10:02 AM EST

Max Baucus, D-MT

Mr. BAUCUS. Madam President, I yield myself 2 1/2 minutes from the time under the control of the managers.

For the benefit of all Senators I want to take a moment to lay out today's program.

The time between now and 11:45 is for debate on the amendment by the Senator from Maryland, Ms. MIKULSKI, the chairwoman of the Subcommittee on Retirement and Aging of the Health, Education, Labor and Pensions Committee.

And at the same time, we will debate the side-by-side amendment by the Senator from Alaska, Ms. MURKOWSKI.

At 11:45, the Senate will conduct two back-to-back rollcall votes on the two amendments, first on the amendment by the Senator from Maryland, and second on the amendment by the Senator from Alaska.

Thereafter, we will conduct approximately 2 hours of debate on the McCain motion to commit on Medicare and the side-by-side amendment by the Senator from Colorado, Mr. BENNET.

At 2:45, the Senate will conduct two back-to-back votes on the amendment by the Senator from Colorado, followed by a vote on the motion to commit by the Senator from Arizona.

Thereafter, we expect to turn to another Democratic first-degree amendment and another Republican first-√źdegree amendment.

This is the fourth day on this bill, and we are only late this morning coming to our first vote. Even for the U.S. Senate, this is a slow pace.

I note that some have made plans for delaying this bill in even more extreme fashion. As the majority leader noted, on Tuesday, one Senator circulated a list of delaying tactics available under the Senate rules.

I presume all Senators know the Senate's rules already. So to send the letter leaves the impression that that Senator would like to urge Senators to use some of the delaying tactics stated in the memo.

But I urge a more cooperative course. Out of courtesy to other Senators who desire to offer amendments. I urge my colleagues to allow us to reach unanimous consent agreements to order the voting of future amendments in a more timely fashion. That is simply the only way that we can ensure that more colleagues will have the time and opportunity to offer and debate their amendments.

I thank all Senators.

10:06 AM EST

Max Baucus, D-MT

Mr. BAUCUS. I ask unanimous consent that the debate time from 2 to 2:45 this afternoon be divided as follows in the order listed: the first 17 1/2 minutes under the control of Senator McCain or his designee; the next 17 minutes under the control of Senator Baucus or his designee; and the final 10 minutes, 5 minutes each for Senator McCain and Senator Bennet of Colorado. [Page: S12266]

10:06 AM EST

Tom Harkin, D-IA

Mr. HARKIN. Madam President, I heard the distinguished minority leader earlier in his comments say that one of the reasons they are slowing this bill down and having all this debate is it has been a strictly partisan venture thus far. I beg to differ with the minority leader.

I see our distinguished ranking member of the HELP Committee here on the floor. In the HELP Committee, for the enlightenment of Senators, we had 13 days of markup, 54 hours, 788 amendments were filed, 287 amendments were considered and debated and voted on or accepted, and 161 Republican amendments were adopted. No one was denied the opportunity to offer any amendment, to discuss them, debate them, and get a vote or have it accepted, whatever the case might be. To me, this is truly a bipartisan

way of proceeding.

The minority leader's argument basically goes to the fact that the people of this country overwhelmingly elected Democrats to guide and make changes for the future. One of the biggest changes is in our health care system. One of the responsibilities of being a majority party is to propose. That is what we have done. We are proposing changes in the health care system. The function of the minority is to offer amendments, constructive amendments, offer different ideas, and if their ideas are better

or if they receive majority approval, then the bill is thus changed. That happened in the HELP Committee. As I said, 161 Republican amendments were adopted. To me, that is bipartisan. That is what we have been doing. What is kind of not acceptable is this idea that things are just going to slow down for the purposes of delaying and eventually making sure we don't have a bill.

Let me say that after all that lengthy debate we had in the HELP Committee, we passed a bill. The same will happen here on the Senate floor. I don't care how many times the minority wants to drag it out and slow it down to try to kill this bill, this bill will pass the Senate, we will go to conference, and we will have it on the President's desk early next year.

10:09 AM EST

Mike Enzi, R-WY

Mr. ENZI. I appreciate the comments, some of which need correction, from yesterday and those that have just been made.

On a partisan bill, I sat through all of those days in the HELP Committee. That bill was rushed and put together. Senator Kennedy was not able to be involved in that part of it. His staff did it. They did it in a hurry. We turned in 159 amendments that were accepted. Most of those were for typos and minor corrections. There were a few that actually had some substance to them. That bill was passed on July 15 out of committee without a single Republican vote. It wasn't published. We didn't see

the final version until September 17. The ones that were really something that could have made a difference were taken out without the permission of any Republican Senator. That is not bipartisan.

We talked about how many hours we spent together. If you don't accept things from the minority party, it is not bipartisan. It is still partisan. Just spending hours doesn't make any difference.

To move on to a different topic, yesterday we were talking about costs. I hope the people take a look at a Wall Street Journal article from yesterday that says:

A bill that raises prices but lowers costs, and other miracles.

We heard all day yesterday that this bill is going to save people a lot of money. This article reads:

We have now reached the stage of the health-care debate when all that matters is getting a bill passed, so all news is good news, more subsidies mean lower deficits, and more expensive insurance is really cheaper insurance. The nonpolitical mind reels.

Consider how Washington received the Congressional Budget Office's study Monday of how Harry Reid's Senate bill will affect insurance costs, which by any rational measure ought to have been a disaster for the bill.

CBO found that premiums in the individual market will rise by 10% to 13% more than if Congress did nothing. Family policies under the status quo are projected to cost $13,100 on average, but under ObamaCare will jump to $15,200. Fabulous news! ``No Big Cost Rise in U.S. Premiums Is Seen in Study,'' said the New York Times, while the Washington Post declared, ``Senate Health Bill Gets a Boost.'' The White House crowed that the CBO report was ``more good news about what reform will mean for families

struggling to keep up with skyrocketing premiums under the broken status quo.'' Finance Chairman Max Baucus chimed in from the Senate floor that ``Health-care reform is fundamentally about lower health-care costs. Lowering costs is what health-care reform is designed to do, lowering costs; and it will achieve this objective.''

Except it won't. CBO says it expects employer-sponsored insurance costs to remain roughly in line with the status quo, yet even this is a failure by Mr. Baucus's and the White House's own standards.

Meanwhile, fixing the individual market--which is expensive and unstable largely because it does not enjoy the favorable tax treatment given to job-based coverage--was supposed to be the whole purpose of ``reform.'' Instead, CBO is confirming that new coverage mandates will drive premiums higher. But Democrats are declaring victory, claiming that these higher insurance prices don't count because they will be offset by new government subsidies.

About 57% of the people who buy insurance through the bill's new ``exchanges'' that will supplant today's individual market will qualify for subsidies that cover about two-thirds of the total premium. So the bill will increase costs but it will then disguise those costs by transferring them to taxpayers from individuals. Higher costs can be conjured away because they're suddenly on the government balance sheet. The Reid bill's $371.9 billion in new health taxes are also apparently not a new cost

because they can be passed along to consumers, or perhaps will be hidden in lost wages. This is the paleo-√źliberal school of brute-force wealth redistribution, and a very long way from the repeated White House claims that reform is all about ``bending the cost curve.'' The only thing being bent here is the budget truth.

Moreover, CBO is almost certainly underestimating the cost increases. Based on its county-by-county actuarial data, the insurer WellPoint has calculated that Mr. Baucus's bill would cause some premiums to triple in the individual market. The Blue Cross Blue Shield Association came to similar conclusions. One reason is community rating, which forces insurers to charge nearly uniform rates regardless of customer health status or habits. CBO doesn't think this will have much of an effect, but costs

inevitably rise when insurers aren't allowed to price based on risk. This is why today some 35 states impose no limits on premium variation and six allow wide differences among consumers.

The White House decided to shoot messengers like WellPoint to avoid rebutting their message. But Amanda Kowalski of MIT, William Congdon of the Brookings Institution and Mark Showalter of Brigham Young have found similar results. In a 2008 paper in the peer-reviewed Forum for Health Economics and Policy, these economists found that state community rating laws raise premiums in the individual market by 20.9% to 33.1% for families and 10.2% to 17.1% for singles. In New Jersey, which also requires

insurers to accept all comers (so-called guaranteed issue), premiums increased by as much as 227%.

The political tragedy is that there are plenty of reform alternatives that really would reduce the cost of insurance. According to CBO, the relatively modest House GOP bill would actually reduce premiums by 5% to 8% in the individual market in 2016, and by 7% to 10% for small businesses. The GOP reforms would also do so without imposing huge new taxes. But Democrats don't care because their bill isn't really about ``lowering costs.'' It's about putting Washington in charge of health insurance,

at any cost.

10:15 AM EST

Tom Harkin, D-IA

Mr. HARKIN. Madam President, parliamentary inquiry: There is time between now and the hour of 11:45 a.m. equally divided between the Republican side and the Democratic side; is that correct?

10:16 AM EST

Tom Harkin, D-IA

Mr. HARKIN. Madam President, I have to respond to my friend from Wyoming about doing this in a hurry. He mentioned that we did the bill in a hurry in our committee. Actually, it was last November, shortly after the election, when I received a call from Senator Kennedy talking about doing a health reform bill, asking if I would take charge of a section dealing with public health and prevention and wellness. I think then he asked Senator Murray to take over workforce development, Senator

Bingaman did coverage, and Senator Mikulski did quality improvements. So that was in November.

I cannot speak for the others who did the other sections. All I can say is, on our side, in what I did, we had five hearings. We had five hearings on public health and prevention and wellness and what ought to go into a bill. I think those hearings commenced in December and went through about February. Then we worked until June, and we did not start our markup until June. So we had almost 6 months of hearings and putting things together in the bill before we started a markup. I rather doubt that

can be said to be rushing anything.

But I just want to focus on the vote that is coming up on the amendment offered by the Senator from Maryland, Ms. Mikulski, which will strengthen provisions in the bill concerning preventive health benefits for women.

As an initial matter, I am proud of the significant investments the bill makes overall in wellness and prevention. It has not been talked about very much. If you read the public press out there, the popular press, and watch TV, about the only thing you think is in the bill is a public option and abortion and that is what this bill is about. Well, those may be the hot points and the flashpoints--it makes for good press--but I submit that one of the most important parts, if not the most important

part, of this bill is what it does for prevention and wellness, trying to move our costs upstream, keeping people healthy in the first place.

I have said many times, what good does it do us if we are just going to pour more money into paying bills for a broken, dysfunctional, sick care system--not a health care system, a sick care system? That is what we have in America today. This bill begins the transformation of moving us from a sick care system to a true health care system.

The Senator from Maryland has a very important amendment to make clear--to make clear--that what is included in the bill is to strengthen the preventive services that basically inure to the women of this country. The Mikulski amendment reiterates the recommendations of our bill, and it also points out that the recommendations of the U.S. Preventive Services Task Force is a floor, not a ceiling--it is a minimum. In other words, health plans are required at a minimum to provide first-dollar coverage

for preventive services recommended by the Preventive Services Task Force, but that is just the minimum. The Secretary of Health and Human Services has full discretion to identify additional preventive services that will be part of the essential package offered by health insurance on the exchange.

Again, there has been some talk here about this task force, the Preventive Services Task Force, that somehow this is a bunch of bureaucrats, it is a government-run task force, it has a political agenda. I have heard all these things said on the floor in the last day or so. Well, in fact, the Preventive Services Task Force is an independent body that evaluates the benefits of clinical preventive services. It makes recommendations--again, no decisions, merely recommendations--about which services

are most effective.

Who is on this task force? Experts and leaders in primary care who are renowned internists, pediatricians, family physicians, gynecologists, and obstetricians. And these professionals are not located in Washington, DC; they are based all over the country. Some may be in one State or another State. They are all over the country, and they are experts in these different areas, recognized by their peers. They do not sit in an office at Health and Human Services. They bring years of medical training

and experience to the jobs they do.

Does that mean they never make a mistake? No. No one is perfect. No Senator is perfect. Neither is every doctor perfect. And neither is any task force always going to make what we might consider to be the perfect answer. But our bill does not grant them the authority to tell insurance companies what not to cover. That is clear. But to hear the debate on the floor, you would think it is just the opposite, that the Preventive Services Task Force can tell insurance companies what they cannot cover.

That is not true. Our bill says that those recommendations that are A and B--categorized by the Preventive Services Task Force, by these expert doctors around the country--these are the ones they say really are key preventive services, have the most benefit. We say in our bill that those services must be covered without copays, without deductibles. That means that is the floor. That is the floor.

Again, I might also add that preventive services that are rated by the Advisory Committee on Immunization Practices and comprehensive guidelines supported by the Health Resources and Services Administration are also part of the recommendations to establish that floor.

So, again, I would say it is a pretty big floor when you put all those together. Again, it does not establish a ceiling and it does not say what cannot be done. It just says you have to do these basics. That is the floor.

I do understand the concerns of some that the task force has not spent enough time studying preventative services that are unique to women. Senator Mikulski goes back a long way on this issue. I can remember some years ago Senator Mikulski pointing out to me, in my capacity as the then-chairman of the Appropriations subcommittee that funds NIH----

10:23 AM EST

Tom Harkin, D-IA

Mr. HARKIN. Senator Mikulski said: If you look at the research being done at NIH, it is almost all done on men and not on women. I remember that some years ago, and all of a sudden a lightbulb went off in my head. I said: You are right. So we had to start changing the focus of a lot of the research done to focus on the unique situations faced by women.

Well, this was also a concern that was raised in our HELP Committee by Senator Mikulski, and we included language to require all health plans to cover comprehensive women's preventive care and screenings based on guidelines promulgated by the Health Resources and Services Administration--again, without any copays or deductibles. That was in our health bill but unfortunately was not included in the merged bill. But Senator Mikulski's amendment, which we are about to vote on,

brings us back to the position we had in the HELP Committee bill. I think that was largely supported, if I am not mistaken, on both sides, at least in our HELP Committee. At least no one offered any amendment to strike it when we were debating it in committee. So I assume it was supported generally by both Republicans and Democrats.

By voting for the Mikulski amendment, we can make doubly sure that the floor we are establishing in the bill for preventive services that are unique to women also has no copays and no deductibles. Again, that is why this amendment is so important. [Page: S12268]

I know our friend Senator Murkowski has a different way of approach. I commend her for her involvement and her interest in this issue. She has been a great member of our committee, and I have done a lot of great work with Senator Murkowski. But I think her amendment misses the mark in this way: It asks insurers to use guidelines from provider groups when making coverage decisions. Well, that does not guarantee women will get any of the preventive services they need.

Here is a statement from the American Heart Association and the American Stroke Association. It says:

..... we are concerned that Senator Murkowski's preventive health services amendment would take a step backwards by substituting the judgment of the independent U.S. Preventive Services Task Force with the judgment of private health insurance companies.

Madam President, I ask unanimous consent that this letter from the American Heart Association and the American Stroke Association be printed in the Record.

There being no objection, the material was ordered to be printed in the Record, as follows:

Statement by American Heart Association CEO Nancy Brown on Murkowski Amendment on Preventive Health Services

(Dec. 2, 2009)

The American Heart Association strongly supports requiring health plans and Medicare to provide first-dollar coverage for clinical preventive services that are evidence-based and necessary for the prevention or early detection of an illness or disability. We appreciate that Senator Murkowski's amendment recognizes the value of the guidelines and recommendations made by professional medical organizations (as well as by voluntary health organizations like the American Heart Association). But even

these guidelines must be held to the standard of being evidenced based. In addition, we are concerned that Senator Murkowski's preventive health services amendment would take a step backwards by substituting the judgment of the independent U.S. Preventive Services Task Force with the judgment of private health insurance companies. Although we

have previously recommended to Congress that the USPSTF membership be expanded to include specialists to broaden the expertise of the Task Force, we believe an expanded USPSTF would be the best entity to objectively and rigorously make recommendations for covering clinical preventive services and do not support eliminating it from this role.

10:26 AM EST

Tom Harkin, D-IA

Mr. HARKIN. Madam President, I will have more to say about the Murkowski amendment later. But, again, the point is, the Mikulski amendment is right on point. It should be adopted.

10:26 AM EST

George LeMieux, R-FL

Mr. LeMIEUX. Madam President, I come to the floor today to draw back the curtain a little, I hope, and to widen the lens to talk about the issue of the bill before us, not just on this particular amendment but on what it is going to mean for my constituents in Florida and for the people of this country.

I had the opportunity last week to be back home in Florida, in south Florida, in Palm Beach County and Broward County and Miami-Dade County, where I talked to doctors, hospital administrators, folks who run Medicare Advantage plans, as well as everyday Floridians, specifically senior citizens. The responses I heard were nearly unanimous, and that was grave concern about the bill that is being debated on this floor and a general confusion as to why the Congress is pursuing the path that it is.

The people of Florida do not understand why we are going to cut Medicare to create a new program. The people of Florida do not understand why we are going to raise taxes to create a new program. The people whom I have spoken to in Florida do not understand why we would undertake a new $2.5 trillion health care proposal if it was not going to reduce the cost of health insurance for the 170 million to 180 million Americans who have health insurance today.

Why are we embarking upon this measure if it is not going to affect most everyday Floridians and everyday Americans who are struggling under the high cost of health insurance? Health insurance premiums have increased 130 percent in the past 10 years.

When the President put this proposal forward and when he campaigned on it, he said his major goal was to reduce the cost of health insurance. When he addressed the Nation in a joint session of Congress on September 9, he said his plan would reduce the cost of health insurance. But we find out that for at least 32 million Americans, it will raise the cost of health insurance 10 to 13 percent. So at least half of the goal, if not most of the goal, of his plan for most Americans in this country

will not be accomplished. Yet we are going to cut nearly $ 1/2 trillion out of Medicare, we are going to raise taxes by $ 1/2 trillion, and we are going to spend $2.5 trillion on this program, which was admitted to by Senator Baucus yesterday on the floor, which cannot be, under my understanding, in any way budget neutral.

But I want to speak specifically about the cuts to Medicare. It cuts $192 billion, according to the Congressional Budget Office, ``to Medicare's payment rates for most services.'' I think we have to be clear here that if you cut providers, you are going to cut services. The very reason we talked about increasing doctor payments in that $ 1/4 trillion program was so that patients would not receive fewer services, so there would be ample doctors providing services for Medicare. It is beyond logic

to argue that cutting providers will not cut services. What will happen when we cut providers, doctors, nursing homes, home health agencies, hospitals? Fewer and fewer of them will provide benefits, and fewer and fewer of them will take Medicare.

The Chief Actuary of CMS believes the cuts in the bill we have before us could cause providers to end their participation in Medicare:

..... providers for whom Medicare constitutes a substantive portion of their business could find it difficult to remain profitable and might end their participation in the program.

Every American understands this. If we pay less money to health care providers, they are going to offer less benefits or more and more they are not going to participate in Medicare.

The Medicare Payment Advisory Commission found in June of last year that 29 percent of Medicare beneficiaries who were looking for a primary care doctor had a problem finding one to treat them. This is of grave concern to the 3 million Floridians who are on Medicare. If a doctor will not see them, what kind of health care plan is this? These seniors, our ``greatest generation,'' have paid into this program their whole life. It is illusory if they can't find a doctor who will treat them.

One of my constituents, Earl Bean, from Sanford, FL, recently told CNN that he called about 15 doctors when he was trying to find health care, and he was told they were not taking new Medicare patients. So when we cut $ 1/2 trillion out of Medicare, is that going to improve health care for seniors or is it going to continue to decline health care for seniors? You can't get blood from a stone. It is going to make the situation worse. For anyone to come to this floor and say that it would not

is incredible.

We have in Florida the second highest Medicare population. When we cut $135 billion from hospitals and $21 billion from the disproportionate share fund, which is basically money that goes to these hospitals to provide health care for seniors and the indigent, how are they going to be able to provide that health care? I spoke to the administrator of the North Broward Hospital District and told him about this cut to the DSH funds, and he told me it would be devastating to their provision of health


Then we are going to take a very popular program called Medicare Advantage--more than 900,000 Floridians in my State--and we are going to cut it as well. I recently visited the Leon Medical Center and their new facility in Miami Dade County where they provide state-of-the-art, first-class health care for seniors; not only normal health care but eyeglasses, hearing aids, dental care, and the constituents who go there love it. They are getting the kind of health care that you would hope your senior

citizens in your family would get.

The principal of the company, Ben Leon, told me they have saved $70 billion in the way they have run their system. He told me if we continue on this path with these cuts to Medicare Advantage, he will not be able to provide [Page: S12269]

these good services going forward. There are some fixes to grandfather folks in, but all in all people will be cut, and all in all the program will not be as good, and it will decline the health care of seniors in Florida and across

this country.

We will cut $15 billion from nursing home care and $40 billion from home health agencies. I spoke to a provider of a home health agency practice in Florida. He said these cuts will put half of the home health care agency folks out of business. At a time when we have 11.2 percent unemployment in Florida, this health care bill is going to cost people their jobs, and it is going to decline the quality of health care.

I am also concerned about this Medicare advisory board. This independent board of nonelected folks is going to have the power to cut Medicare by $23 billion over the next 10 years, and it will be up to this body to reinstate those cuts. These people are not elected, my constituents in Florida don't know who they are, but they are going to be responsible for the decline of their Medicare and their health care.

The ``greatest generation,'' who fought to protect this country, is looking at this health care bill and wondering why. Folks with health insurance in this country--more than 170 million who are not going to see their health care costs go down but up--are wondering why. Americans who are seeing higher taxes and penalties for not buying these health insurance programs under this bill are wondering why.

If we are here to reform health care--and we should be--if we are here to try to make sure the 45 million people in this country and the nearly 4 million Floridians get health insurance--and we should be--then why don't we take a step-by-step approach?

I am new to this body. My first day here was September 10, so I have not even been here 3 months. But I can tell my colleagues, the American people, if they knew what I know now and could see what I see, would be baffled by this process. There is not a give-and-take on this issue. We didn't all sit down together in a conference room and work this out to have a bipartisan bill. The Democratic leader worked on it with his colleagues but not with us.

So now we have a program that cuts Medicare, that raises taxes, that doesn't decrease the cost of health care for the majority of Americans and will cost us $2.5 trillion and can't be budget-neutral, at a time when we have a $12 trillion debt, a debt that requires each of us--each family--to put $100,000 on our shoulders to be responsible for that debt, a debt where the third largest payment in our budget is for interest payments, and over the next 10 years those interest payments will go up

by $500 billion, enough to pay for many of the budgets of the Federal Government----

10:37 AM EST

Barbara A. Mikulski, D-MD

Ms. MIKULSKI. Madam President, health care is a woman's issue. Health care reform is a must-do woman's issue, and health insurance reform is a must-change issue.

