10:06 AM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, for the benefit of all Senators, let me lay out today's program. It has been 3 weeks since the majority leader moved to proceed to the health care reform bill. This is the 11th day of debate. The Senate has considered 18 amendments or motions. It has conducted 14 rollcall votes. Today, the Senate will continue debating the amendment by the Senator from North Dakota on prescription drug reimportation, we will continue debating the motion by the Senator from Idaho on

taxes, and we will continue debate on the bill. Under the previous order, the time until 1 p.m. today will be for debate only, with the time equally divided and controlled between the two leaders or their designees. Beginning at 11 o'clock, Republicans will control the first half hour, and the majority will control the second half hour. We will continue discussions to try to find a way forward.

10:07 AM EST

Mike Enzi, R-WY

Mr. ENZI. Mr. President, I appreciate the statistics the Senator from Montana cited about how long we have been debating this and how many amendments we have done. That is how few amendments we have done, actually. The majority is now filibustering their own bill. I have no idea why that is happening. We have been calling for votes on both of these amendments that have been proposed so far and haven't been able to get the votes. I don't understand how they can talk about how many amendments are

being done.

I also have to voice some other frustration. I don't know how many times I have heard the exact same speech by the Senator from Illinois, Mr. Durbin, on this floor talking about the amount of hours that have been spent together working on these bills in the HELP Committee and the Gang of 6 in the Finance Committee. It isn't about how many hours we spend together. It isn't about how many hours we spend on the floor. It is whether we are accepting ideas. I understand the other party won

the last election, but somehow they will have to get over this attitude that they won the election, they get to write the bill, they don't have to take any ideas from anybody else.

In the HELP Committee, I keep pointing out that most of the things we turned in were kind of punctuation corrections and spelling corrections. Any ideas we actually had that appeared to be accepted to be in the bill were ripped out of the bill before it was actually formally printed, without talking to us. What kind of bipartisan deal is that?

Another thing with the HELP Committee, we have only had 10 days of debate on this. We did more than that in the HELP Committee when we were marking up the bill.

But we are having, in the words of Yogi Berra, déja 2 vu all over again. When we were having that markup, the majority withheld a significant part of the bill, a big part of the bill. It was the government-run option part of the bill. They wouldn't give us the wording on that. I think they were still writing it. Maybe that is what is happening right now too. But we couldn't get the text we were going to write amendments on so that we could deal with the bill. I think America noticed that

in August. People said: How come everybody isn't reading the bill? You can't read what you don't have.

The point I am making is, right now the newspapers are full of information--well, speculation; it has to be speculation--about what this new Medicare expansion does. I haven't run into anybody who has seen the text of that. I have asked some of the media, and they didn't see the text. They got a briefing. We haven't even had a briefing. The majority side has had a briefing, but our folks who have talked to those folks said: Wow, that was pretty general. How could you make up your mind on whether

you are going to support it based on the little bit of information you received? That is not the way to run any kind of an organization, especially if you want bipartisan votes.

You can't write the bill in secret, which is what was done with this bill. There wasn't a Republican involved in the behind-the-door stuff Leader Reid did to put together the bill we have now. That is not bipartisan. There [Page: S12837]

hasn't been a single person from the Republican side briefed on this new proposal that is going to save the world.

Actually, I noticed that the American Medical Association suddenly left the bill and said: This will be the worst thing that could happen to us. The hospital associations, which have been strong supporters of the bill, have also said this won't work, particularly the Mayo Clinic, which we have been holding up as one of the prime examples of the way to do health care, saying: If this Medicare expansion happens, it will cost us millions. We won't be able to provide the kind of care we have been

providing.

What is the deal around here? When are we going to actually get to see something? When is the majority actually going to share with us this marvelous idea they have had? What kind of a way to run a business is that?

Are we going to recess for the weekend? I don't want to recess for the weekend. I am conscious of the 11 days we have been debating, and we have only covered 14 amendments. We have a lot of important amendments that either will be a part of the bill or will help the people in this country to understand what is being thrust on them. There has never been a bill of such importance as this one from the standpoint of how many people it affects. We are talking about reforming health care in America.

