of their lives.

The road to this point has been started many times. It has never been completed. Merging two such large and consequential bills has never been done before. It has been an enormous undertaking and we would not be in this position without the unflagging dedication of many Senators and extremely loyal staff members. At the top of the list are Chairmen Baucus and Dodd who have shown dedication and determination in recent weeks and months that has rarely been seen.

I am proud of every single Senator's input, and I am especially proud of the two most recent classes of Senators. Elected with strong mandates for [Page: S11966]

progress, they have demonstrated a studious approach to our historic endeavor and an unwavering belief that all Americans should be able to afford to live a healthy life.

I wish to explain why we are holding this important vote at this hour. As a matter of principle that I respect, the senior Senator from Arkansas insisted we vote only after Senators had time to read and understand this bill. Senators all have now had ample time to do so. That is because of the chairman of the Agriculture Committee, Senator Blanche Lincoln, of Arkansas.

As I have done many times this year privately, personally, as well as publicly, I again invite my Republican colleagues to join on the right side of history. I, again, invite them to join us, at the very least, in a debate about our future.

Around dining room tables in Nevada and across the Nation, families are agonizing over what to sacrifice next to buy health insurance. They are questioning whether to fill a prescription or go without it and hope for the best. Employers are wondering whether they can afford to provide health care to their employees. They are asking how their businesses can survive while health care costs grow faster than ever. Americans need health insurance reform.

Debate is constant between television commentators and the editorial pages of great newspapers and magazines. The only place where silence is even considered is in the Senate of the United States.

Tonight--finally--we have the opportunity to bring this debate where it belongs. We finally have the opportunity to bring this great deliberation to this great deliberative body. That--and nothing more--is what tonight's vote does. A ``yes'' vote says to America: I know this issue is important to your family and to our country, and the Senate should, at the very least, talk about it.

Let's be real transparent. Beyond all the hype, the hyperbole, and the hyperventilation, that--and nothing more--is what tonight's vote does. A ``yes'' vote says to America: I know this issue is important to your family and to our country, and the Senate should at least talk about it.

Some of my Republican friends would like the American people to think that voting to debate the bill is voting to pass the bill. Any high school civics textbook will tell you that suggestion is absolutely false. Tonight's vote is not the end of the debate, it is only the beginning of the debate.

It is clear by now that my Republican colleagues have no problem talking about health care in press conferences, radio interviews, television interviews, and townhall meetings. My distinguished counterpart, the Republican leader, has given many speeches in this Chamber on the issue of health care reform.

Yet now that we have the actual legislation to debate, to amend, and build on--now that we have a plan on paper and not just wild rumors--will they refuse to debate?

After all, if we are not debating, if we refuse to let the Senate do its job, what are we doing here? If Senators refuse to debate about a profound crisis affecting every single citizen, the Nation must ask, what do you fear? In whose voice do you speak? In whose interest do you vote?

Surely, deliberating health reform cannot be more difficult than deciding, as Americans have to do, whether to pay your mortgage or your medical bills. It can't be more painful than not taking your child to the doctor because it costs too much. It cannot be more humbling than facing your own employees and telling them: I am sorry, you can't count on me for your health insurance next year. You are on your own.

It can't be more upsetting than having an insurance company take away your coverage at the exact moment you need it the most.

My Republican friends, there is nothing to fear in debate. President Kennedy once said:

Let us not be afraid of debate or discussion. Let us encourage it.

Be not afraid of debate. It is our job, and it is exactly what the legislative process is all about--discussing, amending, improving. We Democrats stand ready to do what needs to be done. We welcome debate, encourage debate.

Does any Senator seriously think the Founders conceived the Senate rules in the hopes that legislation would never be deliberated? Of course not.

Did the Framers of the Constitution explicitly enumerate the powers of the Senate but in truth hope this body would avoid the hardest and most urgent questions of the day? Of course not.

Did our Nation's visionaries build this Capitol Building and design this great Chamber we stand in tonight only so it would remain dark and silent? Quite to the contrary.