So many of the women and men of the Senate are here today to fight for change and to make sure we have universal access to health care. When we have universal access, it makes a difference in our lives, which means we have to have universal access to preventive and screening services.

My amendment--and, by the way, it is a bipartisan amendment--makes universal access to preventive and screening services for women available.

There is much discussion about whether women should get a particular service at a particular age. We don't mandate that women get a service; we leave that up to a decision made with the woman and her doctor. But, first of all, they need to be able to have a doctor. So we are for universal access, and this is why the underlying bill is so important.

Then, when you have that, there should also be universal access to preventive and screening services, particularly to the top killers of women, those things that are unique to women. We think about cancer: breast cancer, ovarian cancer, and cervical cancer. Also, women are dying at an increased rate of lung cancer. Then there are these other silent killers that have had a lethal effect on women, and that is cardio and vascular disease. So we want to guarantee universal access to medically appropriate

or medically necessary screening and preventive services.

Many women don't get these services because, first of all, they don't have health insurance; and, No. 2, when they do have it, it means these services are either not available

unless they are mandated by States or the copayments are so high that they avoid getting them in the first place.

The second important point about my amendment is it eliminates deductibles and copayments. So we eliminate two big hurdles: having insurance in the first place, which is the underlying bill, as well as copayments and deductibles. I know of no one in this room who would not want to be on our side on this issue.

I wish to acknowledge the role the Senator from Alaska has played, Ms. Murkowski, as well as Senator Kay Bailey Hutchison, Senator Snowe, and Senator Collins. We, the women of the Senate, have worked on a bipartisan basis for years making sure we were included in the protocols at NIH, increasing funding for important research areas to find that cure, to race for that cure and, at the same time, to be able to have mammogram standards. What the Murkowski amendment--and

by the way, she is Murkowski, I am Mikulski. We sound alike, and the amendments might sound alike, but, boy, are they different.

The Murkowski amendment offers information. I think that is important. That is a threshold matter. You have to have information to make an informed decision. But it does not guarantee universal access to these services, and, of course, it does not eliminate the high payments and deductibles. So her amendment is flawed. My amendment is terrific. My amendment offers key preventive services, including an annual women's health screening that would go to a comprehensive assessment of the dangers to

women, including heart disease and diabetes.

We hope when the Senate makes its decision today, it deals with the fact that for we women, the insurance companies take simply being a woman as a preexisting condition. We face so many issues and hurdles. We can't get health care. We can't get health insurance because of preexisting conditions called a C-section.

I am going to be meeting with an insurance company executive later where his company denied health insurance to a woman who had a medically mandated C-section, and a letter from this insurance company said: We are not going to give you insurance unless you have a sterilization--a coerced sterilization in the United States of America. That is going to be an amendment for another day. But I just wish to give the flavor and the power of what women face when we have to cope with the insurance companies

or where there are barriers to our getting these health care screening services.

So we want to be able to save lives, and we want to be able to save money. We believe in universal access, and if you utilize the service it is because you have had the consultation with your doctor. We do know early screening and detection does save lives, and, at the same time, it saves money.

I will conclude with this: When we look at heart disease and diabetes, not only cancer but early detection of diabetes means, in a well-managed program, under appropriate medical supervision you very likely will not lose that eye, you will not lose that kidney, you will not lose that leg and, most of all, you will not lose your life.

So let's not lose the Mikulski amendment. Let's go with Mikulski and thank Murkowski for her information, but hers is too tepid and too limited. [Page: S12270]

Madam President, I ask my colleague, one of the great guys who supports us, Senator Cardin, how much time he needs.

I yield 5 minutes to Senator Cardin.

10:44 AM EST

Ben Cardin, D-MD

Mr. CARDIN. First, let me thank my colleague, Senator Mikulski, for her leadership on this issue. I strongly support her amendment for the reasons she said. This is a very important point about providing preventive health services to the women of America, a critically important part of our strategy not only to bring down costs in health care, but to have a health care system that is fair in America.

I have been listening to my colleagues on the other side of the aisle talk about the underlying bill. They talk about it as if this is a static situation. Many of the criticisms I hear about the underlying bill are criticisms about our current health care system. I can tell my colleagues the people in Maryland, many of whom are finding it difficult to find affordable coverage today, are outraged with what is happening with private insurance companies and the attitudes they are taking.

As Senator Mikulski pointed out, they are denying coverage for preexisting conditions or imposing arbitrary caps. As has been indicated, if we are unable to get this bill passed, what is going to happen in the future? We know costs are going to become even greater, more people are going to lose their coverage, insurance companies are going to continue their arbitrary practices, and the health care of Americans is in jeopardy.

We are already spending so much of our economy on health care, and if we don't take action, it will be a greater part of our economy.

But we have some good news. The underlying bill has now been analyzed by the CBO; that is the independent scorekeeper. What they tell us is, if we pass the underlying bill, for the overwhelming majority of Americans, they are going to find that their health insurance premiums will either stay the same or go down. For the overwhelming majority of Americans, they will have a better insurance product that will cover the types of preventive services Senator Mikulski is talking about, which

are in her amendment.

We are not only going to bring down the cost for the overwhelming majority of Americans as to what will happen if we don't pass a bill, we are going to provide better coverage for them. The underlying bill will also reduce dramatically the number of people who don't have health insurance in America by 31 million. That will make our system much more effective.

I have heard my colleagues talk about what is going to happen with Medicare. If we pass the underlying bill, we are going to strengthen Medicare. We already have a provision that there cannot be reductions in the guaranteed benefits. We pointed out that AARP endorses the bill. They understand there will be additional preventive health care for our seniors, and we will help fill the doughnut hole in prescription drugs.

When you reduce the number of uninsured, the amount of cost Medicare has to pay for health care in our hospitals is reduced. That is why we can reduce our payments to hospitals in America, because the amount of uncompensated care they currently have will be dramatically reduced. I have heard colleagues on the other side of the aisle talk about Medicare Advantage. I remember when we used to pay the private insurance companies in Medicare a little less than people in traditional Medicare. Then

we paid them the same. Now we are paying them more. That is corporate welfare. Medicare Part B premiums are higher than they should be. Taxpayer support is higher than it used to be. We know these benefits that are being paid could be gone tomorrow. We saw the private insurance companies leave the Maryland market and so many other markets. These are reforms that save the taxpayers money and strengthen Medicare for the future.

Bottom line: The bill is good for middle-income families. It will provide the insurance reform so they have an insurance product that can cover their needs, including wellness and prevention programs. It is good for small business because it offers more choice. I can tell you chapter and verse of small companies in Maryland that, today, cannot get an affordable product and are seeing 20, 30 percent increases in their premiums. They need this bill in order to be able to preserve health care for

their employees.

This bill, with the Mikulski amendment, will provide the preventive health care for all Americans that is so desperately needed, which will reduce costs, improve quality, and make our health care system more efficient and effective in the future, bringing down costs by investing in wellness and prevention.

I urge my colleagues to support the Mikulski amendment and to support the underlying bill.

I yield the floor.

10:49 AM EST

John Thune, R-SD

Mr. THUNE. Madam President, I appreciate the opportunity to speak on this important piece of legislation.

Again, I point out to my colleagues, and to anybody else who may be observing, the volume of this bill. This is 2,100 pages and 21 pounds, which means it is about a pound per 100 pages. It is $1.2 billion dollars per page, $6.8 million per word, and it creates 70 new government programs. It gives the Secretary of Health and Human Services--in 1,600 or 1,700 instances in this bill--the opportunity to create, define, and determine things in the bill.

This is a big government bill, a massive expansion of the Federal Government--$2.5 trillion, when it is fully implemented. Of course, the paid-fors in the bill--all the things in this bill, not only those intended things but also the unintended consequences of the bill--you have some revenue to pay for these things. Where do we get the revenue?

In the Reid bill, they decided they are going to raise taxes on small businesses, individuals and families and they are going to cut Medicare by about $ 1/2 trillion.

What is ironic about that is, a few years ago, the Republicans, back when we were in the leadership in the Senate, tried to do a budget bill that actually achieved some savings in Medicare and Medicaid, to the tune of $27 billion combined. But the Medicare savings in that bill was $10 billion. That was over a 5-year period, at $2 billion per year. I wish to remind some of my colleagues on the other side about some of the comments they made about that.

Senator Reid, at the time--bear in mind this was to reduce Medicare by $2 billion per year, $10 billion over 5 years. The now-majority leader said:

Unfortunately, the Republican budget is an immoral document.

The Senator from West Virginia said this:

This proposed budget would be a moral disaster of monumental proportions.

A couple other colleagues in the Senate commented. The Senator from Michigan said:

People who rely on Medicare and Medicaid are going to be hurt by this bill.

The Senator from Wisconsin said:

I urge my colleagues to reject this bill, and the irresponsible and cruel budget of which it is part.

The former Senator from New York, Mrs. Clinton, said this:

This bill slashes $6.4 billion from Medicare over the next 5 years.

It was actually $10 billion. My point is simply this: It was $10 billion over 5 years, $2 billion per year. Those were the statements--overstatements--about the impact that a $2 billion reduction per year in Medicare was going to have on people in this country. Now we are talking about $ 1/2 trillion in Medicare cuts.

Where do their cuts come from? They will come from $118 billion from Medicare Advantage, which now we have about 11 million Americans impacted by Medicare Advantage. Every State has seniors who have subscribed to that program whose benefits will be cut if this bill is enacted. You get it out of hospitals because there are $135 billion in reductions and reimbursements to hospitals; $15 billion in reductions to nursing homes and reimbursements; $40 billion in reductions to home health agencies;

and $8 billion in reductions to hospices.

Those are all the ways this $2.5 trillion expansion of the Federal Government is to be paid for. I didn't even get into the tax cuts, which will be a debate for another day.

The Medicare cuts in this bill are unlike anything we have seen in the past. [Page: S12271]

Clearly, when you compare it to 3, 4 years ago, when we were trying to achieve $10 billion in savings over 5 years, you thought the sky was falling. Now here they are trying to pay for a $2.5 trillion expansion of the Federal Government by cutting $500 billion out of Medicare.

The point I also wish to make, because it has been made by the other side--by the most recent speaker--is that somehow this recent CBO analysis should be hailed as good news. The corks are popping in the celebration, and people are crowing about the new CBO report because it has such good news for this bill and the impact it will have on people who buy health insurance in this country.

What is it they are celebrating? CBO, in its report, essentially said this: 90 percent of Americans are going to see their premiums increase or see virtually the same increases as they do today year after year.

That is preserving the status quo, not decreasing costs, as promised. President Obama, when he was running for office in 2007, said when he got a chance to do health care reform, he was going to reduce costs by $2,500 for every family in this country and cover everybody.

This bill, after spending $2.5 trillion and creating 70 new government programs, doesn't cover everybody. There are still 24 million Americans who don't get covered under this bill, according to the CBO. Furthermore, nobody--I shouldn't say nobody--90 percent of Americans, those who don't get subsidies, don't come out any better. They will still see the year-over-year increases in premiums they have been seeing for the past several years, and the cost of health care is growing at twice the rate

of inflation. If you assume a year-over-year increase similar to the past several years, in the small group market, you are looking at annual increases of over 6 percent for the cost of health care--to the point where a family that, today, is paying $13,000 a year for health insurance, in 2016, will pay over $20,000 a year for health insurance. So nobody gets any better out of this,

except a handful of people who will get subsidies. If you are in the individual marketplace, your premiums go up. According to the CBO, there will be a 10- to 13-percent increase in premiums in the individual market. If you are in the large group market, you will see an almost 6-percent increase a year. If you are in the small group market, premiums will go up over 6 percent a year.

We are talking about spending $2.5 trillion, cutting reimbursements to nursing homes, to hospitals, to home health agencies and hospices, and raising taxes on health care providers, medical device manufacturers, prescription drugs, raising the Medicare payroll tax which, incidentally, doesn't go to preserve or extend the lifespan of Medicare or put it on a path toward sustainability but creates a whole new government entitlement.

We are going to do all that for what? At best, to keep the status quo for people today; at worst, to increase their premiums by 10 to 13 percent. That is the bottom line. That is what this says. That is the new CBO report. That is the CBO report about which the other side is saying this is great news. They are celebrating. It is great news that premiums are going to continue to go up at twice the rate of inflation, just like in the past, protecting and preserving the status quo as we know it

in America today.

This bill does nothing about the fundamental issue of cost. It doesn't matter what market you are in--small group market, large group market--it stays the same, at best, and in the individual marketplace, your premiums will go up 10 to 13 percent. That is the news being hailed by the other side as validating the argument for why we need to pass a 2,100-page, $2.5 trillion monstrosity of a bill with 70 new government programs in it.

We will vote on the Medicare amendment later. Senator McCain has a motion to commit the bill to essentially take the Medicare cuts out of it. I hope my colleagues vote for it. They are arguing it doesn't cut Medicare. How can you say that with a straight face? How can you say you are going to find $500 billion to pay for this bill out of Medicare and then say it doesn't cut Medicare? Of course it cuts Medicare. Of course it raises taxes. You can't finance $2.5 trillion of new spending

unless you find a way to finance it.

The way they have chosen to finance this is to hit seniors squarely between the eyes and cut reimbursements to the providers all across this country that are dealing with the serious health needs our senior citizens are experiencing. In South Dakota, we have a lot of people who are employed in the health care industry. I think that is true of every State. Even in small towns in South Dakota, in nursing home employment you are talking about almost 6,000 employees. You are going to take $15 billion

out of nursing homes, $40 billion out of home health agencies, $135 billion out of hospitals, and what we are talking about are huge reductions in Medicare, unlike anything we have seen.

As I said, to put it into perspective, a few short years ago, when we were in the majority, in a budget trying to reduce Medicare by $10 billion over a 5-year period, it was referred to as ``immoral,'' as a ``monumental disaster,'' as ``cruel''--$10 billion over 5 years. This has $ 1/2 trillion in Medicare cuts--cuts to Medicare Advantage and providers.

I hope my colleagues will support the McCain motion.

I yield the floor.

10:59 AM EST

Al Franken, D-MN

Mr. FRANKEN. Madam President, I rise to express my support for Senator Mikulski's amendment for women's health.

This amendment is crucial because it is about prevention. Prevention is one of the key ways this bill will transform our system of sick care into true health care. It is common sense. You get the right screenings at the right time so you find diseases earlier. It saves lives and it saves money.

The Senate bill already has several provisions for preventive care, which I strongly support. For example, colonoscopies and screening for heart disease will be covered at no cost. It is a good start.

The current bill relies solely on the U.S. Preventive Services Task Force to determine which services will be covered at no cost. The problem is, several crucial women's health services are omitted. Senator Mikulski's amendment closes this gap. Under her amendment, the Health Resources and Services Administration will be able to include other important services at no cost, such as the well woman visit, prenatal care, and family planning.

These preventive services will truly improve women's health. For example, if all women got the recommended screening for cervical cancer, we could detect this disease earlier and prevent four out of every five cases of this invasive cancer. This will improve the health of our mothers, sisters, and our daughters.

This bill and this amendment will make prevention a priority and not an afterthought.

Although I respect the efforts of my distinguished colleague from Alaska, the Murkowski alternative falls short. The Murkowski amendment does nothing to guarantee women will have improved access to coverage and cost-sharing protections for preventive services. Rather than establish objective, scientific standards about which preventive services should be covered, this alternative only requires insurers to consult with medical organizations when making coverage decisions.

While we know the U.S. Preventive Services Task Force recommendations do not cover all necessary services, the Murkowski amendment entirely removes even this basic coverage requirement from the bill, leaving women without any protections under health care reform for essential preventive care. This means that important preventive care for women, including screening for osteoporosis and sexually transmitted infections, may not be covered by insurance plans.

In the simplest terms, the Murkowski amendment maintains the status quo, and we know the status quo is not working for millions of women who are forgoing preventive care because they simply cannot afford it. The Murkowski amendment continues to leave prevention coverage decisions up to health insurance companies, and that means there would be no guarantee [Page: S12272]

that any health plan will cover basic preventive services at all.

Do we want to leave these important decisions up to the insurance companies? The health of American women is too important to leave in their hands. That is why I urge my colleagues to support Senator Mikulski's amendment and vote to make sure women can get the preventive screenings they need to stay healthy. Most important, this amendment will make sure women have access to these lifesaving screenings at no cost.

11:03 AM EST

Al Franken, D-MN

Mr. FRANKEN. Madam President, prevention is just one of the ways this bill will improve women's health. It also ends insurance companies' practice of charging women more because they happen to be women, or denying coverage based on a history of pregnancy, C-section, or domestic violence.

We need to pass this bill this year to ensure comprehensive, affordable care for women throughout the country. And we need to include this amendment because I want to be able to look my wife in the eye, I want to be able to look my daughter in the eye--my son, too--and my future grandchildren in the eye and say we did everything we could in this bill to improve women's health. We cannot wait any longer. I urge all my colleagues to stand with us and support this amendment.

I yield the floor.

11:04 AM EST

Tom Coburn, R-OK

Mr. COBURN. Madam President, it is interesting, as a practicing physician who has actually cared for women and nobody so far who has been in on this debate has ever done. I congratulate the Senator from Maryland for her care about prevention because we all know that is key.

The mischaracterization we heard about this bill is astounding. The reason we got in trouble with the Preventive Task Force is because it did something that was inappropriate and did not have the appropriate professional groups on its task force when it made its recommendation on breast cancer screening.

The Murkowski amendment says we will rely on the professional societies to make the determinations of what must be available. We have heard the Senator from Iowa say health insurance will decide that. That is absolutely untrue. Health insurance will not decide it. The professional societies will decide what will be covered, and the insurance companies must cover it under the Murkowski amendment.

The second point is there will not be any objective criteria. The objective criteria doctors practice under today are the guidelines of their professional societies.

Here is the difference between the Murkowski amendment and the Mikulski amendment: The Senator from Maryland relies on the government to make the decision on what will be covered. She refers to the Health Resources and Services Administration. She refers to the Health Resources and Services Administration which has no guidelines whatsoever on women's health care right now, other than prenatal care and childcare. That is the only thing they have.

For whom does HRSA work? HRSA works for the Secretary of Health and Human Services. So the contrast between these two amendments could not be any more clear in terms of do we want to solve the problems we just experienced on mammogram recommendations? We can let the government decide, which got us into this trouble, and they will set the practice guidelines and recommendations for screening or you can let the American College of Obstetricians and Gynecologists or the American College of Surgeons

or the American College of Oncologists set and use their guidelines.

The choice is simple: The government can decide what care you get or the people who do the care, the professionals who know what is needed, who write the peer-reviewed articles, who study the literature and make the recommendations for their guidelines.

Every month I get from the American College of Obstetricians and Gynecologists their new guidelines. I try to follow them at every instance. The fact is, the Mikulski amendment says government will decide. That is what it says. The government will decide through HRSA. The Murkowski amendment says it is the best practices known by the physicians who are out there practicing. What is the difference? How does it apply to you as a woman? It applies to you as a woman because the people who know best

get to make the recommendations rather than a government bureaucracy. That is the difference.

If you will recall, under the stimulus bill we passed, we have a cost comparative effectiveness panel, which will surely be in the mix associated with the recommendations. If you look at what the task force on preventive recommendations said from a cost standpoint, they were absolutely right. From a patient standpoint, they were absolutely wrong.

The real debate on this bill--the Mikulski amendment is the start of the real debate--is do we have the government decide based on cost or do we have the professional caregivers who know the field decide based on what is best for that patient. That is the difference.

What the Senator from Alaska does, which is necessary, is she says we will rely on the American College of Obstetrics and Gynecology. We will rely on the American College of Surgeons. We will rely on the American College of Oncologists to determine what should be the screening recommendations for patients.

For, you see, what happens with the Mikulski amendment is the government stands between you and your doctor. That is what is coming. That is what will be there.

There is no choice under the Murkowski amendment for an insurance company to have the option either to cover or not to cover. They must. It says ``shall'' do that. So the mischaracterizations on what the Murkowski amendment actually says and does are unfortunate.

11:10 AM EST

Debbie Stabenow, D-MI

Ms. STABENOW. Madam President, first, I thank Senator Mikulski for her leadership not only on this important amendment but on so many issues in health care, issues for women across this country. We are honored to call her dean for all of us as it relates to focusing on the issues that are so critical to women and their families.

I thank Senator Reid for making this a priority and making this the first amendment we are offering in this debate.

We all know that often women are the ones making health care decisions for their families as well as themselves. They are more likely to be the person making health insurance choices. Women of childbearing age pay on average 68 percent more for their health care than men do. We have so many instances in which insurance companies are standing between women and their doctors right now in making decisions--decisions not to cover preventive services, such as a mammogram screening or a cervical cancer

screening, decisions to call pregnancy a preexisting condition so women cannot get health insurance, decisions not to cover maternity care so that women and their babies can get the care they need so that babies can be successful in life, both prenatal care and postnatal care.

Women of this country have a tremendous stake in health care reform. We pay more now, if we can find coverage at all, and there are too many ways in which insurance companies block women from getting the basic health services they need.

This amendment is critically important to make sure that women are able [Page: S12273]

to get preventive care services without a deductible and without copays. This amendment recognizes the unique health needs of women. It requires coverage of women's preventive services developed by women's health experts to meet the unique needs of women.

Why do we stress that? We stress that because for years we have struggled in so many areas to make sure that women's health needs were focused on and not just health in general. When we look at research through the National Institutes of Health and what it took to get to a place where research would be done for women on women's subjects or on female mice or rats rather than male subjects to make sure that the differences between men and women were considered in research, we have made important

steps in that direction. Again, Senator Mikulski was leading the way as it relates to having a women's health research effort in our country.

This is one more step to make sure we are covering women's preventive services developed by women's health experts for the unique needs of women. That is what this is all about--making sure women have access to preventive services such as cervical cancer screenings, osteoporosis screenings, annual mammograms for women under 50, pregnancy and post partum screenings, domestic violence screenings, and annual checkups for women.

We know more women die of heart disease than actually any other disease. This is something I do not think is widely known. We have even heard that many physicians do not realize the extent to which heart disease is prevalent in women. All of us women have worked together on a women's heart bill and part of that is for screenings. Part of that is to make sure we are screening for heart disease and strokes, the No. 1 killer of women. This would make sure those screenings would be part of health

care reform.

I could go on to list all the different prevention items, but I will simply say that when we are talking about women's health and we are talking about women's lives, this is an incredibly important amendment to adopt.

11:15 AM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. Madam President, I rise to speak on the Mikulski amendment and the Murkowski amendment because I feel very passionate about women's issues. In fact, Senator Mikulski and I have worked throughout my time in the Senate and her time before me on these very issues--assuring that women's health care concerns, which are different from men's in many instances, are a part of any health care coverage in our country, and ongoing we must assure the same.