That is everybody. That is every single individual, every single provider. Every single business will be affected by this bill.

We talk about 2,074 pages, which seems like a lot. It would be for a normal bill that you could debate in a limited period, which is what we are being asked to do. But 2,074 pages isn't nearly enough to cover health care for America.

So why is it only 2,074 pages? There are hundreds of references in there to how the Secretary of Health and Human Services is going to solve all the problems. The things we aren't able to put into detail in there we just assign to her, and she will magically be able to solve the problems for American health care. After all, it is her Department. But that is not going to happen. You can't give that many assignments to any agency, any department, any group of people and expect them, in a reasonable

amount of time, to come up with solutions, solutions that ought to be decided on by this body, the elected officials--not appointed officials but elected officials. That is not going to happen with this bill.

The only way that could happen is if we took significant parts of it and put it up one piece at a time and solved it. That is what seniors are asking for. They are asking for us to take the Medicare part and give them some assurance that when we are through, it will work. We are not even getting to see a significant part of it. We have been pointing out how taking $464 billion out of Medicare will break it, will ruin it. You just can't steal $464 billion out of Medicare and have it come out good.

The majority recognizes that. That is why they put in the special commission that is going to come to us each and every year and suggest the kinds of cuts we ought to make to keep that solvent.

The biggest thing we ought to do is take these cuts that are provided and make them actually apply only to Medicare. But how are you going to fund the expansion of Medicare now down to age 55? How do you do that? I guess you charge a premium to those people. That is kind of the rumor that is out there. How big of a premium? How big of a premium are you going to thrust on those people? I suspect it is going to be the older and the sicker people in that 55- to 64-age category who are going to want

to shift over to Medicare.

If it is a higher premium so the system stays solvent--having nothing to do, of course, with age, because we cannot do that under the bill, or sickness, because we cannot do that under the bill--and those are good ideas--but those better be up in that range of the high-risk pools that the States already have.

People come to me and say: You have to do something about health care because we cannot afford that high-risk pool; it is too expensive. Well, how much more are we going to expect the young people to pitch in in their paycheck? That is where the Medicare money comes from right now. They deduct a portion of the paycheck from every single working American, and that goes into Medicare, and gets paid out right away to Medicare recipients, none of whom or hardly any of whom are the ones paying into

the system. They are hoping that system is going to be there when they get older.

What I am asking for is for the majority to show us the paper and give us a reasonable time to look at it and give America a reasonable time to look at it. I do not think it is unreasonable for that to be on the Internet. That is a significant part of the bill. That would be a significant bill all by itself. It was held from our view when the HELP Committee did it. Incidentally, that HELP Committee bill--that was put together in 2 weeks without our help and put on us--parts of it were withheld,

as this has been withheld, until the last minute and then thrust in.

That is what created this enormous outrage across America of: Did you read the bill? How can you read the bill if you have not seen anything in it, if it has not been given to you? I do not think it is intended to be given to us until we have to shuffle this thing through at the end.

The anticipation was to get this done by Christmastime, and the majority side keeps talking about getting this done by Christmastime. Will we have time to read it before Christmastime? Will we have a chance to do any amendments on it before Christmastime? I am willing to stay around and work through the weekend and keep doing amendments, but I would like to see this marvelous idea that is going to solve the whole problem. If it was that marvelous and that good of an idea, I think it would be

shared already.

Mr. President, I yield the floor and reserve the remainder of our time.

11:30 AM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, we are here, obviously, as we are on a daily basis, to discuss the issue of health care reform. But we are in a rather unusual situation this morning because we don't know what we are discussing or debating. We find ourselves in an interesting situation.

After almost a year of consideration of health care reform, with a measure that has been--at least a couple of the outlines of it we know but, frankly, we have had no details except that Medicare is going to be extended, eligibility for Medicare is going to be extended to age 55.

I just would quote: There was a meeting yesterday amongst Senate Democrats. Many Senate Democrats emerged from yesterday's caucus meeting saying they had learned little about the public option agreement and there were many outstanding concerns.