Imagine if, instead of debating either of the historic GI bills--legislation that has given so many brave Americans the chance to attend college--this body stood silent. Imagine if, instead of debating the bills that created Social Security or Medicare, the Senate voices had been stilled.

Imagine if, instead of debating whether to abolish slavery, instead of debating whether giving women and minorities a right to vote, those who disagreed had muted discussion and killed any vote.

I say to my Republican Senators, don't try to silence a great debate over a great crisis. Don't let history show that when given the chance to debate and defend your position and work with us for the good of our constituents, you ran and hid. You cannot wish away a great emergency by closing your eyes and pretending it doesn't exist.

There is an emergency that exists, and it exists now. The right response to disagreement is not dismissal, it is discussion. Democracy is discussion. Democracy needs deliberation. Let us debate our differences. On some, we will find common ground; on others, we may not. But let's at least tell America their legislators in the Senate are willing to find where we can come together.

Nobel Prize awardee Andre Sakharov, one of the great thinkers of the past century, knew that when opposing sides come together, some of their ideas can outweigh its parts. Sakharov said:

Profound thoughts arise only in debate, with a possibility of counter-argument. .....

So come on, my friends, let us share our ideas in the Senate. Let us legislate. Let us negotiate. Let us deliberate. Let us debate. Our country cries for this debate. Our country deserves this debate. Our country needs this debate.

I extend my great appreciation to the truly tireless men and women at the Senate Finance Committee, Senate HELP Committee, Congressional Budget Office, Senate Office of the Legislative Counsel, Joint Committee on Taxation, the Department of Health and Human Services, the Center for Medicare and Medicaid Services and the White House:

CONGRESSIONAL BUDGET OFFICE

Doug Elmendorf, Director; Holly Harvey, Deputy Assistant Director for Budget Analysis; Kate Massey, Unit Chief, Low-Income Health Programs and Prescription Drugs Cost Estimates; Tom Bradley, Unit Chief, Health Systems and Medicare Cost Estimates; Phil Ellis, Unit Chief, Health Policy Analysis; Jean Hearne, Lara Robillard, Lori Housman, Mindy Cohen, Stephanie Cameron, and the rest of their staffs.

SENATE OFFICE OF THE LEGISLATIVE COUNSEL

Jim Fransen, Bill Baird, Ruth Ernst, John Goetcheus, Kelly Malone, Mark Mathieson, Mark McGunagle, Stacy Kern-Scheerer, Allison Otto, and the rest of their staffs.

JOINT COMMITTEE ON TAXATION

Thomas Barthold, Adam Block, John Bloyer, Tanya Butler, Jim Cilke, Tom Dowd, Robert Harvey, Marjorie Hoffman, Melanie Houser, Deirdre James, Rachel Levy, Julie Marshall, Pam Moomau, John Navratil, Ned Newland, Mary Risler, Cecily Rock, Bernard Schmitt, Chris Simmons, Carrie Simons, Lori Stuntz, Kristeen Witt.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Jeanne Lambrew, Meena Seshamani, Caya Lewis.

CENTER FOR MEDICARE AND MEDICAID SERVICES

Erin Clapton, Ira Burney, Amy Hall, Maria Martino, Isabella Leung, Anne Scott, Nancy DeLew, Sharon Arnold, Allison Orris, Jennifer Snow, Jill Gotts, Chantelle Britton, Molly Long, Adam Aten, Lisa Joldersma, Sylvia Yu, Laura McWright, Greg Jones, Dan Miller, Ariel Novick, Rick Foster.

Program Experts in the following offices/centers (in alphabetical order): Center for Drug and Health Plan Choices (Tim Hill); Center for Medicare Management (Jon Blum, Liz Richter); Center for Medicaid & State Operations (Cindy Mann, Penny Thompson); Office of Clinical Standards & Quality (Barry Straube); Office of E-Standards and Services [Page: S11967]

(Tony Trenkle); Office of Financial Management (Deborah Taylor); Office of General Counsel (Janice Hoffman); Office

of Legislation; Office of Research, Development and Information (Tim Love).

THE WHITE HOUSE

Nancy-Ann DeParle, Mike Hash.

I suggest the absence of a quorum.