I have been an advocate for cancer screening services for women, and I was dismayed when I saw the U.S. Preventive Services Task Force a few weeks ago issuing new guidelines for cancer screening for women--breast cancer screening for women. We have all lived with breast cancer throughout the course of the history of women, but especially in the last probably 25 years the strides that we have made in saving lives and in the survivability of women with breast cancer is because we have had early

detection. We don't have a cure for breast cancer, and we are all fighting for that cure, but until we get it, the first line of defense is early detection.

So now we have a new task force recommendation that says everything we have had and enjoyed over the last 25 years in saving women's lives is no longer relevant because now, before the age of 50, you don't need a mammogram, and after the age of 50 it is every other year.

Well, I know Senator Mikulski and I agree we do not think that is right. Neither did any other woman in the Senate when that was proposed years ago by President Clinton. We all stood up and said no. I am standing up and I am saying no once again, and I am sure every woman in the Senate is, as many women in America are.

But the Mikulski amendment doesn't actually fully address the problem of having the task force--which is relied on 14 times in the bill before us--as the arbiter of what is necessary for our government program and that it then will surely become the private sector standard as well. That task force even has money allocated to advertize its task force recommendations. So rather than the Mikulski amendment severing the ties with the task force, the amendment now has another government agency that

has the same capability to basically interfere between the woman and her doctor, which is where we want the decisions to be made. Coverage decisions will be dictated by both the task force and a new Health Resources and Services Administration entry into the mix.

While I certainly agree with Senator Mikulski about the importance of preventive services for women and insurance coverage decisions, I can't support her amendment because we still have not one but two government task forces and committees that will be in the middle of these health care coverage decisions. I think the coverage decisions should be made by doctors and their patients. That is why I have joined with Senator Murkowski in offering the alternative approach. This is

what we should expect from any future health care reform, and it is certainly what we expect today.

The Murkowski amendment will leave the medical decisions to the guidelines established by those who know medical treatment best, which is our own doctors. In fact, we have just received a CBO assessment of what the Murkowski amendment would cost, and it actually says there will be a savings. So rather than the Mikulski amendment, which would spend $1 billion over 10 years, the Murkowski amendment would actually save $1.4 billion over 10 years. Why? Because the Murkowski amendment relies on the

combined commonsense and clinical judgment of American physicians.

11:20 AM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. So, Madam President, I urge a vote for the Murkowski amendment. I know we have the same goals as Senator Mikulski and her amendment, but I don't believe the Mikulski amendment achieves the goal of having a woman and her doctor make the decisions for her. That is the key that I think is so important in this debate. I urge a vote for the Murkowski amendment.

I thank the Chair, and I yield the floor.

11:21 AM EST

Barbara A. Mikulski, D-MD

Ms. MIKULSKI. Madam President, I yield 4 minutes to the Senator from the State of Washington, who has been a real leader on these issues.

By the way, Madam President, before the Senator speaks, I want to thank Senator Stabenow for a unique courtesy. This is her desk, and as many of my colleagues know, I broke my ankle and I can't get up to where my desk is at this point. I will, however, in a matter of another few weeks. But she has given me this desk on loan so that I could stand on my own two feet to debate this amendment, and I wanted to thank her for the courtesy.

Madam President, I also want to note something while the senior Senator from the Republican leadership is here, and the author of the amendment. We, the women of the Senate, on a bipartisan basis, have worked for women's health. Today, we disagree on what is the best way to achieve it by these two amendments. I want to thank my colleagues for setting a tone of civility. I think this has been one of the most rational, civilized conversations we have had over this, and I would like to thank them.

As the leader on this side of the aisle, in terms of seniority, I would like to extend my hand in friendship and suggest when this bill is done, and this amendment is done, we continue to focus on this wonderful work that we have done together. We have done things that have saved millions of lives, and so I look forward to continuing that.

Madam President, I now yield 4 minutes to the Senator from the State of Washington, Mrs. Murray.

11:22 AM EST

Patty Murray, D-WA

Mrs. MURRAY. Madam President, I thank my colleague from Maryland, and I would just say that wherever she stands on the floor of the Senate, she leads us all. So we are delighted you are here and thank you so much for [Page: S12274]

your leadership on this critical issue of making sure women have access to quality preventive health care services and screenings which are so critical to women across the country.

Madam President, the Senator from Maryland offered this amendment, and I worked with her in the committee. She has been a leader on this for many years, and I echo her comments as well that this has always been an issue. For as long as I have been here--since 1993--the women in the Senate, on both sides of the aisle, have stood up to make sure that women's care is part of health care, and we understand we have to stand shoulder to shoulder. It is unfortunate at this time that we see this in a

little different light, but I agree with Senator Mikulski. We will keep working together throughout our time here to make sure women's preventive services are covered.

I do support the Mikulski amendment and the MIKULSKI approach. Her amendment requires all health plans to cover comprehensive women's preventive care and screenings at no cost to women. I just wanted to come to the floor for a minute and point out why this is so important.

When the economy is hurting, women on the whole tend to think of caring for their families first and not caring for themselves. They take care of their children and their spouses first, and they end up delaying or skipping their own health care in order to take care of their families. In fact, we know in 2007, a quarter of women reported delaying or skipping their health care because of cost. In May of 2009, just 2 years later, a report by the Commonwealth Foundation found that more than half

of women today are delaying or avoiding preventive care because of its cost.

That is not good for women, it is not good for their families, and it is not good for their ability to be able to take care of their families and to take care of themselves. So Senator Mikulski's amendment is extremely important, especially in this economic time. We know if women get the preventive care and care for their needs, then they are able to care for their families. Yet the situation we find ourselves in today is that women are not taking preventive care. They are not taking

care of themselves. Therefore, when they get sick, they end up in the hospital and then their families are in trouble. So we know preventive services can save lives, and it means better health outcomes for women.

We have to make sure we cover preventive services, and this takes into account the unique needs of women. Senator Mikulski's amendment will make sure this bill provides coverage for important preventive services for women at no cost. Women will have improved access to well-women visits--important for all women; family planning services; mammograms, which we have all talked about so many times, to make sure they maintain their health.

Madam President, I want to emphasize that this amendment preserves the doctor-patient relationship and allows patients to consult with their doctors on what services are best for them. This has become a large topic of conversation over the last several weeks, and Senator Mikulski's amendment makes sure if a woman under 50 decides to receive an annual mammogram, this amendment will cover it. She will be able to work with her own doctor and take care of her health.

So, Madam President, I come to the floor today to strongly support the Mikulski amendment, to thank her for her leadership, and I hope we can get to and vote on this important issue and move on and pass health care reform.

My constituents, when I go home, say: Move on. Get this done. We have to take care of this because of our economy, because of the impact on small businesses, because of the rising costs of premiums, and because of the large number of people who are losing their health care coverage. This health care bill is going to make a major difference when we get it passed, and the American public can take a deep breath and say: Finally, our government has moved forward.

So let's get past this amendment. I support strongly the Mikulski amendment. Let's move on this bill and take a major step forward for health care coverage for all Americans and pass the health care bill.

Madam President, I yield the floor.


11:27 AM EST

Sam Brownback, R-KS

Mr. BROWNBACK. Madam President, I rise in support of the amendment of the Senator from Alaska, and I have talked with my good friend, the Senator from Maryland, Ms. Mikulski, about a side issue in this overall debate about what is included in the definition of preventive care. The Senator from Maryland stated in a colloquy that ``there are no abortion services included in the Mikulski amendment.'' She has stated that in colloquy.

I have trouble, however, because I believe a future bureaucracy could interpret it differently. So I asked my friend from Maryland if she would include clear legislative language in this saying simply:

Nothing in this Act shall be construed to authorize the Secretary, or any other governmental or quasi-governmental entity, to define or classify abortion or abortion services as ``preventive care'' or as a ``preventive service.''

I think that clarifies the issue, and it would be my hope that my colleague from Maryland would include that in her language. It is not in there, even though there have been statements on the floor. But, as we all know as legislators, it is one thing to say something on the Senate floor, and it is one thing to have a colloquy, but it is far different to have it written in the base law. This is not in the base law.

So I would urge my colleague, the Senator from Maryland, to include this language. Absent that, I think there is too much room for a broader definition of what preventive care means; that it could include abortion services as well, and I would urge my colleagues to vote against the Mikulski amendment if that is the case.

On that ground, I think there are other issues involved, and that is why I think the approach of the Senator from [Page: S12275]

Alaska is superior, while maintaining the doctor-patient privilege. I think this is a good debate for us to have, given these recent discussions. But absent this change, I think there is another issue that is involved that I would urge my colleagues to consider.

Madam President, I want to yield back to maintain some time for the Senator from Wyoming to be able to speak, so I yield the floor.

11:29 AM EST

Barbara A. Mikulski, D-MD

Ms. MIKULSKI. Mr. President, we are waiting for Senator Boxer to come to the floor, so if the other side of the aisle has another speaker, I know at the end we hope that Senator Lisa and Senator Barb--I say that because our last names sound so much the same--could wrap it up.

How would the Senator from Wyoming like to proceed? We are waiting for Senator Boxer or for Senator Baucus.

11:30 AM EST

Mike Enzi, R-WY

Mr. ENZI. Mr. President, I yield 10 minutes to the Senator from Alaska so she can actually propose her amendment that we have been debating and take up to 10 minutes.

11:30 AM EST

Lisa Murkowski, R-AK

Ms. MURKOWSKI. Mr. President, I want to start my comments by acknowledging my colleague from Maryland and accept her gracious offer to continue to work on this issue as it relates to women's health and women's health services. As has been noted by the Senator from Maryland and the Senator from Washington, this is an issue that we women of the Senate have come together on repeatedly, to work cooperatively. While we do have, some would say, somewhat dueling amendments here, I think it is important

to recognize the goals we are both seeking to attain here are certainly right in alignment. We are just choosing different means to get there. But I appreciate, again, the civility and cooperation from not only Senator Mikulski but the other women of the Senate on this very important issue.

I wish to reiterate a couple of points about my amendment that I made yesterday.

11:32 AM EST

Lisa Murkowski, R-AK

Ms. MURKOWSKI. I will make sure those comments that were made for the Record will be delivered to the Senator personally.

I want to reiterate some points I made yesterday about my amendment and I will also share with my colleagues, I know the Senator from Texas mentioned it as well, the CBO score we received late last evening. It provides us with a score showing a cost savings of $1.4 billion over the next 10 years. I think this is significant, as Members, certainly from the other side, raised the importance of fiscal discipline and our fiduciary responsibility here. Importantly, the CBO indicated the provisions

on the second page which prevent the Secretary from using the recommendations of the USPSTF to deny coverage would cost money which means we are protecting certain benefits and that is very important.

The amendment we will have before us, the Murkowski amendment, is one that allows or requires a level of transparency with the recommended health screenings, prevention services that are deemed necessary not by some task force that is appointed by folks within the administration, not by some commission that has political relationships. What we are urging is that the health screenings, the preventive services, be determined by those who are actually in the field, those practitioners--those who

are engaged in oncology, OB/GYNs. We need to be looking to the experts. We need to be looking to that peer-reviewed science. We don't need to be looking to those entities that have been brought together by a government entity or by the Secretary. We need to be looking to the likes of the American Society of Clinical Oncology, the American College of Surgeons, the American College of Radiation Oncology, the American College of Obstetrics and Gynecology. We need to look to their recommendations.

Again, as I mentioned yesterday in my comments, if you go to their Web sites, if you look to their specific recommendations, they will give guidance, guidance that, again, is based on their practice in oncology, their practice as an OB/GYN. Look to what they set out as the guidelines for cervical cancer screening, for mammograms, and let that information be made available publicly through the pamphlets, the plans that come together from the insurance companies. But allow them--allow me, as a

consumer of health care, me as a consumer looking for the best plan for me and my family--to know what those guidelines are, not from a government task force but from those who are the real experts. I think this is the transparency that health care shoppers are looking for.

Some have suggested: Lisa, your amendment doesn't require the insurance companies to provide any prevention or screening services. There is no mandate in there. If we do not have a mandate, then the insurance companies are not going to provide health care prevention and screening services.

I think we need to ask the question here, what is the point of prevention? It is to prevent more expensive care in the future by preventing the chronic and more acute illnesses. So should not the insurance companies want to utilize more preventive services, utilize more screenings, more wellness services, in order to keep down the costs of care based on the judgment of the doctors, based on the judgment of the professionals, and not necessarily those who, again, are part of a government entity?

I know within my staff I have a member who is on the FEHBP plan, but they contact her on a somewhat regular basis about her diabetes care, ensuring she is taking her medications, getting the necessary preventive services offered by her insurer for her particular condition.

It has been mentioned by several of my colleagues that this USPSTF is not such a bad group of guys, they are not just these nameless, faceless bureaucrats. I think it is important to recognize, and even the American Heart Association has recognized it, that the Preventive Services Task Force is limited to only primary care doctors and not specialists such as the oncologists, the cancer doctors who see patients every day battling cancer. These doctors who are providing Americans with their suggestions

on what services are necessary for cancer screenings, but yet these doctors are not part of this task force, have again shone the spotlight on what happens when you have a government entity or government task force that is basically the one saying this is what is going

to be covered, this is not what is going to be covered. In my amendment, we specifically provide that the recommendations from USPSTF cannot be used to deny coverage of an item or service by a group health plan or health insurance offeror. I think that is very important.

I think it is also important to recognize that what we do in my amendment is make sure the health plans consult the recommendations and guidelines of the professional medical organizations to determine what prevention benefits should be covered by these health insurance plans throughout the country. [Page: S12276]

We also require plans to provide this information directly to the individuals. You get to see it for yourself. You get to make that determination. So what

that means is the doctors and the specialists will be recommending what preventive services to cover, not those in Washington, DC.

My amendment ensures that the Secretary of Health and Human Services shall not use any of the recommendations, again made by the task force, to deny coverage. We also include broad protections to prevent bureaucrats at the Department of Health and Human Services from denying care to patients based on comparative effectiveness research. And finally, we have a provision that ensures the Secretary of Health and Human Services may not define or classify abortion or abortion services as preventive

care or as preventive services.

11:39 AM EST

Lisa Murkowski, R-AK

Ms. MURKOWSKI. I appreciate that. I think my amendment is straightforward. I think it is a good compromise and again it is a clear differential between what we are going to do to allow a woman to have full choice with her doctor as opposed to government telling us who we should be seeing.


Mr. President, I ask consent to call up my amendment, No. 2836.

11:40 AM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, I am going to speak very briefly on the pending subject and then let the sponsor of the amendment, that is the Mikulski amendment, finish up here. I think it is very telling--I know this point has been made before but I think it bears repeating--the American Heart Association, American Stroke Association has written and released to the Senate this letter. I will read the most important part here. Basically they say they strongly support requiring health plans and Medicare

providing first dollar coverage for clinical preventive services that are evidence based and necessary for the prevention or early detection of an illness or disability. We all agree with that.

They go on then to comment on the Murkowski amendment, saying they appreciate the Murkowski amendment recognized the value of the guidance and recommendations but they go on to say that even these guidelines must be held to a standard of being evidence based.

I might say, I run across this over and over again in the medical profession--medical experts. We need to keep moving more and more toward evidence-based medicine.

This statement from the American Heart Association, American Stroke Association, goes on to say:

In addition, we are concerned that Senator Murkowski's preventive health services amendment would take a step backwards by substituting the judgment of the independent U.S. Preventive Services Task Force with the judgment of private health insurance companies.

Frankly, it is a point I very much agree with. I don't think we want the judgment of private health insurance companies making these decisions. I think it is appropriate the sponsor of the amendment finish. She is doing a very good job.

11:42 AM EST

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

Mr. BARRASSO. Mr. President, my wife Bobbi was diagnosed with breast cancer by a screening mammogram in her forties. It is that screening mammogram that has saved her life. By the time of the mammogram, the tumor had spread and she has had two operations and two full bouts of chemotherapy. I do not want a government bureaucrat making a decision for the women of America if they should be allowed to have screening mammograms. It saves lives--1 in 1900, for women in their 40s.

The Reid bill empowers bureaucrats to decide what preventive benefits will be allowed for American women. The amendment from the Senator from Maryland does the same--bureaucrats, not the physicians who are doing the treating. That is why I support the amendment of the Senator from Alaska, because that amendment says the Federal Government cannot use recommendations of the U.S. Preventive Services Task Force, recommendations from bureaucrats, to deny care to anyone including seniors on Medicare--anyone

in America. That is how this decision should be made, not by government bureaucrats.

I yield the floor.

11:44 AM EST

Barbara A. Mikulski, D-MD

Ms. MIKULSKI. Mr. President, I yield myself 3 minutes.

As we get ready to conclude the debate on both the Mikulski as in BARBARA MIKULSKI and Murkowski as in LISA MURKOWSKI amendments, I want to first say a word about the Senator from Alaska. We have worked together on the Health, Education, Labor and Pensions Committee. We have worked together as women of the Senate, to provide access to women's health services. Not too long ago, when I had my awful fall, she gave me much wisdom and counsel and practical tips because she herself had

broken her ankle. To us, when you say to Senator LISA or Senator BARB, ``Break a leg,'' it has a whole different meaning. I again thank her for all her work. I have great respect for her. I look forward to our continued working together. [Page: S12277]

But I do sincerely disagree with her amendment because what her amendment does is, it guarantees, really, only information. It does not guarantee universal access to preventive and screening services.

It also does not remove the cost barriers by eliminating the high deductibles for the copayments when you go to get a preventative or screening service. It tells insurance companies to give information on recommended preventative care. That is a good thing, but it is a threshold thing. You need to have universal access to the service.

In addition, we do not mandate that you have the service; we mandate that you have access to the service. The decision as to whether you should get it will be a private one, unique to you. We leave it to personalized medicine. So in the poignant case of the wife of the Senator from Wyoming, it would have been up to the doctor, the physician, to get her the service she needed.

It is not only I or one side of the aisle that is opposing the Murkowski amendment. The American Cancer Society, the American Heart Association, and the American academy of GYN services oppose it.

My amendment is a superior amendment because it guarantees universal access to preventative and screening services. It also eliminates one of the major barriers to accessing care by getting rid of high payments and deductibles. It doesn't say you will have a mammogram at 40 because, again, we are substituting ourselves for the task force; it says you will have universal access to that mammogram if you and your doctor decide it is medically necessary or medically appropriate.

Vote for Mikulski. Don't vote for Murkowski. And please, on this one, get it straight.

12:13 PM EST

Barbara A. Mikulski, D-MD

Ms. MIKULSKI. Mr. President, I rise in opposition to the Lisa Murkowski amendment. Though well-intentioned, it does not guarantee universal access to preventive and screening services for women. It does not remove the cost barriers of high payments and codeductibles. It is opposed by the American Cancer Society and the American Heart Association. It primarily provides information on those matters.

We salute her intention, but we think her amendment is too limited, and, to quote the American Heart Association, it would be an actual ``step backwards'' in the area of making preventive services available, particularly not only in the matter of cancer but in heart and vascular disease--the emerging No. 1 killer for women.

I urge defeat of the Murkowski amendment.

12:14 PM EST

Lisa Murkowski, R-AK

Ms. MURKOWSKI. Mr. President, the purpose of this amendment is to ensure we do not have government entities that are making those decisions we as individuals working with our doctors feel is best.

The intent behind this amendment is to ensure that those medical professional organizations, whether it is the American Society of Clinical Oncology or the American College of Surgeons or the American College of Radiation Oncology or the American Society of Obstetricians and Gynecologists--those who are in the practice, those who are making the recommendations--these are the individuals we want to know are being consulted, not some entity that has been created by those of us in the government

or by some administration, by some Secretary.

So what we propose with this amendment is an insurance offering, if you will. You will know fully what is part of your plan. It is you and your doctor making these decisions.

I urge a ``yes'' vote on this amendment.

12:15 PM EST

Lisa Murkowski, R-AK

Ms. MURKOWSKI. Mr. President, the purpose of this amendment is to ensure we do not have government entities that are making those decisions we as individuals working with our doctors feel is best.

The intent behind this amendment is to ensure that those medical professional organizations, whether it is the American Society of Clinical Oncology or the American College of Surgeons or the American College of Radiation Oncology or the American Society of Obstetricians and Gynecologists--those who are in the practice, those who are making the recommendations--these are the individuals we want to know are being consulted, not some entity that has been created by those of us in the government

or by some administration, by some Secretary.

So what we propose with this amendment is an insurance offering, if you will. You will know fully what is part of your plan. It is you and your doctor making these decisions.

I urge a ``yes'' vote on this amendment.

12:36 PM EST

Michael Bennet, D-CO

Mr. BENNET. Mr. President, I was paying very close attention to the floor debate over the last few days, and at times I am beginning to wonder what bill it is we are debating. Only in Washington could an effort to extend the life of the Medicare trust fund be viewed or distorted somehow as being unfair or bad for seniors.

We know--and it is in print in the CBO report--this bill doesn't take away any senior's guaranteed Medicare benefits. We know the bill extends Medicare solvency for 5 additional years. How does it do that? It does it in a way that is different from the way government usually does business, which is either adding or cutting from a program. It changes the way we deliver medicine in this country, and it does it in a way that protects senior benefits, and it extends the life of Medicare.

The attacks on this bill and my amendment have nothing to do with those facts. The sad part is that there are ideas on every side of this debate that are worth considering. We should be debating those ideas rather than claiming something that is just not true about the bill.

These Washington tactics of trying to shift health care reform back to some committee to languish is exactly why nothing ever gets done around here. The almost unbelievable part of this is that the opponents of my amendment say the health care bill hurts seniors. Yet the bill and our amendment is being supported by the AARP, the Alliance for Retired Americans, Center for Medicare Rights, and the National Committee to Preserve Social Security and Medicare.

What are the opponents of my amendment actually saying--that AARP and other senior advocates don't know what they are doing? They know what they are doing, and they also know what is in the bill. The AARP has seniors' best interests in mind, and they want what is best for Medicare in the long run. This bill makes tremendous strides to a more solvent, more stable Medicare Program for years to come.

Unfortunately, in the hopes of eventually trying to kill the bill, there are people who are making claims that are frightening our seniors--meant to frighten them--here and also in Colorado, where people have been calling on their phones convinced that somehow I want to cut their benefits. Nothing could be further from the truth. I believe strongly in the sacred trust we have created with our seniors. That is why I introduced this amendment. Seniors are looking for simple clarity, and health

care reform can help their lives.

This amendment says, in the clearest and most unambiguous of terms, as directly as we can say it, that nothing in this bill will cut guaranteed Medicare benefits. All guaranteed Medicare benefits stay intact for every senior in Colorado and all across the country. Seniors will still have access to hospital stays, to doctors, home health care, nursing homes, and prescription drugs.