Senator Mary Landrieu called the agreement ``a very good idea.'' Senator Blanche Lincoln said, ``More information is needed.'' And Senator Ben Nelson said, ``I just want to know what the costs are.''

So do the rest of us. So do the rest of us. Here we have a proposal after nearly a year that is being assessed by the Congressional Budget Office, and here we are with no knowledge of what that bill is about, with the exception of some bare essentials that have been leaked.

What did this have to do with change? What does this have to do with bipartisanship? What does this have to do with anything?

Frankly, we have an editorial in the Washington Post this morning that calls it ``Medicare Sausage?''

I ask unanimous consent the editorial from the Washington Post be printed in the Record.

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

11:32 AM EST

John S. McCain III, R-AZ

Mr. McCAIN. ``The emerging buy-in proposal could have costly unintended consequences.''

But we don't know what it is. But we know that never before in this entire year--I ask my colleagues--have we seen a proposal that would change eligibility for Medicare down to age 55, never before.

The majority leader came to the floor this morning and said if we accept [Page: S12854]

an omnibus, a multitrillion-dollar bill by unanimous consent--by the way, the Omnibus appropriations bill is six bills totaling $450 billion, 1,351 pages long, with 4,752 earmarks totaling $3.7 billion. And, by the way, spending on domestic programs is increased by 14 percent except for veterans, which is increased by only 5 percent.

The majority leader wants us to go out for the weekend, after keeping us in all last weekend. Here we have an unspecified proposal--none of us know the details or the cost--so I am supposed to go home to Arizona this weekend and say: My friends, we have been working on health care reform for a year. And guess what. I can tell you nothing.

We need to stay in, we need to know what the proposals are, we need to have votes on it, and we need to tell the American people what is going on behind closed doors.

11:34 AM EST

Mitch McConnell, R-KY

Mr. McCONNELL. I recall our good friend, the majority leader, telling us on November 30 that we would be here the next two weekends. Then I recall our friend, the majority leader, saying Monday of this week we would be here this weekend.

My assumption was we were here to deal with this important issue that the majority has been indicating to everyone is so important, that we must stay here and do it. We are prepared to be here.

11:35 AM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. I think it is important to reflect on the season we have here. A couple of nights ago, the Senator from Arizona gave an impressive speech in front of the Capitol for the lighting of the Christmas tree. This is the Christmas season coming up, 2 weeks from tomorrow, a very important season. The majority leader said it is very important for us to stay through Christmas if necessary to debate this bill. We said: All right, that is what we will do. We will stay to New Year's Day. We

will stay to Valentine's Day because this is indeed a historic bill and we don't want to make a historic mistake because it affects our children, our grandchildren, 17 percent of the economy, all 300 million Americans.

None of us have ever seen our constituents more involved in an issue than in this issue. So we are here ready to go to work.

I am wondering, as I listen to the Senator from Arizona, not only do we not know what this bill is that we are supposed to enact by 2 weeks from today, our friends on the other side don't know what it is. They cannot tell each other what it is.

They came out of--they had sort of a rally yesterday. One of the Senators described it as sort of a ``go team, go'' rally, but they did not know what they were going to. All we have heard they are going to--and I imagine the Senator from Oklahoma, who is a physician, who has delivered many babies, seen many patients, still continues to do it, would have some comment on this--all we have heard is they may try to expand Medicare.

We heard yesterday from the executive director of the Mayo Clinic Health Policy Center, I ask unanimous consent to have his letter printed in the Record.

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

Medicare Expansion Won't Get Us There

PROPOSAL WOULD NOT INCREASE ACCESS TO HEALTH CARE SERVICES OR CONTROL COSTS

The current Medicare payment system is financially unsustainable. Any plan to expand Medicare, which is the government's largest public plan, beyond its current scope does not solve the nation's health care crisis, but compounds it. We need to fix Medicare by moving it to a system that pays for value--quality health outcomes that are affordable over time--and ensure its success, before bringing more people into a broken system.