The second part of the amendment goes further and says clearly and directly to seniors that we will use this bill to further protect and strengthen Medicare. We will extend the life of the Medicare trust fund. We will lower premiums or cost share, increase Medicare benefits, and improve access to providers. You don't need to believe me. Look at the CBO. These improvements will be paid for with money saved in Medicare under this bill.

What is so regrettable about the debate, and so tragic, is, if we don't actually get this done, Medicare would be bankrupt in just 7 years--in 2017. In the Senate bill we are now considering, we extend the trust fund's solvency by 5 years. We lower premiums for seniors by $30 billion over 10 years. That is real money back in the pockets of our seniors. We eliminate copays that seniors now have to pay for preventive care. That means when seniors go to the doctor for a colonoscopy, they would not

have to make the copay like they have to under current law. When they go to get a mammogram, the same is true. We know preventive care like that saves lives and also money.

Most seniors live on a fixed income. Free preventive care is the best way to encourage seniors to seek important medical precautions. More preventive care is proven to save lives and lower health care costs.

Mr. President, health care reform will cut the cost of brand-name prescription drugs in half for those who are stuck in the gap of coverage between initial and catastrophic coverage. We eliminate the 20-percent cut physicians would otherwise see next year, making sure seniors can continue to see their own doctor.

Opponents of health care reform don't have a plan to protect seniors and strengthen the Medicare Program. I have heard more criticism about the number of pages in the bill than I have heard about a responsible alternative that would extend the life of Medicare and make the other benefits that are in this bill.

I wanted to come to the floor with a simple and straightforward message to seniors: We will protect Medicare. This bill does. We will make sure nobody touches your guaranteed benefits. This bill does. We will make sure Medicare is around for future generations. This bill gets us started in that direction. That is why I have introduced this amendment and why I support health care reform.

Everything I have said today is entirely consistent with the findings of the CBO, the nonpartisan organization that advises this Chamber. This legislation makes explicit the commitment that all of us share to the seniors across the United States of America. It is my hope that once this amendment passes, we can get beyond the debate we have had over the last 72 hours and get on to the substantive aspects of the bill.

I urge support for my amendment. I yield the floor.

12:42 PM EST

George V Voinovich, R-OH

Mr. VOINOVICH. Mr. President, over the past several months I have come to the floor on a couple of occasions to remind my colleagues and the American people about the unsustainable fiscal crisis confronting this country.

Our national debt has exceeded $12 trillion for the first time in history. In fact from 2008 to 2009 alone, the Federal debt will increase 22 percent, boosting the country's debt-to-income ratio--or national debt as a percentage of GDP--from 70 percent last year to 86 percent this year. We have not seen this kind of debt to GDP ratio since the Second World War 65 years ago.

The American people know that this is unsustainable, but my Senate colleagues from on the other side of the aisle continue to ignore this reality. I pledged that I would continue to cry ``the emperor has no clothes'' until we did something to address this crisis.

I should explain. Most people know the story, ``The Emperor's New Clothes,'' by Hans Christian Anderson.

In the tale, an emperor goes about the land wearing a nonexistent suit sold to him by a new tailor who convinced the monarch the suit is made of the finest silks. The tailors--two swindlers--tell the emperor that the threads of his robes will be so fine that they will look invisible to those dimwitted, or unfit for their position. The emperor and his ministers, themselves unable to see the clothing, lavish the tailor with praise for the suit, because they do not want to appear dimwitted or incompetent.

Word spread across the kingdom of the emperor's beautiful new robes. To show off the extraordinary suit, a parade was formed. People lined the streets to see the emperor show off his new clothes. In this case, the health care reform bill before the Senate.

Again, afraid to appear stupid or unfit, everyone pretends to see the suit. It is only when a child cries out ``the emperor wears no clothes'' does the crowd acknowledge that the emperor is, in fact, naked.

Like the little boy crying out, those of us on this side of the aisle are pointing out this bill is fiscally not responsible.

Yet, while not addressing our current health care challenges, the so-called health care reform bill we are debating also creates new programs at a time when we aren't paying for the one we already have, and it adds $2.5 trillion to what we are already spending.

I learned as a mayor and as a Governor, if you cannot afford what you are doing, how can you take on new responsibilities?

We could be using this opportunity to fix our health care system by finally working to lower health care costs and pass those savings on to citizens who are already overburdened by an expensive health care system.

Yet instead of commonsense incremental reforms that increase access to affordable, quality health care, reduce the costs of health care for all Americans, and lower our national health care spending, we have this bill before us.

Unfortunately, the bill violates the medical principle, first, do no harm. Instead, it is more of the same--more spending and more taxes--on an already struggling economy, this at a time when we are currently witnessing the worst recession this country has experienced since the Great Depression.

The legislation we are considering when fully implemented, as I pointed out, spends $2.5 trillion to restructure our health care system. Yet it fails to rein in the cost of health spending in the next decade. According to the Congressional Budget Office, the Federal Government's commitment to health care; that is, the cost of health care paid for by the Federal Government, would actually increase. In other words, we are adding more on to this extraordinary debt we have--unfunded mandates we have--in

terms of Medicare.

The bill's proponents will tell you it is paid for. But as David Broder points out in his November 22 Washington Post editorial:

While CBO said that both the House-passed bill and the one Reid has drafted meet Obama's test by being budget neutral, every expert I have talked to says the public has it right. These bills, as they stand, are budget-busters.

And that is what many people are hearing right now from their constituents, particularly many of those individuals who are taking advantage of the Medicare Advantage Program.

Furthermore, as former CBO Director Douglas Holtz-Eakin pointed out in the Wall Street Journal, this bill uses ``every budget gimmick and trick in the books.''

What are these gimmicks? Most troubling to me and what my colleagues on the floor have been discussing for the last few days is what the bill does to the Medicare Program.

I think we need to be honest with the American people. The Medicare Program is already on shaky footing. Despite $37 trillion in unfunded--unfunded--future Medicare costs and the prediction that the Medicare trust fund is expected to be insolvent by 2017, this bill calls for $465 billion in cuts to Medicare, not to fix the program but, as I said, to create new programs.

For example, this health care bill fails to acknowledge the $250 billion that is necessary to reform the Medicare physician payment formula to ensure that our Nation's seniors will be able to see the doctor of their choice in the future. I have heard it firsthand from family and friends that in some places in Ohio, Medicare beneficiaries already face delays for physician services.

Right in my hometown, I have had doctors tell me: George, if I have somebody before they are Medicare eligible and they go on Medicare, I will take care of them. I am not taking anymore new Medicare patients because of the reimbursement system. I heard the same thing in terms of Medicaid.

We have a problem out there. Sadly, my friends on the other side of the aisle do not want to be honest with the American people and include the cost of the physician payment fix in the bill. It should be there. Let's be honest about it. Let's be transparent. It is another example, I think, of the smoke and mirrors and budget gimmicks and tricks that former CBO Director Douglas Holtz-Eakin mentioned.

Like I said, we must fix our health care system to help millions of Americans who find themselves without insurance and those struggling to pay their health insurance premiums. We must increase competition in the private market, make it easier for small businesses and individuals to purchase insurance and reform our medical liability system. I call this malpractice lawsuit abuse reform. We should have done that a long time ago. But the fact is that the trial lawyers do not want that to happen.

So we are doing nothing about a problem that is causing physicians to give unnecessary tests that are driving up the cost of health care in this country.

Most important, we need to focus our efforts on jobs, jobs, jobs, jobs, jobs because one of the best things we can do to increase health care coverage is to help businesses start to hire again. I need a job. One of the reasons I need a job is when I have a job, in most instances, I have some form of health care. We have a lot of people who are being dropped off. We need more jobs. We should be concentrating on that if we want to up the number of people who can get health care.

To repeat, we do not need to create another set of government programs that spends an additional $2.5 trillion to build a new entitlement system when we cannot afford the one we have now. That is the biggest thing with me. If you cannot afford what you have, how can you take on more? When we do that, we are being fiscally irresponsible. We should deal with what we have. It is amazing to me. If you look around the country, States are cutting their expenses and they are raising taxes. And what

are we doing in Washington? We are taking on more expensive programs we cannot afford. That is what I think is troublesome to me as a debt hawk.

We need to understand what we are doing. The American people are paying attention and they know that the emperor has no clothes when it comes to doing something about our unsustainable fiscal crisis.

We are losing our credibility and our credit worldwide. They know it is immoral to be putting this debt on the backs of our children and grandchildren. I believe this health care bill does that exactly. It exacerbates our current fiscal situation.

There are lots of good things out there, a lot of good things we all would like to do. But just like a family, if you cannot afford what you are doing now, how can you afford to take on more responsibility in terms of debt?

Mr. President, I yield the floor.

12:52 PM EST

Jack Reed, D-RI

Mr. REED. Mr. President, I think it is important to focus on the fiscal difficulties we have today, but I think it is also important to recognize the probable causes of these huge deficits: two wars, unfunded, no attempt to fund them, spent simply by running up the deficit; tax cuts, which were unfunded and which did not ultimately generate the kind of sustained economic growth and job growth that their supporters advertised, and then the Medicare Part D program, an entitlement program which

was also completely unpaid for.

Today we have people talking about entitlement reform, how that is a key aspect of health reform. But so many of my colleagues on the Republican side supported President Bush when he [Page: S12280]

proposed the Medicare Part D program, a worthy program in concept, but in the context of not paying for it, it is a concept that is costing us greatly today.

Additionally, it is particularly ironic at this moment, because we are considering a McCain motion that would report this health care bill back to the committee with the instructions to restore $400 billion in spending, roughly, over 10 years. I cannot think of anything more contrary to the notion of entitlement reform.

What we have tried to do in this bill is to restructure Medicare so that it will continue providing quality health care, but also recognize the high costs we are facing going forward and the general economic climate we face today. Again, let me remind you, in January 2001, the unemployment rate was about 4.6 percent. When President Obama took office, it was double that and growing and continuing to grow.

We have seen some effects to limit this growth, but it is still a critical issue. Again, this reform package is designed not only to deal with the quality of health care, accessibility to health care, and affordability of health care, but it is designed to, over the long term, begin to rein in costs that are absolutely out of control.

Those suffering the most from this course are the American people and, in some respects, small business men and women. Their health care costs are going up faster than

any other costs, and in many instances faster than wages, and it is unsustainable.

If in my State of Rhode Island we do not take effective action, we will see within several years premiums reaching $24,000 to $30,000 a year for a family of four. We cannot sustain that.

If someone is interested in taking the very difficult step of entitlement reform, they would reject the McCain motion. But there are other reasons to reject the amendment, as well. First, the funding that has been eliminated from the current health care system and the system going forward, has been eliminated because it does not improve care. This is particularly true in Medicare Advantage.

This was a program that was developed and sold essentially to the American people as cost containment for Medicare. This was one of the proposals that would rein in out-of-control health care costs by giving insurance companies the ability to manage more effectively.

Of course, what we have seen is a significant increase in payments to Medicare Advantage payments over traditional Medicare. Of course, these insurance companies can manage health care very well as long as they are receiving very significant premium payments from beneficiaries. But, those premiums do not essentially go to better health care. It certainly goes, however, to better profits for the insurance companies.

Indeed, with Medicare Advantage there is a rebate given to each insurance company. This is not the case with traditional Medicare. The rebate was designed essentially to provide, again, lower cost access to health care benefits for the consumers of Medicare Advantage.

The GAO found that 19 percent of Medicare Advantage beneficiaries actually pay more than traditional Medicare for home health care and 16 percent pay more for inpatient services. Here is the irony. We are paying the insurance companies more, but the beneficiaries of Medicare Advantage are, indeed, are also paying more. So there is no cost savings in this regard, in this program at least.

The other point, which is I think critical and I alluded to, is that for the same services you receive in Medicare Advantage, there is, on average, a 14-percent increase overall for those similar services in traditional Medicare.

We have to, I think, take tough steps to eliminate these over-payments, but steps that will enhance the quality of care for seniors, and that is what is being done in this bill. While some of these resources are being used to help redesign a system for all Americans, there will also be significant improvements for seniors, for care that is more effective and efficient, and less costly.

Let me suggest something else. We are all paying right now for the cost of uninsured Americans. It has been estimated that every private insurance plan in this country is paying--every individual payer, businesses or individual--about $1,000 a year for uncompensated care. That is the cost hospitals shift from their uncompensated care on to the insurance providers, the carriers, and that is translated into higher premiums for all Americans.

Under this legislation, the hospitals will now see patients presenting themselves with an insurance card. Mr. President, over 94 percent of Americans, it has been estimated, will be covered under our proposal. So instead of showing up for free care, they will be under an insurance plan. The hospitals will benefit. Medicare, Medicaid, and the whole health care system will benefit.

Again, this is one of the changes that would be reversed by the McCain motion.

Also, we have taken steps so that hospitals will be much more effective in managing their patient flow. Readmissions will hopefully be reduced by some of the provisions in this legislation.

There are many things we should do and will do, but I believe we can successfully balance expanding our coverage system, protecting quality of care, but also recognizing, as has been suggested, the fiscal implications not just for the moment but going forward. I suggest if someone is serious about entitlement control, serious about the fiscal implications of this legislation or any other legislation, they will not simply order the committee to restore these cuts. They would do something much

more proactive and, indeed, support what I believe are sensible, sound proposals to provide quality, to ensure that over the long run, Medicare is more solvent.

In fact--the final point--the legislation before us would extend the life of Medicare, the solvency of Medicare over at least 5 years. So for those people who say we are trying to end Medicare, their solution is simply to let it go bankrupt apparently in 2017 or to simply ignore it and let it find its own fate.

We can do better. I urge rejection of the McCain motion. I yield the floor.

1:00 PM EST

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

Mr. BARRASSO. Mr. President, I come to the floor also to talk about Medicare and what I see to be significant cuts in the Medicare Program. I practiced medicine in Wyoming for 25 years, taking care of families from across the State and many of these wonderful folks who are on Medicare. They depend on Medicare for their health care. They depend on Medicare. Patients depend on it, the hospitals depend upon it, the physicians, the nursing homes, the home health care agencies--all of them depend

on Medicare for their health care.

I listened to my close friends from across the aisle come to the floor as well, and they seem to be trying to convince the American public that the 2,074-page bill which weighs over 20 pounds actually does not cut Medicare.

I heard the chairman of the Finance Committee talk about it on the floor; I have heard it from the majority leader.

The health care reform plan we are looking at on this floor cuts $464 billion from Medicare, and I have a list of all the Medicare cuts in this bill, page after page, column after column. When you add them all up, it cuts $135 billion from our hospitals--from our hospitals--that are providing the care. We have heard about some of the cost shifting from the Senator from Rhode Island. Cost shifting occurs. Medicare is one of the biggest deadbeats when it comes to paying for hospital services, and

it is why hospitals end up shifting more costs to people who have health insurance, and why, for those people, their premiums will go up if this bill becomes law. So $135 billion cut from hospitals.

The bill cuts $120 billion from a program called Medicare Advantage. There are 11 million Americans in this country who are on Medicare Advantage. They know who they are. They know it is a program that has worked well for them. People ask me what the difference is. Why would somebody want to be on a program called Medicare Advantage? Well, there is an advantage to those seniors who depend upon Medicare for their health care if they are on Medicare Advantage. The No. 1 advantage is, it actually

helps coordinate care. [Page: S12281]

We know one of the best ways to help people keep down the cost of their medical care is to find problems early and to get early treatment. So find the problem and treat it before it gets too bad. Well, Medicare Advantage does both preventive care as well as coordinated care. One of the big problems with Medicare is, it will pay a lot for doing something to someone, but it will not pay much for helping someone stay healthy. But now all of a sudden we are going to cut $120 billion from Medicare

Advantage, which actually works on prevention and on coordinated care.

Then there is $42 billion from home health care agencies that will be cut. Those are the folks who come into someone's home and help them stay out of the hospital. The advantage of home health care is to allow people to get care at home and not need to be in the hospital, but suddenly we are looking at $42 billion in cuts on Medicare for home health care agencies.

Then let's take a look at nursing homes: $15 billion in cuts for nursing homes--those facilities taking care of people on Medicare--which, to me, means they are actually cutting it from the people who depend on Medicare for their nursing home needs.

As an orthopedic surgeon, I have taken care of many people, such as a grandmother who breaks her hip. She doesn't need to go into a nursing home permanently, but what she needs to do is to go there for a short period of time for rehabilitation, where she can get better and get stronger. She is not ready to go home, and she does not need to stay in a hospital, but she needs to be in a nursing home for a period of time to get rehabilitated and then to get ready to go home and go back to an independent

life. There is a gap in time, and nursing homes help with that. They are wonderful as a way to give somebody an opportunity to gain their strength. In our country, such as it is now, so many grandparents are living in communities where, perhaps, their children or grandchildren are no longer living or they can't go and live with a son or daughter, but they need additional help and so they go to a nursing home.

So for that patient who has broken a hip--the type of patient I have taken care of in the hospital--this bill is going to end up cutting from the hospital $135 billion from Medicare for that patient. It will end up cutting nursing homes by $15 billion, for patients who rely on nursing homes as they recover from their hip surgery. Then once they get home and get ready for an independent life, a lot of times they can benefit from home health care--someone coming into the home and checking on them,

giving them medications, making sure they are doing all right, checking their wound, and a number of different things--this bill will cut $42 billion from home health care agencies; again, cutting the services to people who depend upon those services for their health care needs.

Then there is an $8 billion cut from hospice providers, people who take care of our patients--my patients--in the final stages of their life. At a time in their life when their body may be riddled with cancer or they just need a place to go and be treated with respect and to be cared for, we are cutting $8 billion in this bill from the hospice providers--people who are there and helping people in the final stages of their life.

When I look at this, I say: How in the world can my colleagues on the other side say they are not cutting Medicare for our seniors? I read through the bill and there is $135 billion from hospitals, $120 billion from Medicare Advantage, $40 billion from home health care agencies, almost $15 billion from nursing homes, and $8 billion from hospice providers, for a total of $464 billion for this country's seniors. I don't think we should pass this bill. Of course, there is another $500 billion in

taxes. It is a huge and hugely expensive bill.

To me, this is absolutely nothing but robbing our folks who are on Medicare to start a whole new government program. I am worried seniors all around the country are going to have less access to doctors, especially in rural and in frontier States, such as Wyoming. I am concerned they are going to see community hospitals and home health care agencies and nursing homes--skilled nursing facilities--struggling to keep their doors open.

It is time for this Congress, for this Senate to listen to America's seniors. Let's listen to the administration's own chief actuary. Richard Foster, the chief actuary for the Centers for Medicare and Medicaid Services, said if these Medicare cuts take effect, then many providers ``could find it difficult to remain profitable and might end their participation in the program.'' They may say: I don't want anything else to do with Medicare. I am closing my doors to Medicare patients.

We cannot have that in this country, but I believe that is what this bill does. Even the nonpartisan Congressional Budget Office said these Medicare cuts could ``reduce access to care or diminish the quality of care.'' Is that what this Senate wants, to reduce access to care or diminish the quality of care?

How many experts does it take to convince the majority party that cutting Medicare to pay for a brandnew government program is irresponsible? We all agree Medicare is going broke. The trust fund will run out of money in the year 2017. It has more than $37 trillion in unfunded liabilities. The Presiding Officer knows that in his State, as well as in mine, Medicare's physician payment formula, which calls for doctors to face a more than 40-percent cut over the next 10 years, is a system that is

broken. The Reid bill does nothing to fix this problem. Instead, it takes $ 1/2 trillion from Medicare to create a brandnew entitlement program. It punishes a group of people in order to benefit another. To me, that is not reform. It will only make the system worse.

That is why I support the motion we will be voting on today, the McCain motion. It says we are not going to finance a new government program on the backs of our Medicare patients, on the people who depend upon Medicare for their health care. It instructs the Finance Committee to write a bill that doesn't cut hospitals, that doesn't cut home health care, that doesn't cut Medicare Advantage, and that doesn't cut hospice for our seniors who depend upon those services. A vote for the McCain motion

gives us a chance to get this right.

I do want health care reform. I just don't want this bill. This is the wrong prescription for our country. I don't believe we have to take the money out of Medicare and then spend it on a brandnew entitlement program. I go home to Wyoming every weekend--and I know other Members go home and listen to their constituents--and what I hear from the people in Wyoming is: Don't cut my Medicare. Don't raise my taxes. Don't make things worse for me in this economy. I certainly can't afford it. The people

of Wyoming want practical, commonsense health care reform; reform that drives down the cost of medical care, improves access to providers and creates more choices.

It is clear this bill has a very different plan in mind. It is not too late to work together for meaningful reform. We do not have to dismantle the current health care system and build it up in the image of big government and then try to say this is reform. The American people are telling us what kind of changes they want, and that is why I will be voting for the McCain motion.

I yield the floor.

1:11 PM EST

Max Baucus, D-MT

Mr. BAUCUS. I am thankful to my good friend and neighbor to my State.

Is it true the CBO letters say the Senate bill will extend the life--extend the solvency of the Medicare trust fund? Is that true?

1:12 PM EST

Max Baucus, D-MT

Mr. BAUCUS. I don't have the letter in front of me, but in all deference and respect to my good friend from Wyoming, the CBO says the exact opposite. It is the conclusion of the Congressional Budget Office that this legislation will help seniors by extending the solvency of the Medicare trust fund by, I guess, 4 to 5 years. That is black and white. If I had the letter in front of me, I could read it to him, but that is a [Page: S12282]

fact. This legislation will

extend the solvency of the Medicare trust fund by another 5 years.

So instead of being insolvent in the year 2017, under this legislation, that is extended to the year 2022. That is a fact. At least the fact is that is what CBO concludes in their letter. That is a fact.

Second, as a caring physician, does the Senator think that we as a country should try to find a way to provide health insurance for so many Americans--some of them lower income--who don't have health insurance in our country? Because, after all, we are the only industrialized country in the world that doesn't find a way to make sure its citizens have health insurance.

As a physician who sees patients, many of whom can't pay their bills and defer medical treatment because they do not have health insurance, I am wondering if the Senator believes this country should try to find a way where its citizens have health insurance.

1:13 PM EST

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

Mr. BARRASSO. The Senator absolutely believes we need to find a way to make sure all the citizens of this country have insurance, and there are ways to do it: allowing people to buy insurance across State lines. That doesn't take a 2,000-page bill. There are ways to do it to help get down the cost of care that give individuals incentives to buy their own insurance, giving tax breaks to those individuals. We could do things with tort reform, such as the loser pays rule. We could allow small groups

to join together to have a better ability to bargain and get the cost of insurance down.

So this Senator absolutely believes we need to find a way to get everyone insured. There are people who need help who don't have help, and we need to find a way to do that, but it is not this 2,000-page bill.

1:14 PM EST

Max Baucus, D-MT

Mr. BAUCUS. I will ask this question, and then I will finish because I know my colleagues want to speak.

One of the basic underpinnings of this legislation is that we should change the way we reimburse providers, moving away from quantity and volume and more toward quality. I am curious--and this is not an antagonistic question. I am just trying to get a physician's point of view because so many doctors I talk to think that although it creates a little uncertainty, probably that is the right thing to do--to move our reimbursing based on quality, coordinated care, and focusing on the patient rather

than our current system, which reimburses more on quantity and the number of services provided, et cetera.

Is that something the Senator thinks we should pursue in this country?

1:15 PM EST

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

Mr. BARRASSO. The current system is broken, Mr. President. The reimbursement system focuses more on doing things than on helping patients stay healthy and get better. Medicare has done a terrible job of that over the years, in terms of giving incentives for people or even for paying for preventive services. They have not done that over the years.

This is an illustration of how the system is broken. It is now December--the end of the year--and it is the busiest time of year for me as a physician in Wyoming because people have met their deductibles--those who have insurance have met their deductibles for the year--and they come into the office and say: Is it now time for my operation? I have to get it done before the 1st of the year because my deductible has been used up, and I want to have my operation so I am not going to have to pay

for it.

In this country, we have the incentives all wrong in terms of health care. We do need health care reform.

1:16 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, I have to address that one. My colleagues want to speak, but I think it is worth repeating over and over again: This legislation is designed to retain the uniquely American solution to health care--roughly half public, half private. It is designed to make sure patients can still, as they should, choose their own doctor, any doctor they want--primary care doc, specialist, no gatekeepers and all that stuff. The doctors are totally free and should be free to make their

own decisions, after consultation with their patients, as to what procedure makes sense or doesn't make sense.

In addition to that, frankly, more competition with the exchanges. This legislation, frankly, is rooted almost entirely on maintaining the current free market system in health care. There is some insurance market reform, which I think everybody agrees with, which is denying preexisting conditions as a basis for denying coverage, and there is a modest expansion of Medicaid for lower income people who just can't get health care, but otherwise this is legislation which is rooted in the current American


We have a good system. It works. This is just designed to make it work a little better by making sure it reimburses, as the Senator from Wyoming wants, based more on quality. He didn't mention this, but I know he agrees, also insurance market reform so those patients who come to him don't have to wait until the end of the year in the future as they have in the past.

But I want to get it very clear, this is no ``government takeover.'' That is a scare tactic. It is not accurate. It is basically maintaining our current system.

I would now like to yield 10 minutes to my good friend from Vermont.

1:28 PM EST

Tom Harkin, D-IA

Mr. HARKIN. I am deeply saddened that my Republican colleagues have, now we see very clearly, resorted to fear tactics in their desperate attempt to preserve a dysfunctional, costly, status quo medical system that we have in this country today. Republicans, in their attempt to strike fear in seniors across the country, are trying to convince the people that they have changed from the party that has always opposed Medicare to now being Medicare's staunchest defenders. But we all know, if it were

up to our friends on the other side of the aisle, there would be no Medicare. They fought its very creation. Don't take my word for it, take one of their standard-bearers who ran for President. Senator Bob Dole, who was here when we created Medicare, Senator Dole, a friend of mine--I have a good deal of admiration

for Senator Dole--said, ``I was there, fighting the fight, voting against Medicare--one of twelve--because we knew it wouldn't work in 1965.'' He said that in 1995 when he was running for President. He was proud of the fact that he and Republicans had opposed the establishment of the Medicare system.

You might say: That was then, what about recently? Here is the former Speaker of the House, Newt Gingrich. He said, ``We believe it's going to wither on the vine,'' speaking of Medicare.

Now my friends on the other side of the aisle--listening to them, you would think they were the biggest supporters of Medicare forever, when they opposed it from its very beginning.

Now we hear all the stuff about Medicare Advantage. If, in fact, we are going to be cutting a little bit out of Medicare Advantage, they would like to tell you that somehow this is going to ruin Medicare. If that were true, why would the National Committee to Preserve Social Security and Medicare, AARP, the alliance for retired Americans, groups that represent tens of millions of seniors--why would they stand with us in support of our bill and not with the Republicans, who want to gut the very

provisions we have in there that will strengthen and preserve Medicare?

Do people really believe our Republican colleagues care more about seniors than these groups that actually represent seniors?

The truth is, when we talk about Medicare Advantage, we are talking about private insurance companies who promised that through competition they were going to deliver better quality health care to seniors at a lower cost. It all sounded good. But what has happened since Medicare Advantage has come in? The reality is, Medicare is now paying on average 14 percent more to these private plans than it would cost to cover the same beneficiaries under traditional Medicare. In some cases, it is as high

as 50 percent more. That is $12 billion a year more than if these beneficiaries stayed in Medicare. Basically, we are giving a $12 billion subsidy to these companies.

Again, don't take my word for it. This is from a June 2009 MedPAC report:

We estimate that in 2009, Medicare paid about $12 billion more for enrollees of [Medicare Advantage] plans than it would if they were in [fee-for-service] Medicare.

A $12 billion slush fund. We are saying we are going to reduce some of those subsidies. I hear my friends on the other side: My gosh, Medicare is going to take away all these benefits, and all that other kind of stuff. Not necessarily. Right now we know, according to CBO, our bill will lower seniors' Medicare premiums by $30 billion over 10 years.

Then the other side says: But if you cut these Medicare Advantage payments, you will see their benefits cut. [Page: S12284]

That is absolutely not true. All Medicare plans, whether traditional Medicare or private, must offer all required Medicare benefits. Here is the kicker. If, in fact, there are some cuts made in Medicare Advantage, then these private companies that are making $12 billion in their slush fund, maybe rather than cutting benefits, maybe they will decide to cut their CEO salaries from $12 million a year to $10 million a year. Maybe they will decide instead of three or four corporate jets, they only

need one. Maybe they will start reducing some of the profits they are making, huge profits they are making off of the taxpayers and off of Medicare payees right now.

Again, if we cut the Medicare Advantage Program, I guess my friends on the other side would say, No. 1, they can continue to pay their CEOs $12 million a year salaries. They can continue the corporate jets. They can continue to have fancy buildings. They can continue to have outrageous profits. But they will have to cut Medicare. That is what the other side is saying.

We are saying: No, cut the CEO salaries. Cut the enormous profits. Cut those corporate jets. Cut all of that stuff you are using the slush fund for, but keep the benefits for Medicare.

As I said, under present law they cannot cut the basic Medicare benefits. No senior anywhere in America will lose their core Medicare benefits under our bill. Let's be clear about that. If they did, AARP, the National Committee to Preserve Social Security and Medicare, and the National Alliance for Retired Americans would never be supporting our bill.

Lastly, according to an economic survey done at Boston University, they extensively analyzed Medicare Advantage payments and found that just 14 percent of the additional funds these private plans have received have gone to benefit Medicare enrollees. The vast majority of the payments, 86 percent, go to profits, CEO salaries, corporate jets, all these other things, or some of it may go to things such as gym memberships, spa memberships. I raised the point the other day. Why should my Medicare

beneficiaries in Iowa have to pay more in Medicare so that a Medicare beneficiary, say, in Arizona can go to a spa and have it paid for by Medicare Advantage, paid for by the subsidies of $12 billion that we give them that come both from taxpayers and from Medicare recipients right now? I don't think it is fair for my seniors in Iowa to have to pay for that.

A lot has been said about all the people who are in the Medicare Advantage plans. I looked up the figures. Right now, nationally, only 18.6 percent of all enrollees are in Medicare Advantage, a little less than one out of five. In my State, in Iowa, it is 10 percent, 1 out of every 10. Why is that? We don't have a lot of spas in Iowa. We don't have those fancy things like they have in Florida and Texas and Arizona and California, wherever else all this stuff is going. What my seniors need is

the peace of mind of knowing that Medicare is going to be there for them in the future. They need to know they are going to get the benefits we have put in this plan that are in our bill and that will help Medicare beneficiaries.

Here is what they are. AARP says:

The new Senate bill makes improvements in the Medicare program by creating a new annual wellness benefit, providing preventive benefits and, most notably for AARP members, reducing drug costs for seniors who fall into the dreaded Medicare doughnut hole.

The bill also makes improvements on age rating, a discriminatory practice that allows insurers to charge exorbitant age-based premiums to older Americans.

Finally, AARP strongly supports provisions in the Senate bill to strengthen long-term services and supports. We also applaud inclusion of provisions to improve access to Medicaid home and community-based services.

All is in our bill, all of which would fall if we adopt the McCain amendment. I urge colleagues not to listen to the rhetoric from the other side. Listen to those who really do represent seniors. Make sure we preserve and protect the basic Medicare functions for seniors and for those who are about to retire. You will not get that through Medicare Advantage. If Medicare Advantage wants to exist and compete on a level playing field, God bless them. Go ahead and get it done. That is what we were

promised when Medicare Advantage came through here. I remember. Competition. But what we found is, we had to cough up an additional $12 billion to subsidize them.

It is time for us again to say no to the fearmongers, to those who are trying to strike fear in seniors. It is time to stand up, support the Bennet amendment, which makes very clear that any savings that come from Medicare has to go back into Medicare. That is the way it ought to be. That is what is in this bill. The Bennet amendment makes that crystal clear. The McCain motion does away, basically, with all of the protections, all of the things we have worked so hard for since 1965 to provide.

The McCain motion, when you strip away all the verbiage, really what it does is, it basically takes us back to pre-1965 when we didn't even have Medicare. That is the kind of intent behind it.

1:39 PM EST

Sherrod Brown, D-OH

Mr. BROWN. I thank the Senator for his incredible leadership on this issue and the public option, affordability, and on prevention and wellness.

I have listened to the debate with Senator McCain and others on Medicare. It seems what they are protecting is not Medicare but the huge insurance company subsidies when President Bush moved to privatize Medicare. It used to be the insurance companies told us they could do their part of Medicare, one-fifth, one-sixth of Medicare; that they could do it more efficiently even though insurance companies have a 15-, 20-percent administrative cost overhead and Medicare's is 3 or 4 percent

or 2 percent.

1:40 PM EST

Tom Harkin, D-IA

Mr. HARKIN. As I said earlier, what they are talking about in preserving these benefits and this subsidy for Medicare Advantage is the big CEO compensation packages, the corporate jets, the fancy buildings, the high profits, somewhere between 30 percent and 200 percent profits made by these companies that are providing Medicare Advantage. That is what the Republicans are trying to protect, not the Medicare recipients.

1:41 PM EST

Robert F. Bennett, R-UT

Mr. BENNETT. Mr. President, I listened with some interest to the comments made when I came on the Senate floor. I simply want to make this one observation about Medicare Advantage. President Obama promised that Americans who have coverage they like would not lose the coverage they have. There are a number of Americans who have Medicare Advantage. They like it, and they want to keep it. This Congress is about to say: No, you can't. This Congress, through this bill, if it passes, is going to eliminate

Medicare Advantage. Frankly, the people who go after Medicare Advantage because they like it are going to be the ones who are disadvantaged. They are going to be the ones who will see President Obama's pledge violated.

Frankly, I don't think they much care about how much an executive is paid or what happens in the company. They care that they have coverage they like, coverage they are paying for, coverage they have chosen, and they are being told by the Federal Government they cannot have what they want.

There is another aspect to this that I would like to explore in the time I have. We keep hearing so much about the CBO and all of the scores the CBO is pointing out along with rhetoric that says we can't afford to wait, we need a solution now, the status quo is unacceptable. I would like to point out that the status will remain quo for 4 years if this bill passes. In the budget smoke and mirrors that have been put into this bill in order to make it look as if it costs less money, they make the

effective date in 2014, so there will be 4 years after the passage of this bill where Americans will not see any kind of change in their plans. What they [Page: S12285]

will see is an increase in their premiums. They will see an increase in taxes.

Why do I say that? Between January of 2010 and January of 2014 there will be four open seasons in which plans can be changed. As the taxes start to hit, as the costs start to hit, those companies that are involved in offering these plans will say: OK, we have to get ready for the expenditures. What do we do? We have four open seasons in which to change our plans before this thing hits.

Obviously, that cannot be scored by CBO because CBO does not know what changes will be made. But do we really think we can go through four open seasons with no change whatsoever in the face of this enormous change that will hit in January of 2014? Do we really think everything is going to remain static? That is what the CBO computers are. Do we really think the $500 billion they want to take out of Medicare to help pay for this will not be hashed over again and again?

One of two things will happen. No. 1, the Democrats will blink in the face of the anger of senior citizens and say: We really didn't mean it. Yes, the bill cuts Medicare by $500 billion, but we really didn't mean it. We have 4 years in which to fix it; that is, 4 years in which to replace that $500 billion. Of course, when that $500 billion is replaced, if that is the way they decide to go, then we will know that the numbers we are getting out of CBO are completely phony. Then we will know the

statement that this bill is revenue neutral is a nonstarter. Then we will know there was never any intention to try to deal with this cost.

Suppose future Congresses stand firm and say: Yes, we are going to stand firm in this 4-year period. We are going to stand firm against the anger of senior citizens who are seeing their Medicare benefits get cut.

We are going to take the $500 billion out of Medicare. Then we will see the promises that are being made around here--that there will be no cut in Medicare services--all disappear.

I hear people say: We are not cutting benefits. We are just cutting payments to providers. That statement is being made over and over again on the other side of the aisle: We are not cutting benefits. We are going to take that $500 billion away from the providers, but the benefits will remain the same.

In my State, I have plenty of providers that are on the edge, right now, financially. They are on the edge of going out of business, right now, financially because of the cuts that have been made in Medicare in the name of cutting down payments to providers.

What happens to the people who are in a nursing home that is currently dependent upon Medicare payments in order to survive if they come in and say: All right, we are not going to do anything to the benefits these people are entitled to in this nursing home, we are just going to cut enough payments to the nursing home that the nursing home goes out of business. What happens to the people who are in the nursing home under that circumstance? Well, they are going to have to go someplace else and

there is going to have to be money to pay for them to go someplace else and the money is going to have to flow through Medicare someplace else and then we are back to the first option I talked about, which is we were not serious when we said we were going to take $500 billion out of Medicare. We were not serious. In order to make sure

you do not lose your benefits, we are going to have to start reinvesting in some of these providers. We have seen providers go out of business because of the cuts into Medicare. We need to start putting that money back into Medicare. Then we are back into the circumstance we have been talking about all along: This thing is not paid for.

One final point I wish to make: We had a hearing today with the Chairman of the Federal Reserve. Ben Bernanke is up for reappointment and, of course, the entire conversation was about the economy and what is the future of the economy. There were a number of people who had a conversation about the past, but I wished to focus on the future.

I pointed this out to the Chairman and asked for his comments with respect to the future of our economy. Most of my constituents do not understand what I am about to say. Frankly, most of the people in the press do not understand it, and maybe even some Members of this body do not understand it. When we talk about the Federal budget, two-thirds of the Federal budget is beyond the control of this Congress. Two-thirds of the Federal budget is on autopilot, unless this Congress changes entitlements.

Somebody says: Well, what does this word ``entitlement'' mean? Why do you talk about entitlements? Entitlement means, by law, these individuals are entitled to this money, whether we have it or not. The Federal Government has made a contract with them. All right, it is a social contract rather than a legal contract, but it is as binding politically where the Federal Government has to spend the money, whether it has it or not.

Indeed, that is what we have seen in fiscal year 2010. The budget we passed said revenues are going to be $2.2 trillion and entitlement spending is going to be $2.2 trillion, which means every function of the government--our Embassies overseas; our troops, wherever they may be; education; national parks; whatever it is--every dime will have to be borrowed in fiscal year 2010, every single dime because every penny coming into the Federal Government is already programmed to go out, without coming

through the Congress. It does not go through the appropriations process. We do not get to vote on it. People are entitled to receive this money, and it is going to go out there.

What are we talking about? We are talking about creating a new entitlement, a very expensive new entitlement. How are we going to pay for it? According to this bill, we are going to pay for it by transferring money from an existing entitlement. Anyone who thinks that is what is going to happen, in the face of the anger that is being generated by people who read about this, believes a fairytale.

The whole notion of trying to balance the cost of this tremendous new entitlement by somehow a bookkeeping entry that says we will take it out of the Medicare account and we will put it in this account, and the computers that do not think--the computers simply compute--will say: Well, then, if you put it in this account, then this account is revenue neutral. But the government's account is not revenue neutral. This thing is going to cost $500 billion, wherever we get the money. It is a cynical

ploy, smoke and mirrors of the worst kind, in a budgetary bait and switch, to say we are going to take this out of Medicare.

I hear from my constituents--I hear from people who are not my constituents who recognize me as a Senator in airports and other places--as they say, increasingly: Do not pass this bill. We see it in the polls, but we see it in the passion of the people who come up to us and let us know how firmly they are opposed to this bill. The American people do not want it, and the American people are right.

I yield the floor.

1:52 PM EST

Chuck Grassley, R-IA

Mr. GRASSLEY. Mr. President, I would like to also make a statement related to the amendment that is being presented by the Senator from Colorado. Speaking for several Members on my side--hopefully, for all the Members on my side--we are very concerned, as I think we have all made clear by now, that the Medicare savings in this bill are being used not for preserving Medicare but, instead, are being used to finance the creation of a new Federal entitlement program.

My understanding of the purpose of the amendment of the Senator from Colorado is to indicate that Medicare savings will be used for extending the solvency of Medicare and the trust fund, reducing Medicare premiums and other cost sharing for beneficiaries, and to improve or expand Medicare benefits and access to providers.

Nobody can argue with that purpose the Senator has expressed or his amendment expresses. But the concern on our side that we have with this amendment is it does not require that the savings from Medicare would only--with emphasis upon the word ``only''--be used for that purpose.

As the Congressional Budget Office has made clear, the cuts in Medicare in this bill are not being used solely for Medicare, as the Senator's amendment suggests, but, instead, are being used [Page: S12286]

mostly to fund the creation of an entirely new and separate subsidy program. For the Senator to accomplish what he intends to accomplish would require entirely different language to ensure that savings from Medicare in this bill would only be used to protect Medicare

benefits for seniors, as the law now expresses.

The right approach would include language making sure seniors have the same access as they have today, to home health services, skilled nursing facilities and services, hospice care, hospital services, preventive benefits, and the benefits provided in the Medicare Advantage Program. So the Senate, it seems to me, should also ensure that Medicare savings in this bill are not being siphoned off to finance a new and separate entitlement program.

It is very clear to me--and I hope we are able to make it clear to people, all 100 Senators--that the Bennet amendment, as written, does not protect Medicare.

I yield the floor.

1:55 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, I do not think I have any time, but I ask unanimous consent that as to the time I do have after 2 o'clock, I can take 2 minutes of that so I can ask a question of my good friend from Iowa.

1:56 PM EST

Chuck Grassley, R-IA

Mr. GRASSLEY. That is true. But I do not think the Senator wants to go down that road because, do not forget, there are 6 years of programs, of expenditures, and there is 10 years of revenue coming in. If you want to play that game, you can pay down the entire national debt.

1:56 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Well, I do not know--to be totally fair and respectful to one of my very best friends in the Senate--to cover that point, isn't it also true the Congressional Budget Office said in the second 10 years this bill will reduce the budget by one-quarter percent of GDP? Isn't that also true, according to the Congressional Budget Office?

1:57 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, I ask unanimous consent that my colleagues and I--the Senator from Tennessee, Mr. Alexander; the Senator from Oklahoma, Mr. Coburn; Senator LeMieux from Florida; Senator Enzi; and Senator Crapo--be allowed to engage in a colloquy.

1:58 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, I wish to begin our conversation with a brief comment about the American Association of Retired Persons, known as the AARP, that has now come out against this amendment, incredibly.

It is a fascinating history of that liberal Democratic group because, in 1993, when we had some savings in Medicare, the AARP said:

If we're talking about Medicare cuts alone as a way of financing health reform, we would fight that with all our strength--we've gone as far as we can go down that road.

The AARP, on $6.4 billion Medicare cuts in 2005, said: ``Strongly Opposes.'' They said the:

..... conference agreement ..... undermines the critical protections built into both the Medicaid and Medicare programs. Instead of ..... shared sacrifice to achieve budgetary savings. .....

Every time there has ever been a savings in Medicare or Social Security in any way, shape, or form, the AARP has come out against it, except now when there is the most massive cut in Medicare in history and a transfer of those funds to a vast new $2.5 trillion entitlement program. It was described as $2.5 trillion just yesterday by the chairman of the Finance Committee.

I say shame on the AARP. I say to my friends, especially those who are under the Medicare Advantage Program, the 330,000 in my State, for whom, admittedly, they are going to cut their Medicare Advantage benefits, take your AARP card, cut it in half, and send it back. They have betrayed you.

2:00 PM EST

Tom Coburn, R-OK

Mr. COBURN. Mr. President, the chart behind me shows the cuts in Medicare that are in this bill. We have heard all sorts of arguments. I have a few rhetorical questions for my colleagues and my friend, the President of the United States.

There is no question Medicare Advantage costs too much. I have agreed to that with the chairman of the Finance Committee. But you cannot say that coordinated care does not improve the care of seniors, and that is going to be cut. You cannot say that eyeglasses and hearing aids are not going to be cut, and they do improve the care. You cannot say to seniors who cannot afford a supplemental policy, who have Medicare Advantage, they are not going to lose some of their care. They are. In fact, 2.6

million, according to the Congressional Budget Office, are going to lose that very care--not some of it, all of it. They are going to lose that advantage under this legislation.

The answer to the question, will this impact seniors care, is yes. We have heard these cuts aren't going to impact anybody or the only people they are going to impact are the insurance companies. Well, I am all for impacting the insurance companies, but I don't want to impact patients negatively.

So we have cuts to Medicare, including hospitals, of $134.7 billion; hospices, $7.7 billion; nursing homes, $14.6 billion; Medicare Advantage, $120 billion; home health agencies, $42.1 billion; and then you say you are not going to do anything to impact the care of seniors. My colleague from Iowa, whom I love, disputed my statement about the fact that the life expectancy is going to go down under this bill. He has never practiced medicine a day in his life. I know what goes on inside hospitals.

When you cut $130 billion out of the hospitals, the time you are going to wait for me, the time you wait after you push your call button is going to get extended and the complications from that are going to result in decreased quality of care and shortened life expectancies. There is no question about it.

So we can play the game, but the real thing Americans ought to know is almost $500 billion of spending on Medicare patients today is going to go by the wayside to be spent on a new entitlement, on a brandnew entitlement.