Expanding this system to persons 55 to 64 years old would ultimately hurt patients by accelerating the financial ruin of hospitals and doctors across the country. A majority of Medicare providers currently suffer great financial loss under the program. Mayo Clinic alone lost $840 million last year under Medicare. As a result of these types of losses, a growing number of providers have begun to limit the number of Medicare patients in their practices. Despite these provider losses, Medicare has

not curbed overall spending, especially after adjusting for benefits covered and the cost shift from Medicare to private insurance. This is clearly an unsustainable model, and one that would be disastrous for our nation's hospitals, doctors and eventually our patients if expanded to even more beneficiaries.

It's also clear that an expansion of the price-controlled Medicare payment system will not control overall Medicare spending or curb costs. The Commonwealth Fund has reported this result for Medicare overall by looking at two time periods--one four-year period where Medicare physician fees increased and one four-year period where Medicare physician fees decreased. Overall cost per beneficiary increased at the same rate during each time period. This scenario follows the typical pattern for price

controls--reduced access, compromised quality and increasing costs anyway. We need to address these problems--not perpetuate them--through health reform legislation.

We believe insurance coverage can be achieved without creating or expanding a government-run, price-controlled, Medicare-like insurance model.

Mayo Clinic supports the proposed insurance exchange model based on the Office of Personnel Management's Federal Employees Health Benefit Plan (FEHBP). This system will improve access to insurance, make reforms to the current insurance system that eliminate pre-existing condition exclusions, and create an individual mandate where individuals can purchase private insurance in various ways: through employers; on the individual market; through co-operatives; or through an exchange model like the

FEHBP.

We also believe that the government should help people pay for insurance premiums through sliding scale subsidies as needed.

Jeffrey O. Korsmo,

Executive Director,

Mayo Clinic Health Policy Center.

11:37 AM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. I will just read one sentence from it:

Expanding the current Medicaid system to persons 55 to 64 years old would ultimately hurt patients by accelerating the financial ruin of hospitals and doctors across this country.

I am very puzzled why ideas like this are being cooked up behind closed doors 2 weeks before Christmas, and we do not know what they are, they don't know what they are, and the suggestion is we not vote today and we go home this weekend.

11:37 AM EST

John S. McCain III, R-AZ

Mr. McCAIN. Not only are there questions--not only is there opposition from the Mayo Clinic but the American Hospital Association and the AMA. They have all come up steadfastly against this.

Could I ask my colleague from Oklahoma--and I quote from this editorial. Here we are supposedly going out for the weekend and the editorial from the Washington Post says:

Presumably, the expanded Medicare program would pay Medicare rates to providers raising the question of the spillover effects on a health-care system already stressed by a dramatic expansion of Medicaid. Will providers cut costs--or will they shift them to private insurers, driving up premiums? Will they stop taking Medicare patients or go to Congress demanding higher rates? Once 55-year-olds are in, they are not likely to be kicked out and the pressure will be on to expand the program to make

more people eligible. The irony of this late-breaking Medicare proposal is that it could be a bigger step toward a single-payer system than the milquetoast public option plans rejected by Senate moderates as too disruptive of the private market.

11:39 AM EST

Tom Coburn, R-OK

Mr. COBURN. I will answer my colleague as somebody who has practiced medicine for 25 years: MedPAC, last year, said 29 percent of Medicare beneficiaries it surveyed were looking for a primary care doctor and had great difficulty in finding somebody to treat them.

That is now. In the State of Texas, 58 percent of the State's doctors took new Medicare patients, but only 38 percent of the State's primary care doctors took new Medicare patients.

I would make the case to you that if you delay care, that is denied care. It is exacerbated in our older population because an older person with a medical need is much more susceptible to the complications that can come from that initial problem. So if you delay the care, you are denying the care and you are actually increasing the cost.

There are 15 million people in this population. I have no idea if their plans include all of them. But if you add 15 [Page: S12855]

million new people to Medicare, what you are going to have is 50 percent of them are not going to find a primary care physician to care for them because the rate of reimbursement does not cover the cost of care.

I think the editorial you quote is exactly right.