2:03 PM EST

Mike Crapo, R-ID

Mr. CRAPO. If the Senator from Oklahoma will respond to a question, he is a physician, and he has very well pointed out how the cuts to Medicare Advantage will reduce benefits to senior citizens. The impacts on the hospitals and home health care and the skilled nursing facilities and so forth will be reduced services. I am aware of a June 2008 report from the Medicare Payment Advisory Commission, MedPAC, which said 29 percent of Medicare beneficiaries they surveyed who were looking for a primary

care physician had trouble finding one who would treat them. A similar survey in Texas showed that in that State, only [Page: S12287]

58 percent of the State's doctors would be willing to take a new Medicare patient, and only 38 percent of the primary care doctors accepted new patients.

So my question is, in addition to the reduction of benefits, in addition to the reduction of access to hospitals and skilled nursing facilities and so forth, won't these cuts and the impact on Medicare also represent a lack of ability by Medicare recipients to literally find physician care?

2:03 PM EST

Tom Coburn, R-OK

Mr. COBURN. There is no question, to answer my colleague from Idaho, that if it doesn't eliminate the ability, it will deny by delaying the ability. Care delayed is care denied. All you have to do is read all of the tragedies that have gone on in this country for people who have delayed care which has resulted in large complications for that individual.

2:04 PM EST

Mike Enzi, R-WY

Mr. ENZI. Mr. President, I wish to raise a point as the accountant around here. You have mentioned some ways to cut Medicare to pay for this. Actually there are only two ways you can pay for a government program. You have to do it through cuts or through taxes. I don't think there is anybody in America who believes you can do $1 trillion worth of new programs and have them all paid for, unless you steal somewhere. That is what we are doing from Medicare. We say that is not going to affect Medicare.

If you eliminate the DSH payments which are part of this, it is going to put some Wyoming hospitals out of business. I can assure you that if those seniors can't go to a hospital in their town, they are going to consider that a benefit cut. They are going to be upset, and they ought to be.

The same with nursing homes. If you cut back on nursing homes, the people who have to move to another town for a nursing home--because all of our towns don't have more than one nursing home--puts quite a burden not only on the patient who isn't going to get to see their family as much, but also on the family who has to travel a long way to see the patient. So I don't think we ought to be paying for the new programs by doing this when Medicare needs an extended life.

I am always fascinated when they explain that this will extend the life of Medicare because, yes, if you cut payments to everybody, that maybe saves money and extends the life of it, if we did that. Is there anybody who thinks we are going to cut the doctors over the next 10 years by $250 billion? No, we are not going to do that. We never have.

2:06 PM EST

Tom Coburn, R-OK

Mr. COBURN. My one criticism of my colleagues in writing this bill is I think there is money we can save in Medicare. It is called waste, fraud, and abuse. A Harvard professor who studies this says there is at least $125 billion a year in fraud. We have had several studies that say it is anywhere from $100 billion to $175 billion a year. There is nothing in this bill to eliminate fraud. What we are doing is we are taking care from seniors instead of taking the money from the fraudulent actors

in the health care system.

2:06 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. Mr. President, if I may say to the Senator from Arizona, I greatly appreciate his making this amendment, because there is so much said here on the Senate floor that must be hard for many people to follow. But one thing I believe everybody agrees on is there are going to be $465 billion in cuts to Medicare over the next 10 years, period. Everybody agrees with that. The President of the United States has said we are going to pay for this new health care bill with one-half from Medicare

cuts and one-half from taxes. Everyone agrees with that.

What Senator McCain's amendment is saying is two things--and Senator McCain, let me see if I characterize properly your amendment, because it is a very simple amendment, as I read it. It is saying, send it back to the Finance Committee and say, bring the health care bill back without the Medicare cuts, without these cuts to hospitals, cuts to hospices, cuts to nursing homes, cuts to Medicare Advantage, and cuts to home health agencies.

Second, if we are going to take money from grandma's Medicare, let's spend it on grandma. Let's take the savings we find in Medicare and absolutely make sure we spend it on Medicare, which the trustees have said is likely to go broke between 2015 and 2017.

Did I correctly characterize the Senator's amendment?

2:08 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. And does the Senator recall a few years ago when the Republicans suggested saving $10 billion over 5 years in Medicare, the majority leader said that was immoral, and that other Democratic Senators thought it was awful? If $10 billion in savings to try to make Medicare stronger is immoral, what is spending nearly $ 1/2 trillion on a new program called?

2:09 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. Well, if I may say--and then I think maybe others could respond--if you are going to spend $2.5 trillion a year, you have to get the money from somewhere. What the Democratic health care bill does is get it three places. One is from seniors, one is from taxes, and one is from the grandchildren of seniors; that is, debt. It comes from those three places.

What we heard earlier this week was the Congressional Budget Office saying the total effect of that $2.5 trillion is that for most Americans, premiums would continue to go up as they already are, and that for people who go into the individual market they will go up even more--they will go up even more--except there will be some subsidies for a little over half of those people, and where is the subsidy money coming from? It is coming from Medicare. So that is the answer to the question.

2:09 PM EST

George LeMieux, R-FL

Mr. LeMIEUX. It would seem to me--and again, I am new to this process--that 100 Senators would vote for Senator McCain's proposal because everyone in this Chamber believes we should strengthen Medicare. Who could be for taking money out of Medicare if we don't need to? These are two separate issues. Shouldn't every Senator in this Chamber say let's send this back to the Finance Committee so those cuts can be restored and we can start over and take a step-by-step approach? That

only seems fair to me.

Perhaps my colleague from Oklahoma could comment on that.

2:10 PM EST

Tom Coburn, R-OK

Mr. COBURN. I thank the Chair.

We are in trouble in Medicare in this Nation. Everybody knows it. We have made promises. The unfunded liability on Medicare is $79 trillion. For us to take $ 1/2 trillion, no matter what the Enron accounting says afterward, the fact is we are going to reduce that; we are going to make that worse. We may not make it worse next year or the year after, but we are going to make it worse. It is going to be worse for seniors, but it is also, as the Senator from Tennessee said, going to be extremely

worse for the seniors' kids and grandkids. Not only have we done that, we have raised the taxes in Medicare on a certain group of people and we are going to take that money and not put it in Medicare; we are going to take that money, a Medicare tax, and create a new entitlement.

So the Senator from Florida is absolutely right. If you vote against the McCain motion you are saying you want to cut $ 1/2 trillion out of Medicare and that it will have no effect whatsoever on the care.

I remind the Senator from Florida, there are 1 million people on Medicare Advantage in the State of Florida, 1 million people who are going to lose benefits under this bill. One million people in the State of Florida will lose benefits under this bill.

2:12 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. Mr. President, I would ask the Senator from Oklahoma, who is a physician himself, if one of the [Page: S12288]

effects of cuts in Medicare is to make it more difficult for people who are on Medicare to see a doctor. It is like giving somebody a bus ticket and not having a bus.

I have been reading in the newspapers, for example, in the Washington Post last month, that the Mayo Clinic, which is often held up as an outstanding example of a clinic that keeps costs under control, has announced it no longer will accept Medicaid patients from Nebraska and Montana, and some Mayo clinic facilities in Arizona and in Florida are beginning to say no more Medicare patients.

Is this what the Senator from Oklahoma thinks could be happening at other hospitals and centers, even very good ones such as the Mayo Clinic where they allegedly keep costs at a reasonable level?

2:12 PM EST

Tom Coburn, R-OK

Mr. COBURN. I think that is entirely possible. I don't know that to be factual as of yet. What I do know is we are going to have 44 million baby boomers in the next 12 years jump into Medicare and we are cutting Medicare. We are going to have 44 million baby boomers jump into Medicare. I am one of them. We are going to cut the amount of available funds from Medicare under this bill.

2:13 PM EST

Mike Enzi, R-WY

Mr. ENZI. Mr. President, I wish to ask the Senator from Idaho what he thinks will happen with these Medicare cuts as they affect jobs and the economy. That is one of the biggest things on people's minds right now, jobs and the economy. We are concentrating on something here where we are going to maybe make a difference, even though CBO says it won't be much of a difference.

2:13 PM EST

Mike Crapo, R-ID

Mr. CRAPO. I thank the Senator from Wyoming for that question, because as we have already reviewed, there will be major cuts in benefits to Medicare, to the Medicare Advantage Program. There are going to be major reductions in access to Medicare, in terms of access at hospitals and skilled nursing homes and facilities and home hospice and other care.

But one of the other things we haven't focused on--and it is kind of interesting that today is the big White House jobs summit--what is going to happen as a result of these Medicare cuts. In addition to the reduction of access and care and benefits to seniors, we are going to lose jobs. I have had in my office here representatives of nursing and home health care facilities from Idaho who have told me that if this bill is adopted, a number of those facilities are simply going to have to go out

of business or they are going to have to dramatically reduce the services they provide, meaning that the nurses and the other caregivers who work there will no longer have jobs. That is part of the way our senior citizens will lose access because there will simply be fewer places, fewer physicians, fewer facilities that will take Medicare patients with this kind of an attitude of the Federal Government toward funding of Medicare.

In the end, what do we have? We have a massive expansion of government, $2.5 trillion for a massive new entitlement program, along with which come these incredible government controls over the economy, as well as the creation of a new government insurance company, funded by $ 1/2 trillion, almost, of Medicare cuts, $ 1/2 trillion in taxes, and a massive debt, an unfunded mandate pushed on to the States.

That is one of the reasons why I think the Senator from Arizona was so wise in bringing this motion as the first step in focusing on one of the first fixes that needs to be made to this bill. Let's step back. Let's not pay for a brandnew $2.5 trillion entitlement program on the backs of our senior citizens.

2:16 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, I mentioned the AARP and their opposition to this amendment. There is an organization called 60 Plus that has millions of supporters and members. They also feel very different from the AARP. Their message is:

Soon you [the Senate] will vote on the McCain motion to commit with instructions. The motion would commit it to the Senate Committee on Finance--

Et cetera.

I and the 5.5 million supporters of 60 Plus urge you to support this motion. The Patient Protection and Affordable Care Act is nothing of the sort. It would cut Medicare by $500 billion. These cuts would harm seniors who have paid into the program and expect it to be there to help them with their health care needs. At 60 Plus, we pride ourselves on advocating for the best interests of seniors. That is a ``yes'' vote on this motion.

Let's pay attention to 60 Plus.

2:17 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Our figures are that 330,000 people in my State of Arizona are on Medicare Advantage. I noticed yesterday, when the distinguished chairman of the Finance Committee and the Senator from Connecticut were talking, they were disparaging the entire program, saying how it wasn't any good, talking about the cost overruns and saying it was a bad program. They have opposed it from the start.

So the message to the 330,000 Americans in Arizona who are on Medicare Advantage is that they are out to get you.

2:18 PM EST

Mike Crapo, R-ID

Mr. CRAPO. According to the Senator from Tennessee, it is my understanding that nationwide it is about one-quarter of all Medicare beneficiaries. About one in four Medicare beneficiaries in America will see their benefits cut. All Medicare beneficiaries will see their access cut. So these problems we are talking about are not just limited in their impact.

2:18 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. I will respond again. There are cost problems with Medicare Advantage, but those cost problems can be fixed. Those cost problems can be brought under control. But the fact is, to do away with a program that allows them a choice in how they receive their care is, of course, again, an effort to have the government make the decisions for people, which flies in the face of everything we stand for and believe in.

2:18 PM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. I may say to the Senator from Arizona, I have heard our friends on the other side say Republicans are scaring seniors about Medicare cuts. Mr. President, it is not Republican Senators who are scaring seniors about Medicare cuts; it is the Democratic health care bill that is scaring seniors, because there are $ 1/2 trillion of Medicare cuts that will pay for half of this program, and they are outlined on this chart, as the Senators have discussed.

2:19 PM EST

Max Baucus, D-MT

Mr. BAUCUS. I will yield myself about 10 minutes. The Senator from Tennessee says this is going to hurt seniors. Let's ask the senior organizations what they think about that.

Let's also look at this organization called 60 Plus. What does the AARP say in the letter to Senator Reid, dated December 2? It talks about this legislation:

The legislation before the Senate properly focuses on provider reimbursement reforms. .....

I am sorry all my colleagues have fled the Senate. I would like for them to stay and listen to this. I would like to hear their response. But they have just fled the Senate after making sound bites.

2:24 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, I think it is pretty clear that the main organizations that care about seniors support this bill. Another organization--60 Plus--I don't know what they think. I guess they oppose it because they want to privatize Social Security, and they get most of the money from the pharmaceutical industry. I don't think they care about senior citizens, frankly, and certainly not as much as these other organizations.

I think it is also important to point out that this legislation is deficit neutral over not just the first 10 years but over the next 10 years. It is more than deficit neutral. This legislation generates a $130 billion surplus the first 10 years and, as we all know, reduces the budget by a quarter of GDP over the next 10 years. So this is not irresponsible; it is very fiscally responsible. It is strongly supported by the senior organizations that care for seniors. I might say, too, it is not

raiding Medicare at all. It is strengthening the Medicare trust fund and it extends the solvency of the trust fund.

Therefore, I think, clearly, as AARP says, we should oppose the McCain amendment, which hurts Social Security beneficiaries, does not help them. [Page: S12291]

I yield such time as the Senator from Illinois needs.

2:26 PM EST

Dick Durbin, D-IL

Mr. DURBIN. Mr. President, I ask to be recognized for 5 minutes. If the chair would advise me when I have used that time.

I found it interesting, as I am sure the Senator from Montana has, to listen to all of the Republican Senators who have come to the floor to defend Medicare. I am sure the Senator from Montana has the same memory I do--that when it was created, it was created by the Democratic side of the aisle, with the general opposition of the Republican side of the aisle. They said it was socialized medicine, too much government, and it would fail. Now they are coming riding to the rescue of Medicare. We

have a right to be skeptical about the arguments they are making.

Imagining these Republican Senators defending Medicare is trying to imagine a fish riding a bicycle. I cannot put it in my mind. But they are doing it. The Senator who sponsored this motion to commit, Senator McCain, just a year ago, in the course of his Presidential campaign, called for eliminating $1.3 trillion in spending from Medicare and Medicaid. Now he comes to the floor and says this bill, which would reduce costs in Medicare by less than half of that amount over a 10-year period

of time is irresponsible and the death knell of Medicare.

What is the real story? The real story is the Republican side of the aisle is defending the private health insurance companies--companies making generous profits from Medicare Advantage. This is a program offered by private health insurance companies to replace government-run Medicare. It turned out, in many instances, to have failed miserably. It costs more money because these private health insurance companies are taking profits out of the Medicare Advantage Program. So they have pleaded with

the other side of the aisle to come to their rescue. They have sent in their best troops on the other side of the aisle, headed by the senior Senator from Arizona, who has said the first thing I will do is to protect these private health insurance companies and their rights to overcharge seniors in Medicare for Medicare Advantage.

He talks about the people now receiving Medicare Advantage, who may be disadvantaged and see a different policy in the future. What the Senator from Arizona and others don't dwell on is that everybody under Medicare today pays $90 a year more into Medicare to subsidize the private health insurance companies that offer Medicare Advantage. This is a tax--a tax--which the Senator from Arizona is trying to preserve. It is a tax on Medicare recipients.

The Senator from Arizona was right a year ago. We can take an honest look at Medicare and Medicaid and take money out of the system without disadvantage to the people involved.

I want to say to the Senator from Arizona and others that once we have dispatched his motion to commit, he will have a chance to vote for Senator Michael Bennet's amendment. It could not be clearer. It has two parts. It says--repeating what this bill says, it says unequivocally:

No provision in this Senate bill can reduce any Medicare benefit guaranteed by statute.

Next paragraph:

Savings in Medicare from the bill will go to extend the life of the Medicare trust fund, lower part B premiums, or cost sharing, expands benefits, improves access to providers.

We know, and the seniors across America know, that left unattended and uncared for, Medicare may go broke in just a matter of 7 or 8 years. This bill before us will extend the life of Medicare for at least 5 years. It will put Medicare on sound footing which every senior and their families want to have. That is why AARP, the largest organization of senior citizens across America, has urged Members of the Senate in both parties to oppose the McCain motion to commit. That is why I stand today with

the Senator who is chairman of the Finance Committee and say to my Republican friends, with their newfound love affair with Medicare, that they should reject the 60 Plus organization, this ``wise counsel'' they turned to that came up with the idea of privatizing Social Security.

How would you like to have had all your Social Security money in the stock market over the last 2 years? Boy, there is a great idea. Stick with this 60 Plus group if you like the notion of privatizing Social Security. Stick with AARP if you want Medicare to be strong, on sound financial footing.

I yield the floor.

2:31 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, I think it is appropriate to remind people of some of the provisions that are in this bill.

To repeat, because some people have listened to some of this debate and some have not and some might be tuning in right now, the fact is, without reform, without this legislation, Medicare is expected to go broke in the next 8 years. That is according to the Medicare trustees report. With this legislation, that is extended for at least 5 more years. That protects seniors. This legislation protects seniors. Without reform, that is, without this bill, costs will rise and seniors will be forced

to bear more and more of the burden out of their own pockets. This legislation adds benefits for seniors. It does not take it away, as the other side implies.

Without reform, seniors will struggle to afford prescriptions in the doughnut hole. I remind my colleagues that this legislation will cut the cost of brand-name prescription drugs in half for seniors during that gap, the so-called doughnut hole.

It will also help provide more benefits in terms of annual wellness visits. When seniors go to the doctor for a colonoscopy, mammography, or other preventive screenings, they will not have copays, as is currently the case today. That is an added benefit this legislation provides for seniors.

Also, this legislation helps seniors who are eligible for both Medicare and Medicaid with access to home, community-based alternatives. A lot of our seniors would like that additional benefit. That is all in this legislation.

This legislation provides more benefits for seniors, not fewer. This legislation protects seniors; it does not harm them. This legislation extends the solvency of the trust fund rather than not.

I might also say--and I think the Senator from Illinois made a very good point--currently, seniors who are paying a Part B premium are really paying a $90 tax per year for those persons who are in Medicare Advantage. We know Medicare Advantage is overpaid. The Senator from Oklahoma, Mr. Coburn, agreed with me when I asked him just yesterday if Medicare Advantage was overpaid. He said, yes, it is overpaid by a very large margin. This legislation can adjust that overpayment.

I might also say, too, that the groups I mentioned support this legislation. But the main point I want to make is this: There are so many fundamental provisions in this legislation that really have not come out much in debate, a little esoteric but under the heading of ``delivery system reform.'' We must begin to change the way we reimburse doctors and hospitals so we are focusing much more on quality of care rather than quantity of care. Some of that is already happening in America without legislation.

Basically, it is the nature of integrated systems. We all talked about them. I know Senators on the other side of the aisle also agree with this new trend where hospitals, doctors, nursing homes, and other groups get together and they coordinate their care. Their care is much more patient focused. We have to move much more in that direction.

This will go a long way once it starts kicking in--it is going to take maybe 3 or 4 years to finally have an effect--toward eliminating the waste in our current system. Estimates are we have between $200 billion to $300 billion to $800 billion annually in waste in the American health care system. That is the reason health care costs are so high for family, businesses, governments, whatnot. We have to begin to get that under control, and this legislation does that.

If we do not pass this legislation, we will be postponing the day when we have to begin to get some of these excessive costs under control, and then the problem will be much more difficult. An ounce of prevention is worth a pound of cure in medicine. It is also true in legislation. Clearly, now is the [Page: S12292]

time to exercise a little ounce of prevention by starting to curb excessive costs, and this bill does that.

2:36 PM EST

Chuck Grassley, R-IA

Mr. GRASSLEY. Mr. President, as I stated earlier, the Bennet amendment, as written, does not protect Medicare. So I have a modification I would like to present that ensures Medicare savings in this bill are not being siphoned off to finance a new and separate entitlement program.

To that end, I ask unanimous consent to modify the amendment by adding the following before the period at the end of subsection (b):

..... and furthermore that, notwithstanding any other provision of this Act or amendment made by this Act, net Medicare savings specified in the most recent estimate available from the Director of the Congressional Budget Office before enactment are appropriated to the Secretary and shall be used for such purposes and to maintain Medicare policies for home health services, skilled nursing facility services, hospice care, hospital services, and benefits provided by the Medicare Advantage program,

as under the provisions of such Title as specified on the day before the date of enactment of this Act.

End of my amendment.

2:37 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Reserving the right to object, under current law, if less is spent for Medicare providers, the benefits inure to the Medicare trust fund beneficiaries.

Although I have the greatest respect for the Senator from Iowa, this is a stunt, and I object.

2:37 PM EST

Chuck Grassley, R-IA

Mr. GRASSLEY. Mr. President, I would like to make very clear that this objection confirms that the Bennet amendment does not protect Medicare as the other side claims that it protects Medicare.

I yield the floor.

2:37 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, this motion sends the legislation back to the Finance Committee for a short period of time with instructions to report back with cost offsets other than Medicare cuts. The motion says we should retain the provisions in the legislation addressing fraud and abuse and retain those savings to strengthen the Medicare trust fund. Instead of cutting over $450 billion from Medicare providers and beneficiaries, the committee should do what it should have done in the

first place--protect seniors' benefits and access to providers. It is much needed.

Mr. President, I say to my friends, let's save seniors who have paid into the Medicare Program their whole lives from these damaging cuts. I hope my colleagues will vote in favor of this motion. Let's use Medicare savings to save Medicare, not to fund a whole new $2.5 trillion entitlement program. I urge a vote in favor of the motion.

I yield back the remainder of my time.

2:39 PM EST

Michael Bennet, D-CO

Mr. BENNET. Mr. President, I wish to sum up the debate over Medicare in the Senate health bill and on the motion and amendment before us.

Only in Washington, DC, could an effort to extend the life of Medicare somehow be distorted as being bad for seniors. We know from the Congressional Budget Office, a nonpartisan organization that supports both sides of the aisle, that this Senate bill does not take away any seniors' guaranteed Medicare benefits. It extends Medicare solvency for 5 additional years. My amendment simply confirms these two facts.

I am the first person who would insist we have an open process for this debate. I think there are ideas on each side of this debate on this bill that are worth considering and should be considered. But it is why I find it so confounding that opponents of my amendment want to send the entire bill back to committee so debate stops. How can we return home to the people of our States and admit to them we just gave up and sent health care back to the committee for another round?

The people who do not want change are the people who are content to leave it the same and do not have a theory about how to extend Medicare. They would have seniors believe the bill is bad for seniors. Yet AARP, the Alliance for Retired Americans, the Center [Page: S12293]

for Medicare Rights, and the National Committee to Preserve Social Security and Medicare beg to differ. They disagree. They agree with this amendment and with the underlying bill. Senior advocacy

organizations, grassroots organizations with their ears to the ground hearing the voices and concerns of seniors, support health care reform, and they agree that with my amendment, this bill strengthens Medicare and preserves seniors' benefits.

With the Senate bill finally reaching the floor, seniors are looking for simple clarity on how health care reform can help their lives. Nothing in this bill will cut guaranteed Medicare benefits, and this bill will extend Medicare solvency for 5 additional years. It actually makes the system work better instead of cutting or adding to a program. It actually changes the way Medicare works so it will be stronger and more stable.

People may disagree with the prescription, but as a general matter everybody knows the status quo is unsustainable, and this bill helps seniors. It eliminates the copay seniors have to pay for preventive care. We know preventive care saves lives and it saves money.

As we close debate on my amendment and the alternative motion to commit the bill to committee, I urge all the Members of this body to consider the consequences of inaction. My amendment affirms what the current Senate bill does to help seniors and strengthen Medicare. We all know even more can be done, so let's continue this debate and reject the motion to commit the bill back to the Senate committee.

I urge every Member of this body to support my amendment. Please vote yes on the Bennet amendment and protect our seniors.

I yield the floor.

3:08 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, the McCain motion is next. Unless we act today and pass health care reform, the Medicare trust fund runs out of money in 2017. There are two ways to keep Medicare solvent: find efficiencies so Medicare spends less or increase revenues going into the trust fund--two ideas. Our bill would make Medicare Advantage more efficient. We would introduce competitive bidding----

3:09 PM EST

Max Baucus, D-MT

Mr. BAUCUS. I thank the Senator from West Virginia.

We extend the trust fund for 5 more years. That is in this bill. Yes, Medicare Advantage plans would not be overpaid as much, but those plans could pay for greater efficiency by cutting their profits or cutting their executives' pay. They could do that. Nothing says they have to go after beneficiaries.

Our bill does nothing to reduce the guaranteed Medicare benefits. To the contrary, our bill would improve Medicare benefits. It would help seniors on the prescription drug doughnut hole and add new preventive benefits such as annual wellness visits. The bill would help ensure doctors would be available to treat Medicare patients. We would prevent the 21-percent cut in doctor payments under current law. For all those reasons, the American Association of Retired Persons supports reform and opposes

the McCain motion.

I urge my colleagues to support reform and oppose the motion to commit.

3:10 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, this motion proposes to send the legislation back to the Finance Committee to remove the nearly $ 1/2 trillion in cuts that will severely impact all seniors who are eligible for Medicare. As the Senator from Montana mentioned, the system is going to go broke in 7 years. So what does this legislation contemplate? That we take $ 1/2 trillion out of their savings and use it to fund a $2.5 trillion new entitlement program. What does that do for the Medicare trust

fund? Nothing.

I urge my colleagues to vote in favor of this motion and send it back to the Finance Committee. Do the right thing for the seniors of this country.

3:29 PM EST

Roger Wicker, R-MS

Mr. WICKER. Mr. President, I appreciate the Senator yielding to me. I think it is important for us all to understand where we are now. We have had a debate about the Medicare issue. The Senate had an opportunity, with the McCain amendment, to protect Medicare from the almost one-half trillion dollars in cuts the Reid bill proposes to do to Medicare. We said no to that opportunity and instead passed the amendment offered by Senator Bennet of Colorado which in sum total does absolutely

nothing. What we have done now with the Bennet amendment is say that along with apple pie and motherhood, we also love Medicare, and we want everybody to know that. But the substantive effect of what we have now done is nothing.

I have this challenge to the managers of the bill on the other side and to the Democratic leadership: Now that Bennet has passed and McCain has been defeated, I challenge them to take this bill, send it back to CBO and CMS and have the independent analysts there look at it again. They will be duty bound to come back with the facts. The facts will be that the almost one-half trillion dollars cut in Medicare is still there.

Now that the McCain motion to commit has been defeated, and the sham of the Bennet amendment has been passed, there are still the same cuts to hospitals, there are still the same cuts to Medicare Advantage and to all the senior citizens who depend on that and who were told during the campaign their coverage would not be taken away from them if they liked it. The cuts to nursing homes are there. The cuts to home health are there. And the cuts to hospice are still there.

Send the bill back to CBO. We can continue debating it. We will not have to miss out on one bit of rhetoric that we have already had. But ask the independent analysts: Are the Medicare cuts still there? They will be duty bound to come back to us and say: Yes, the same cuts that were there before are current in the bill now.

We have accomplished absolutely nothing today to protect Medicare.

I thank the Senator for yielding.

3:31 PM EST

Mike Crapo, R-ID

Mr. CRAPO. Mr. President, I thank the Senator from Mississippi.

Mr. President, I ask unanimous consent that several of my colleagues and I may engage in a colloquy during the time we have.

3:32 PM EST

Mike Crapo, R-ID

Mr. CRAPO. Thank you, Mr. President.

I wish to follow up on the comments of Senator Wicker from Mississippi because it is very critical that the American public understand what has happened in the Senate.

When you talk about health care reform, the vast majority of Americans have a couple of ideas in mind. First and foremost, they want to lower health care premiums and costs. That is what Americans think about primarily when they think about the need for health care reform.

They also want to see better access to quality health care and make sure those who are uninsured have access to health care, and those who are underinsured have access to health care, and that we all have access to quality health care. That is what this debate should be about.

But, instead, the legislation we see before us does not achieve that. Does it reduce the cost of health care? No. It drives up the cost of health care. It raises taxes hundreds of billions of dollars. It cuts Medicare by hundreds of billions of dollars. It grows government by $2.5 trillion of new spending. It forces the most needy in our society into a failing Medicaid system. It imposes a damaging unfunded mandate on our struggling States. It still leaves millions of Americans uninsured and

establishes massive government controls over our health care economy, including the creation now of a government insurance company.

We have been focusing in the debate on one part of this for the last little while; that is, the Medicare cuts. Mr. President, $464 billion of the revenue to pay for this massive new entitlement that is being created is to come from Medicare, and it is nothing other than a direct transfer of assets in the United States from America's seniors in the Medicare system to a new government entitlement program.

There are other cuts. There are details of these cuts that I will put up right now on a chart.

The debate we have been having over the last, oh, almost 3 or 4 days now, is whether we should commit the bill back to the Finance Committee so these Medicare cuts can be removed. We just had two votes. One was what I will call a cover vote. It said we do not want to cut Medicare benefits and we should make sure that anything we do protects Medicare. It did not have any detail in it, but it passed 100 to nothing because it does nothing. It does not change what is in the bill. By the way, as I

said, that vote just passed by 100 to nothing.

The second vote we took failed. Was the vote 40 to 60? I do not recall the exact vote. What would that amendment have done? That amendment would have put the bill back into the Finance Committee and required that we take out the Medicare cuts.

So let no one be confused, after the first round now in the Senate, we still see this in the bill--a transfer of $464 billion from the Medicare Program to the establishment of a new entitlement program. I do not believe that is what Americans had in mind when they were talking about reform of health care.

There has been a study that came out--OK. I have the exact vote here. It was not 40 to 60. It was 42 to 58, but it was defeated, in any event, and now we still have the cuts to Medicare in the bill. Well, we are going to continue debating this issue.

I myself have an amendment that will send--for the skilled nursing homes--the bill back to Finance to correct the cuts for the skilled nursing homes. There are others who will try to address some of the pieces of this legislation to see if we can't find a way to fix and restore the strength and stability of the Medicare system.

Everyone admits we need to reform Medicare. But until this bill, none of us thought we were talking about taking from Medicare in order to create a massive new entitlement program, with the government control that comes along with it.

What do these cuts do? I am going to start out with the hospitals, the hospice services, the nursing homes, and the home health agencies. The reduction in Medicare spending on these medical providers will basically result in lower access to care for our seniors. I have had representatives in my office of both skilled nursing facilities and home health agencies who have talked to me about what this means to them. They have pointed out that the last time Congress did something like this, we lost,

in Idaho, 30 percent, for example, I believe it is, of our home health agencies. They are not there anymore. If we have these kinds of deep cuts in the future, we are going to lose more of our home health care agencies. [Page: S12295]

One of the owners said to me--he put it this way: If you reduce the allocation of income to home health agencies, I have to either reduce employment, which means not hire as many nurses and medical providers, or I have to close parts of my building and stop operating as many rooms in the building, or do something to reduce costs.

What that means is that seniors will have less access. But that is not all this bill does. In addition to reducing the access for hospitals, hospice service, nursing homes, and home health agencies, it also cuts Medicare Advantage deeply.

Quickly, what is Medicare Advantage? Medicare Advantage is a program that about one out of four American seniors participate in in Medicare. It is an opportunity which Congress started a few years back to try to let the private sector become a part of the delivery system in Medicare. In other words, to put it simply, private sector insurance companies can contract with the Federal Government to provide Medicare services to Medicare beneficiaries, so it is the private sector getting involved in

health care delivery rather than the government simply delivering the health care through a single-payer system. That, in a quick summary, is what Medicare Advantage was all about.

What we found was that it was phenomenally successful because the private sector was able, through its management, to not only provide the statutorily required Medicare coverage but additional benefits, very critical additional benefits, such as preventive health care, dental coverage, vision coverage, and things such as that--things that make a big difference in the lives of our seniors and enables some of those who cannot buy additional coverage for those things Medicare does not cover to get

access to it through Medicare Advantage.

That is why in my State 27 percent of all of the Medicare recipients have moved to Medicare Advantage. It is the most popular part of Medicare in America today, and it is growing faster than any other part of Medicare because it is delivering more to the Medicare beneficiaries.

This bill slashes $120 billion from it, some of us believe because there is a bias against the private sector delivery of health care. But for whatever reason, the Medicare Advantage portion is where the cuts are focused.

Let's put up the next chart.

When we had the issue before the Finance Committee, we

had the head of CBO before us, and I asked him a question about the cuts to Medicare Advantage. We had a colloquy between us at that point, and I asked:

So, approximately half of this additional benefit--

In other words, these additional things that Medicare Advantage has been able to provide to our seniors under Medicare--

So, approximately half of this additional benefit would be lost to those current Medicare Advantage policyholders?

And his response was:

For those who would be enrolled otherwise under the current law, yes.

The point being, not only will we lose skilled nursing facilities, home health care, hospice care, and hospital care, and access to that care, we are also going to see senior citizens lose benefits. Again, what is the purpose? The purpose is not to shore up Medicare. In fact, it will take $464 billion--taxpayer dollars that are allocated to Medicare in our current system--and transfer that straight over to the establishment of a new entitlement program.

I want to let my colleague from Nevada comment on this for a minute, but before I turn it over to my colleague from Nevada, I wish to point out that as we approach this issue, the question of why would we transfer $464 billion out of the Medicare system to a new government entitlement program, one of the reasons is because the President pledged he would not sign a bill that did not reduce the deficit.

As I said earlier, this bill grows the spending in the Federal Government by approximately $2.5 trillion over the first full 10 years of its implementation of spending. The only way to cover that increase in the size of the government is to either raise more taxes or to cut spending somewhere, and what the bill does is both. It raises taxes--which we are going to be talking about in future days--and it cuts spending. The place where it cuts spending is Medicare. That is why what we see is increased

taxes, cuts in Medicare, growth of government, and the establishment of a new Federal entitlement program, with all of the accompanying accoutrements of Federal control, including a new government owned and operated insurance company.

I see my colleague from Nevada standing and turn to him for his comments on this issue.

3:42 PM EST

John Ensign, R-NV

Mr. ENSIGN. First of all, I think my colleague from Idaho has made some excellent points about, truly there will be cuts that are going to happen in Medicare. And do not just take the politicians' word for these cuts. Listen to the CBO Director. He is the nonpartisan, I repeat, nonpartisan, official scorekeeper. When asked direct questions, by not only the Senator from Idaho but others, he absolutely says the benefits, especially under Medicare Advantage, will be cut.

In my home State of Nevada, tens of thousands--I think about 200,000 altogether--of seniors have voluntarily chosen Medicare Advantage over traditional Medicare. The reason? Very simple. There are extra benefits in Medicare Advantage. You hear the Democrats talk about the doughnut hole in Medicare Part D, which is prescription drug coverage. Well, there is not a doughnut hole under most of the Medicare Advantage plans because the private sector, through its efficiency, has been able to fill that

doughnut hole. In other words, they get complete coverage of prescription drugs through their Medicare Advantage plans.

Also, under Medicare Advantage, they get additional preventive health care services. They also get vision and dental. And depending on the plan, depending on its makeup, there are different types of benefits to attract seniors to certain plans. It is no wonder that about one out of four seniors in America have voluntarily signed up for Medicare Advantage. Nobody forced them into this system. They voluntarily chose this system.

If you think about it, seniors do not like change. For most seniors, they like what they have. They do not like to change. For one out of four seniors to have voluntarily changed, there has to be something pretty attractive about Medicare Advantage.

There are some real attractive things for seniors in Medicare Advantage plans. That is why when you actually poll seniors regarding Medicare Advantage, the vast majority of them are thrilled with the coverage they have. They do not want to lose benefits. Who would want to voluntarily lose benefits?

But with the $120 billion cut in Medicare Advantage the Democratic majority has put in this bill, about half of the benefits in Medicare Advantage plans will be cut. Isn't that correct, I ask my friend, the Senator from the State of Idaho?

3:45 PM EST

Mike Crapo, R-ID

Mr. CRAPO. The Senator from Nevada is correct. In fact, I am just thumbing through here to get the exact statistics. But the bottom line is, the CBO indicated, I think it was something like from an average number of $140 or so of extra benefits--that it would go down to about half of that. So they would get about half of those extra benefits.

3:46 PM EST

Roger Wicker, R-MS

Mr. WICKER. We have three Republicans standing now saying this, and we have had quoted some official independent sources.

Let me quote a Democrat, Representative Michael McMahon of New York:

Medicare Advantage, which serves approximately 40 percent of my seniors on Medicare, would be cut dramatically.

That is why that Democrat from the State of New York voted no on the plan when it was before the House of Representatives. So you don't have to take our word for it, from a partisan standpoint. Democrats are saying no because of the Medicare cuts and the cuts to Medicare Advantage--drastic cuts.

3:46 PM EST

John Ensign, R-NV

Mr. ENSIGN. The Senator from Idaho and I serve on the Finance Committee [Page: S12296]

where a large portion of this bill was written. We both heard Democrats on the other side of the aisle complaining about cuts to Medicare Advantage. Yet when I look in this bill, the total dollar figure in cuts to Medicare Advantage is the same as what came out of the Finance Committee; isn't that correct?

3:46 PM EST

Mike Crapo, R-ID

Mr. CRAPO. The Senator from Nevada is correct. I have in front of me the exact numbers right now from CBO that were provided in the Finance Committee markup. During the markup, CBO estimated that the value of the extra benefits offered by Medicare Advantage plans will drop from $135 a month to $42 a month, based on the cuts contained in that bill, which are essentially the same level of cuts we now see in the bill before us on the floor.

3:47 PM EST

John Ensign, R-NV

Mr. ENSIGN. Let me make a couple other general points about this bill. I think we have pretty well covered the fact that Medicare Advantage is going to take a severe hit. Medicare overall, that includes hospice care, hospital care, nursing home care, home health--all of them are taking severe cuts. More than likely, those cuts are going to come, if the government doesn't rescue those cuts in the future, from benefits to seniors.

If the government decides not to have those cuts in the future, then the deficit is going to go up. You can't have it both ways. You can't have both a deficit-neutral bill and not have the cuts in Medicare. In other words, you are going to either have the cuts in Medicare or you are going to have ballooning deficits into the future.

There are several other problems with the bill that I would like to point out. First of all, we know it is over 2,000 pages; there is incredibly complex language in those over 2,074 pages. It places bureaucrats in charge of health care decisions instead of creating a patient-centered health care system that says the doctor-patient relationship is where most of the health care choices should be made. As a matter of fact, according to the National Center for Policy Analysis, in almost 1,700 places

in this bill it authorizes the Secretary of Health and Human Services to ``make, create, determine, or define'' things regarding health care policy. Mr. President, 1,697 times, to be exact, the Secretary of Health and Human Services basically makes health care policy--not doctors, not health care providers; bureaucrats in Washington, DC.

You mentioned before there were $ 1/2 trillion in new taxes and about $ 1/2 trillion in Medicare cuts. We know this bill will lead to millions of Americans having increased premiums.

We have talked a lot about what is wrong with the bill, however, many on this side of the aisle have offered positive solutions. We have talked about allowing small businesses to join together to take advantage of purchasing power that big businesses have. We have talked about allowing people to buy insurance across State lines. Some States have less expensive plans than others. You can buy your auto insurance across State lines. Why shouldn't we be able to buy our health insurance across State


3:50 PM EST

Mike Crapo, R-ID

Mr. CRAPO. If I could interrupt, my understanding is, the Republican bill in the House, which has both ideas in it and which was evaluated, what it would do to the cost of health care and health care insurance premiums, that those ideas would actually reduce health care premiums by, I think, 5 or 6 or 8 percent. I don't remember the exact number, but the point is, those ideas would hit the reason Americans want health care reform; that is, reduce the cost of health care coverage.

3:50 PM EST

John Ensign, R-NV

Mr. ENSIGN. I am glad the Senator from Idaho made that point, because the No. 1 problem with health care in the United States is not quality. We have the finest quality system--by almost any measure, the finest quality health care system in the entire world. The problem is that it is too expensive. We should be going after costs. This bill does not do that. This bill actually raises premiums for tens of millions of Americans. That isn't the direction we should be taking health care.

Another idea the vast majority of people on this side have supported is medical liability reform. Once again, in the Finance Committee, we asked the question--I, personally, asked the question of the CBO Director: How much money would medical liability reform--the common one I offered and Senator Hatch offered--how much would that save between the government and the private sector? He said: Over $100 billion. Well, that is not chump change; that is a significant amount of money, $100

billion. Add that to buying across State lines, add that to small business health plans, add that to incentivizing healthy behaviors--add that to the elimination of preexisting conditions. I think Republicans and Democrats alike agree, if you have insurance and you have played by the rules and you get a disease, your insurance should not be taken away or denied. We should eliminate preexisting conditions for those that

have played by the rules. We shouldn't allow insurance companies to unexplainably increase rates. We should take a step-by-step, incremental approach to health care reform instead of gutting Medicare, as the Senator from Idaho has talked about, to create a new government entitlement program. That is what we are saying on this side of the aisle. However, it seems to be falling on deaf ears on the other side of the aisle.

3:52 PM EST

Roger Wicker, R-MS

Mr. WICKER. Mr. President, if I could just maybe take 1 minute of that time and then y colleagues can wrap it up.

I wish to emphasize what a devastating effect these Medicare cuts are going to have on rural America. Once again, I wish to quote some of my colleagues from the other end of the building because it shows the bipartisan opposition we have against these cuts from rural America.

Mike Ross, a Democrat from Arkansas, said:

With more than $400 billion in cuts to Medicare, it could force many of our rural hospitals to close, providing less access and care for our senior citizens.

Representative Larry Kissell of North Carolina:

From the day I announced my candidacy for this office, I promised to protect Medicare.

So he voted no on the bill in the House of Representatives.

Ike Skelton said:

The proposed reductions to Medicare could further squeeze the budgets of our rural health care providers.

Finally, Representative Boucher, a senior Democrat from Virginia, said:

The plan could place at risk the survival of our regions' hospitals.

Unless these Medicare changes are taken out of the bill, this bill devastates health care for senior citizens in rural America.

I thank my colleague for yielding me the time.

3:53 PM EST

Mike Crapo, R-ID

Mr. CRAPO. Thank you very much. I wish to use the remainder of our time to speak for a minute about what this bill does to different costs in our country. I think the point we made in this colloquy is, after the votes we just took, let no one be confused; the $464 billion of cuts to Medicare remain in the bill.

Let's talk about the question of the cost curve. There has been a lot of talk about what has become known as the cost curve. It has been said by everybody we need to bend the cost curve down. Some are saying this bill bends the cost curve down. Well, which cost curve are they talking about? Are they talking about the size of government, the growth of government? No. If you take the first full 10 years of the growth of spending in this bill--which, by the way, is delayed for 4 years--if you start

when the spending starts and take the first full year, 10 years of spending, the new spending, the growth of government is about $2.5 trillion. I don't see how anybody could say that cost curve is bending down. It has skyrocketed.

Well, would it be the cost of health care, which I think is the cost curve Americans were thinking about, health care insurance and the quality of health care that is provided? Well, CBO just came out with its report that analyzed that issue and there are a number of independent groups that have analyzed it and they all pretty much say it is not going to reduce the cost of health insurance. It is not going to reduce the cost of health care. In fact, for [Page: S12297]


neediest in America, those who are in the individual market, it will drive up the cost of their insurance and not by just a little bit, by around 10 to 13 percent. For those in the small group area, it will drive up theirs--not as much--by about 1 to 3 percent. For those in the large group area, there is a possibility that theirs might taper off a little bit; the estimate is somewhere between zero impact and 2 percent reduction.

But is that what we are talking about in America, 30 percent of the people in this country seeing their health care insurance costs go up and the rest seeing theirs remain basically stable? That is not the cost curve reduction I thought Americans were talking about in health care reform.

So then what other cost curve could they be talking about? Well, there is a lot of talk about the deficit. Sometimes they try to shift away from the cost of health care to the cost of the bill to the people of America, and they say the deficit is reduced. Well, how can you say that? There is only one way you can say that and that is if you accept the budget gimmicks in the bill. If you raise taxes by around $500 billion and if you cut Medicare by $464 billion, then you can say this massive expansion

of government is somehow covered and that the deficit won't grow.

Well, I think we have talked about the Medicare cuts part of this. We are going to talk about the tax increases, which are hundreds of billions of dollars of new taxes in the future, but what did I mean when I said you can only say the deficit goes down if you accept the budget gimmicks?

This bill starts the collection of revenues and the cuts out at the front end but doesn't start the spending for 4 years, so you have 10 years--in the 10-year window we are looking at, we have 10 years of revenue and 6 years, basically, of spending. Sure, if you only count 6 years of the spending side of the bill against 10 years of its collection side, you are going to be able to make that deficit look a little better.

In addition, there are major expenditures we all know are going to have to be done in health care, such as the SGR fix for physician compensation in Medicare, that are not even in the bill, an expense we know over 10 years is around 200 billion to 250 billion of extra dollars; simply not there, not counted. Well, if you want to show a deficit reduction, you certainly want to leave out of your bill a lot of the spending you are going to do in the future. It is gimmicks such as these, it is tax

increases, and it is Medicare cuts that allow one to say the deficit goes down.

In conclusion, the reality is, this bill will increase the growth of government by $2.5 trillion for a full 10-year measure, increase taxes by hundreds of billions of dollars, cut Medicare by hundreds of billions of dollars, create a Federal insurance company, create massive Federal controls over the health care economy, push the neediest of the uninsured not into an insurance policy but into a failing Medicare system, and push an unfunded mandate of tens of billions of dollars onto our States.