I would also note, if I may, that President Obama loves the Mayo Clinic, and rightly so. I had a brain tumor removed the summer before last by the Mayo Clinic. I am standing here on the Senate floor because of their expertise.

11:40 AM EST

Tom Coburn, R-OK

Mr. COBURN. I will ignore that comment.

The fact is, what Mayo says is we have to figure out how we create incentives in terms of how do we get people cared for at a lower cost. Medicare is not the way to do it.

As a matter of fact, I heard our colleagues talk. We have had eight votes since last Saturday. We are ready to vote. This is a 2,074-page bill. I have 15 amendments in the queue. I want to vote on them.

They don't want to vote because they don't want the American people to hear all the bad things about what is going to happen to their health care if this bill passes. If we do Medicare, what is going to happen is Medicare costs are going to skyrocket, but access is going to go down.

11:41 AM EST

John S. McCain III, R-AZ

Mr. McCAIN. Apparently, I would ask my colleague from Tennessee, we do not know what we would be voting on because there has been a whole rewrite of this health care reform here after a year. We do not even know what the provisions of that bill are except what has been leaked. Apparently, my colleagues on the other side of the aisle, with the exception of the majority leader, don't know what it is either.

11:41 AM EST

Tom Coburn, R-OK

Mr. COBURN. If the Senator will yield, there are some things we could vote on. President Obama outlined some very specific things that ought to be in this bill. We ought to vote to put them in the bill.

What he said he wanted and what this bill presents are two different things. We ought to vote on making sure everybody has access. We ought to vote on making sure we are under the same plan as everybody else we are going to put into any new expanded health care coverage. We ought to vote in making sure everybody is treated fairly in this country. We ought to vote on your prescription drug reimportation. We ought to vote. But what we are doing is we are getting a slowdown.

We heard we are obstructing the bill. We are not obstructing the bill. Any other bill that comes before this body that had 2,000 pages in it we would allot 8 weeks, 10 weeks to debate.

As our colleague from Maine knows, there is not a more complicated subject that will affect more people that this body has ever taken up. We are trying to squeeze that into 3 1/2 weeks, and the last 2 weeks we don't know what is in the bill.

Time out.

11:43 AM EST

Bob Corker, R-TN

Mr. CORKER. I would like to thank the Senator from Arizona for his great leadership on this issue. I agree with all here. I would like to continue to discuss this, ``colloquize,'' if you will, and vote. That is what we need to do all weekend is talk about this issue and vote.

There are numbers of amendments. But the thing that is interesting to me, I say to the Senator from Arizona--he has been one of the great champions in this country as it relates to how we live within our means. He has pointed out waste in government. He has pointed out overspending.

What has happened during this Christmas season is, for our friends on the other side of the aisle Medicare has become the gift that just keeps on giving.

I know the Senator talked about, during his campaign--and all of us have--that we need to get Medicare to a point where it is solvent, where seniors actually have the ability to use the benefits later on that now are in place. We have all talked about the need to make it solvent.

What does the base of this bill do? It takes $464 billion out of Medicare to create a whole new entitlement. It doesn't even deal with the doc fix, as we have said many times.

The reason, by the way, we do not know what this says is the leadership on the other side--this is another one of those yellow post-its. They are throwing it up on the wall just to see if it works. They are not telling us what the game plan is because they don't yet know whether it works. What they are hoping to do is to solve a major problem they have within their caucus, again, by taking from Medicare.

If you think about the fact that the Mayo Clinic, which is the model for all of us, would not even take new Medicare patients, and yet our friends on the other side of the aisle are trying to throw a whole new decade of seniors into the plan, what that means is less and less seniors are going to have access to care. That is what this means.

The other side of the aisle, I will have to say, based on history, I am surprised, but they continue, through their policies, to throw seniors under the bus.

I do not understand what has happened. This must be about a political victory and not about health care reform. What we would do is more firmly put in place, again, bad policy. The problem with Medicare today is physicians and providers are paid fees to do more work. So now what we would be doing, instead of health care reform, which is what Senator Coburn and all of us have talked about for some time, we are putting in place, in cement, something that works poorly, that the Mayo Clinic

said is damaging to them and their patients, we would be putting it in place for even more people.