That is not the kind of health care reform we need. As my colleague from Nevada indicated, there are reforms that do make a difference that will reduce the cost of health care, that will cut down the spiraling costs of health care insurance, and will not require us to have such an intrusion of the Federal Government into the management of our economy.

It is time for us to slow down and start, step by step, to address the kinds of reforms that will reduce the cost of insurance and the cost of health care and that will help us to increase access to quality care in America. We can do it, and we have a number of very good ideas on the table we will be exploring in greater detail in future days as well that will help us to do it.

With that, I reserve the balance of our time.

May I ask how much time remains?

4:00 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Madam President, I think it would be instructive to stop all this rhetorical talking past each other on Medicare Advantage and explain a little bit about how we got to where we are in this legislation.

I don't know the exact year, but I think it was back in the 1980s sometime, up to a certain point Medicare was basically paid fees for services. That is the basic Medicare model. The service was provided and there are certain set rates for that service. Then, in the 1980s, private companies thought maybe they could be more efficient, private insurance companies. So they came to Congress and said: We can do a better job in compensating Medicare based on fee for service, so let's set up something

called Medicare Advantage, private entities.

So Congress said: OK, competition is a good thing. So we did that. Congress did that. We basically set the rates to be paid to Medicare Advantage plans at 95 percent of fee for service. After all, the plan said they could do it more cheaply and they could compete. So we said: OK, that sounds like a good idea. We will pay you 95 percent of what otherwise would be paid under fee for service. That continued for a while.

In 1997, the plan said: Gee, we need a little more money. So Congress said: All right. And we gave a little more money to Medicare Advantage and basically said, OK, that will pay the 95 percent. But if you are not doing so well and making money at 95, we will set kind of a higher floor, according to certain areas of the country, and you could choose whatever enables you to have the greatest compensation.

The big change occurred in 2003, in the Medicare Modernization Act, otherwise known as the drug bill. It was the legislation that created drug benefits for seniors. As we all know, frankly, when Medicare was created, it didn't have an outpatient drug benefit because drugs weren't comparatively as important then as they are today. Today there are miracle drugs that help in a lot of ways. We created the drug benefit in 2003.

The Congress did something else then. Many Members of Congress were concerned that Medicare Advantage might not offer the plans in rural parts of America, that there wouldn't be enough incentive for Medicare Advantage to go to rural America to offer the drug benefits--not only the drug benefits but other benefits they provided. Congress, frankly, gave a lot of money to Medicare Advantage plans so there could be at least two plans operating in all parts of the country. Give them enough money and

they will go; that was the theory. Guess what happened. We gave them a lot of money and they went.

We have reached the point now where Medicare Advantage is, by everybody's estimate, quite dramatically overpaid, as the Senator from Oklahoma, Mr. Coburn, said when I asked him yesterday whether Medicare Advantage plans are overpaid. He said, ``Yes, they are definitely overpaid.''

MedPAC, which advises us on Medicare reimbursement, said to us that we are way overpaying Medicare Advantage plans. I hear figures of from 14 to 18 percent overpayment. It depends on what part of the country you are in. Let's be conservative and say it is 14 percent in fee for service, that they are overpaid. MedPAC is an independent advisory group that helps us figure out what in the world we pay hospitals, nursing homes, home health agencies, etc. We are not the experts. We need help. MedPAC

said to the Congress that we are overpaying them big time.

We decided let's figure out a way to reform the system. How about a little competition? Right now, Medicare Advantage plans are paid what is called a benchmark, depending upon the fee for service in their certain area. We all know fee for service is much less in rural America, and I am sure in the home State of the occupant of the chair. Fee for service is much higher in other more urban States and so forth.

As it turned out, under the benchmarks for fee for service, they were way overpaying in States where fee for service is so high, and not quite as much overpaid where fee for service is so low. That is a nutty system in the current law today.

What we are doing in this legislation is, basically, we are saying: Look, let's introduce a little competition. We are saying: Let's get rid of the benchmark-type fee for service. It is out of whack in different parts of the country. What are we going to do? We say: OK, we will divide the country into geographic areas. In your area, wherever you might be, Uncle Sam--or Medicare--will pay the average competitive bid [Page: S12298]

for that area. The average cost you

bid for that area is what we are going to pay, which eliminates this big disparity between States and makes it much more fair so that reimbursement is based much more on what it actually costs in a certain area, but it is competitively bid. That is what we are trying to do.

Is that a good thing to do? I think most of us think so. Is it perfect? I don't know for sure, but we are trying our best to make this a better system, a better program than we currently have. As a consequence, we are going to save some money, and there will be competition. Most of us think competition is often a pretty good thing. That is what this is, I remind my colleagues. As a consequence, we are not going to be overpaying Medicare Advantage plans anymore. The amount we reduced the payment

to is in line with what MedPAC says we should pay, the Medicare Payment Advisory Commission.

We are trying to be responsible and reasonable with taxpayer money, seniors who pay into Medicare. The point is often made that, gee, this will hurt Medicare Advantage, hospitals, and so forth. I think it is worth reminding all of us that a meeting occurred at the White House, I think, 4 to 6 months ago, when all of the so-called providers--the hospitals, insurance companies, including Medicare Advantage plans--all got together with the President and said: Mr. President, we agree this country

needs health care reform. They all agreed.

Let's move back in history a little bit. When President Clinton attempted health care reform, all those groups were opposed to health care reform. This time, they are pretty much in favor of it because they know if we don't fix it, it is going to collapse.

Back to that meeting. What did they say? They said: Mr. President, we have all gotten together and we think we can contribute. We can cut collectively $2 trillion in payments that go to us over the next 10 years.

That is what they said. That is pretty interesting. Thank you very much. So we are working together to get health care reform.

Why do you think they would agree to $2 trillion? They got their calculators out and got their financial officers together and said: Gee, if everybody has health care--remember, 46 million Americans don't have health insurance--if everybody had health insurance, hospitals, Medicare Advantage plans said: Hey, we can make some money because everybody has health insurance.

So that was the deal. They will have a little lower margins, but they will make it up on volume. That is why they said to the President: We can cut $2 trillion that otherwise would be reimbursements to us.

In this legislation, did we reduce the rate of increase over 10 years by $2 trillion? No. Did we decrease the rate of increase in expenditures by half of that or $1 trillion? No. Do we reduce the rate of increase of health care expenditures down to, say, $450 billion, close to $500 billion? Yes, that is what we did. About one-quarter of the industry said they could voluntarily contribute. Are they squawking today? No. Why? Because they got a pretty good deal. They know they can continue to provide

services and the hospitals are going to do well and home health care agencies will do well. I will add that the profit margin for home health agencies is about 17 percent. That is pretty good. So we are cutting them a little bit. The profit margin for nursing homes--Medicare payments to nursing homes--is about

15 percent. We are cutting that a little bit. But they are still making money and still will do well. In fact, their average rate of growth over the next 10 years is going to be in excess of 5 percent a year. Wall Street analysts say these outfits are doing pretty well. You don't see their stocks going down.

We are trying to do what is right and to reform Medicare Advantage, as I just outlined it. It is a pretty fair attempt at reform. Also, we will reduce payments to hospitals and other providers in an amount that they can live with--not be happy with but an amount they are OK with, and where they know they can still make money. That extends the solvency of the Medicare trust fund another 5 years because those providers are not being paid as much as they would otherwise be paid.

I hear Senators crying crocodile tears about how seniors are going to be cut, and so forth. Frankly, with the changes we made, I think it is very fair, and it will extend the solvency of the trust fund. There is not one dime of guaranteed Medicare benefits that will be cut--not one thin dime--in this legislation. It is true that because

Medicare Advantage--the rate of growth of increase in Medicare Advantage plans is trimmed back a little, perhaps there will not be as many extra benefits--not the guaranteed benefits but extras, fringe benefits, like gym memberships and things like that. Don't forget, that is not because that is a decision made by Medicare or by Congress; that is a decision made by the executive offices of these private companies. I am not saying they should do this. They could trim salaries, overhead, and they

could have a little less return to stockholders, and they could cut down administrative costs. There are various things they could do, which doesn't have to be passed on to reductions in fringes. Let's keep things in perspective as to what is actually going on.

4:13 PM EST

Chris Dodd, D-CT

Mr. DODD. If my colleague will yield, I appreciate what the Senator has just done. This is an area where I think there is a lot of confusion and misunderstanding. A lot of it begins with just the branding, the title of something. This was, frankly, a revelation to me, going back a number of weeks ago. I heard the words ``Medicare Advantage.'' I thought this has to be part of the regular Medicare Program because it has that title.

4:14 PM EST

Chris Dodd, D-CT

Mr. DODD. In looking back a few years ago, the original reason--and I don't recall the debate as well as my colleague, the chairman of the Finance Committee, does. As I remember, the original idea behind this was--and he said this already, but it deserves being repeated--this was a way of cutting costs, reducing expenditures. In a sense, we were sold this idea on the fact that we could do this better, more efficiently, at far less cost.

4:15 PM EST

Chris Dodd, D-CT

Mr. DODD. And that the average Medicare couple over the age of 65 is paying, I am told, about $90 a year more in Medicare payments for benefits they don't get.

4:15 PM EST

Chris Dodd, D-CT

Mr. DODD. Our bill does something that I think our friend from Oklahoma, Senator Coburn, pointed out that is absolutely critical, which is that competitive bidding did not exist in the original.

Who was setting these rates originally during this period of time? How did these rates get set? Did Congress set them?

4:16 PM EST

Chris Dodd, D-CT

Mr. DODD. So there is an incentive to trim the cost of the administration of the program. It is also true the plans get bonus payments for care, coordination, and quality, and plans can use these bonuses to improve benefits? [Page: S12299]

4:16 PM EST

Max Baucus, D-MT

Mr. BAUCUS. That is correct. Under this legislation, we say--frankly, under the earlier Medicare Advantage plans, HMOs had some coordinated care, but the other half, the private fee for service, preferred provider organizations did not have coordinated care.

We are saying in the legislation that if you are in the Medicare Advantage plan, which includes a whole list, and you provide coordinated care, we are going to give you a bonus.

4:17 PM EST

Roger Wicker, R-MS

Mr. WICKER. I realize we do not have much time. I have a quick question. I was listening to the debate on television. I understood the Senator to say Medicare Advantage is not part of Medicare. My question is: I have here the Medicare handbook for 2010, ``Medicare and You.'' It says right on page 50:

Medicare Advantage Plans (Part C). A Medicare Advantage plan ..... is another health coverage choice you may have as part of Medicare.

My question to the Senator is--to my friends on the other side of the aisle: Is the Medicare handbook inaccurate and, if so, will you be calling CMS, Medicare, and be asking them to change what they say explicitly on page 50 of the Medicare handbook?

4:17 PM EST

Roger Wicker, R-MS

Mr. WICKER. I realize we do not have much time. I have a quick question. I was listening to the debate on television. I understood the Senator to say Medicare Advantage is not part of Medicare. My question is: I have here the Medicare handbook for 2010, ``Medicare and You.'' It says right on page 50:

Medicare Advantage Plans (Part C). A Medicare Advantage plan ..... is another health coverage choice you may have as part of Medicare.

My question to the Senator is--to my friends on the other side of the aisle: Is the Medicare handbook inaccurate and, if so, will you be calling CMS, Medicare, and be asking them to change what they say explicitly on page 50 of the Medicare handbook?

4:18 PM EST

Chris Dodd, D-CT

Mr. DODD. They are wrong. It is a private health care plan. It is a private health care plan. Medicare is a public plan. Medicare Advantage is not Medicare, and it is certainly not an advantage, given the overpayments that occurred.

4:18 PM EST

Chris Dodd, D-CT

Mr. DODD. It is a private plan. My colleague understands that, I hope. Medicare Advantage is a private plan. You know that, of course, don't you? I assume you know that.

4:18 PM EST

Roger Wicker, R-MS

Mr. WICKER. I know this. It is in the handbook. I want my two friends of the majority party to get it out of there. We thought all along it is part of Medicare and the millions of senior citizens who rely on this and who were told in the campaign, if you are satisfied with your coverage, you don't have a thing to worry about, they are going to be able to keep their coverage. Under the Democratic legislation, they would not be allowed to keep their coverage under this bill.

4:19 PM EST

Chris Dodd, D-CT

Mr. DODD. If I can reclaim my time, 80 percent of older Americans are paying $90 more a year for this. Do they have any say in this? They don't get any of the benefits. Why are they writing a check for $90 a year to pay a private plan from which they get no benefits? What about them? Don't they deserve something in all this?

4:19 PM EST

Roger Wicker, R-MS

Mr. WICKER. I realize my friends have a difference of opinion. The authorities for Medicare who put this publication out year after year say Medicare Advantage is part of Medicare. It is Part C. I think it is disingenuous for my friends to say it is not.

4:19 PM EST

Chris Dodd, D-CT

Mr. DODD. The only reason it is part of it is it is subsidized. This plan gets subsidized by the American taxpayers. That is the only qualification that puts it under the Medicare umbrella because our taxpayers are writing a check to a private company. That is why it gets included as part of Medicare. Other than that, it is a private plan.

4:20 PM EST

Max Baucus, D-MT

Mr. BAUCUS. This legislation, if I may say, expressly states there will be no reduction in what is called guaranteed benefits under Medicare. No reduction, whether it is under Medicare Advantage, whether it is under fee for service--whatever it is, no reduction whatsoever.

To be fair to my good friend, I used the words ``guaranteed benefits.'' Guaranteed benefits are the usual benefits seniors think of when they are under Medicare. They go to a doctor, hospital, so on.

We have given, unfortunately, so many additional dollars to the so-called Medicare Advantage plans--way above what they should have received. MedPAC agrees. Senator Coburn totally agrees they have been paid way too much. They have taken advantage of that advantage by giving additional benefits, in addition to the guaranteed benefits. Those additionals are things such as gym memberships--a lot of extra stuff that, frankly, is not part of Medicare, is not directly related to health.

I might say, too--I have said this a couple, three times and I will say it again--a reduction in the increase of payments to Medicare Advantage, the effect of

those reductions is a decision made by the officers of that company. They could take those reductions and apply them anywhere. They could reduce their salaries. They could reduce their admin costs. They could take other actions that would reduce the rate of growth, the rate of return of their stockholders. They do not have to take it out of the beneficiaries. That is their choice. They do not have to.

4:22 PM EST

Chris Dodd, D-CT

Mr. DODD. Medicare Advantage decides how to use their extra payments to provide benefits. They decide; Congress does not. There is nothing in the legislation that forces plans to reduce benefits at all, rather than reducing profits.

Medicare Advantage is one of the profitable business lines of the private insurance. In fact, the New York Times on November 2--just about a month ago--reported:

Humana, the health insurer, posted on Monday a 65 percent jump in third-quarter profits--

We are talking about private health care. These are profits, a 65-percent jump in profits off this plan--

as bulging membership and premiums from Medicare Advantage overcame a lackluster commercial segment.

I appreciate the fact that people are getting eyeglasses and things. That is wonderful. But we need to be clear about this. These are not the guaranteed benefits, and 80 percent of Medicare beneficiaries get none of these advantages and yet pay more so other people under this private health care plan--because it is subsidized by the American taxpayers--get them.

Again, now we are going to put competitive bidding in place. Our bill allows, under these plans, if they follow and do some of the incentives, to actually share in some of the profits. We are not talking about eliminating all of this plan. We are trying to make it work better for people under the bill.

We have to be honest what we are talking about. This is a private insurance company that is subsidized by the American taxpayers. It is not what, traditionally, people think of Medicare.

4:23 PM EST

Roger Wicker, R-MS

Mr. WICKER. The chairman, when he is calling HHS to change the handbook, also needs to tell them to change their Web site, where it says Medicare Advantage is part of Medicare.

Can the Senator from Connecticut guarantee that under this legislation, the benefits to Medicare Advantage recipients will not be cut? Can he make this guarantee?

4:24 PM EST

Chris Dodd, D-CT

Mr. DODD. Let me claim my time. There is not a single guaranteed benefit under Medicare that is cut in this bill. Not one. I defy any Member of this body to identify a guaranteed benefit under Medicare that gets cut. You cannot find one. Do we cut out gym memberships and things such as that? Yes, that may happen. But on the guaranteed benefits--operative word is ``guaranteed''--under guaranteed benefits, there is not a single cut to a benefit. That is why an organization representing 40 million

Americans that endorsed the Bush prescription drug plan, by the way, in 2003--hardly a partisan organization as some have suggested today--has basically opposed [Page: S12300]

the McCain motion and has endorsed the legislation before us today. That organization, I say to my good friend, would never be endorsing a bill that was going to cut guaranteed benefits under Medicare.

4:25 PM EST

Max Baucus, D-MT

Mr. BAUCUS. I wish to say something else to put this in perspective. That is according to analysis of Medicare Advantage plans from Oppenheimer Capital Fund, dated November 12 of this year, between 2006 and 2009. Their estimate is, Medicare Advantage accounted for nearly 75 percent of the increase in gross profits among the larger Medicare plans in the industry.

Let me say this:

..... Medicare Advantage ..... has been a huge driver--

Quoting from the Oppenheimer Capital Fund--

a huge driver of earnings growth for the industry in recent years. Between 2006 and 2009, we estimate that Medicare Advantage accounted for nearly 75 percent of the increase in gross profits among the larger plans in the industry, highlighted by an estimated gross profit increase of $1.9 billion in 2009, relative to commercial risk earnings gains--

That is basic health insurance, not Medicare Advantage plans but basic health insurance--

of nearly $600 million. Medicare Advantage probably won't be as much of a contributor in 2009--

But it is going to be a very large contributor in 2009 because of advantages they get.

4:26 PM EST

Roger Wicker, R-MS

Mr. WICKER. It is clear the Senator does not like Medicare Advantage. It is also clear no guarantee can be made that Medicare Advantage benefits will not be cut under this legislation. It is also clear there are tens and tens of millions of American senior citizens who like their Medicare Advantage, notwithstanding the Senator from Montana, and they stand to lose those benefits under this legislation.

4:27 PM EST

Chris Dodd, D-CT

Mr. DODD. Let me point out, one of the things we have not talked about, I say to my friend from Mississippi, under our legislation, this bill protects seniors in Medicare Advantage from plans that care more about profits than seniors, trying to pass the buck. Under our bill, it allows the Secretary of Health and Human Services to kick out any plan under Medicare Advantage that significantly increases their premiums or decreases their benefits. Under existing law, that would not happen; under

our bill, it does.

It is not about being hostile to Medicare Advantage. It is being realistic about all this and trying to make the tough decisions we have to make about trying to stabilize Medicare, seeing to it we are going to have protections in premium reductions and cost savings, as well as increasing access and quality.

All we are trying to point out is, when you have a Medicare Advantage plan that has run as poorly as this one has, at great cost we now learned--14 percent above, on average; some places it is 50 percent above average--where is the equity. By the way, I say to my friend from Mississippi, it is a private health care plan that receives subsidies from the American taxpayers, where 80 percent of seniors today pay more and get nothing for it. Where is the equity in this? There is no equity in this.

Why should 80 percent of that population pay $90 or more a year, on average, for a benefit they don't get? Where is the equity?

4:28 PM EST

Max Baucus, D-MT

Mr. BAUCUS. I might add, too, to remind us all, this legislation provides additional benefits for all seniors, including Medicare Advantage recipients--additional benefits. What are they? No copayment for certain preventive care--mammograms, for example, colonoscopies, screening benefits that are not in existence today. There are a whole host of other things that are additional.

This legislation provides additional benefits to Medicare Advantage members that are not there today.

When I say ``guaranteed benefits,'' I am talking about the usual benefits seniors think of under Medicare. It is hospital care, it is nurses, it is all medically necessary physician care, diagnostic testing, supplies. It is home health care, preventive care, skilled nursing, hospice--all the things that are basically related to health care.

The only thing that might be trimmed back a little is, I call them the fringe stuff, the excesses, such as gym memberships. I wish I had the whole list because some of them are not related.

As I said earlier, they may not be cut. They don't have to be. It is up to the private companies whether to cut. I have nothing against companies making profits. They should make profits. It is our responsibility as Senators to make sure the reimbursement rates Medicare pays providers are fair and reasonable and not excessive. We have been told they are excessive. So we are trying to find a way to make it fairer.

4:30 PM EST

Roger Wicker, R-MS

Mr. WICKER. This segment of debate will end at the bottom of the hour, so it is almost over. I appreciate my friends yielding. This debate will continue for days, weeks. I say to my friends, there are Members on their side of the aisle who have come before this body and said these Medicare Advantage cuts are unacceptable. I think they are going to have to have a lot of convincing too. Democratic Members of the House have also come forward. I am not convinced. I don't think they are convinced.

4:30 PM EST

Chris Dodd, D-CT

Mr. DODD. Madam President, let me say to my colleague again that here we have two organizations representing 43 million seniors in our country, and these are organizations that don't just write letters on the fly. They have staffs that examine proposals here, and that is all they do. We have AARP, which is an organization that is highly regarded and well recognized, representing 40 million seniors in the country, and the Commission to Preserve Social Security and Medicare, which represents an

additional 3 million, and that is all they do. This is a totally nonpartisan examination. These two organizations, representing almost 50 million of our seniors, have examined this bill in detail--every dotted ``I,'' every semicolon, every comma, every proposal--and have done exhaustive research, and they have said: This is a good bill. This bill is deserving of support.

We received a letter today from them. They are not Democrats. They are not Republicans. They are not trying to get an advantage over anybody. They are examining whether this bill stabilizes and strengthens Medicare, puts seniors in a stronger position, is going to see to it that we can extend the life of the program and provide guaranteed benefits that are needed, and their answer was a resounding yes--yes, this bill is deserving of our support.

Again, I appreciate the political debate here, but at some point we have to step back and let those whose job it is to analyze our suggestions and our ideas--just as AARP supported President Bush 6 years ago with his prescription drug bill. They didn't join Democrats or Republicans; they liked the idea--still do--and supported it. Today, they are not supporting us as Democrats. They would reject this bill out of hand if they thought we did something adverse to the interest of their membership.

But they said: No, this is a good bill, deserving of support. The two largest organizations in this country representing seniors have said: Get behind this bill. Let's support our seniors. Let's make Medicare stronger and strengthen it. And this bill does it.

That is why we should be joining together, not fighting over this. Medicare Advantage is a private health care plan subsidized by the American taxpayer. Eighty percent of the seniors don't get the Advantage. That is why we are creating these changes in this bill.

I applaud my colleague from Montana, the chairman of the Finance Committee, who did incredible work, along with his staff and other members, in producing this product.