I thank the Senator for his leadership. I hope to be with him all weekend discussing amendments that are important and voting on those amendments. I can't imagine a better place for all of us to be.

11:46 AM EST

John S. McCain III, R-AZ

Mr. McCAIN. I thank the Senator. May I ask the Republican leader, again, to be very clear that it is his view and that of all Republican Members that we will stay in for as long as it takes to get this issue resolved and we are prepared to vote throughout the entire weekend. If the majority leader moves to the Omnibus appropriations bills, we will have a conference report, and we will certainly have discussion about a bill that has 4,752 earmarks totaling $3.7 billion. But we should

not get off this, should we?

11:47 AM EST

Mitch McConnell, R-KY

Mr. McCONNELL. My friend is entirely correct. I can only quote the majority leader himself who said we were going to be here this weekend. We expect to be here this weekend. If he tries to leave, we will have a vote to adjourn, and I am confident every Republican will vote against adjourning. This either is or it isn't as important as the majority says it is. If it is that important, we need to be here. More importantly than being here, equally important to being here is to vote. We

tried to get a vote all day yesterday on a motion by Senator Crapo. What we heard from the other side is: We are working on a side-by-side. That is kind of parliamentary inside talk for delay. We are ready to vote. As several of our colleagues have suggested, we keep hearing about these new iterations of this bill. It reminds

me of the end of a football game, trying to throw a ``Hail Mary'' pass, just somehow, some way find a way to pass this bill. I think it important to remember what happens to most Hail Marys. They fall to the ground incomplete. You get the impression they are far less interested in the substance of the bill than just passing something.

When the President came up here last Sunday, he said: Make history. Make history? The American people are not asking us to make history by passing this bill. They don't believe it is about the President. They believe it is about the substance. We are out here prepared to talk about the substance of this measure, offer amendments, and we fully intend to do it for as long as it takes. As the Senator has suggested, if the majority leader pivots to a conference report, which he is able to do under

our process, we will spend all the time it takes to deal with the conference report.

11:49 AM EST

John S. McCain III, R-AZ

Mr. McCAIN. May I point out, again, as the Senator from Maine, Ms. Snowe, pointed out--and it was highlighted in the Wall Street Journal--no major reform in the modern history of this Senate has been enacted without bipartisan support, a reason for us to go back to the drawing board.

I know the Senator from Texas has been heavily involved in the issue of [Page: S12856]

hospitalization and the American Hospital Association's reaction to what appears to be an expansion of Medicare.

11:49 AM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. I thank the Senator from Arizona. I am pleased our leader is standing strong to say nothing should take precedence over our handling of this bill and making sure it is done right. That is what the Republicans are trying to do, to make sure this is done right. We talked about the Medicare expansion that is in the purported bill that we have not seen yet but that Democrats appear to be putting forward. We have also been spending the week talking about $ 1/2 trillion in cuts to

Medicare. Now we are talking about possibly expanding Medicare at the same time we are cutting $ 1/2 trillion out of the care Medicare patients would get.

I have an amendment. It would stop the $135 billion in cuts in the underlying bill to hospitals, cutting hospital reimbursements for Medicare patients. That is my amendment. Now we are talking about possibly expanding Medicare. The American Hospital Association put out an alarm, an action alert. It says:

Medicare pays hospitals 91 cents for every dollar of care provided. Medicaid pays just 88 cents for each dollar of care provided.

Medicaid, which may also be expanded, and the cuts in Medicare, which we are talking about possibly expanding, would go forward. Which means what? The hospital association knows what. ``What'' is rural hospitals that care for Medicare patients are going to go under. What kind of services can be provided if there is no hospital in the whole county that can provide care to these senior citizens? I ask the Senator from Arizona, who has been such a leader on this, we are going to cut $135 billion

out of Medicare coverage for hospitals. We are going to now talk about expanding the coverage of more Medicare patients, which will mean we will cut more from the hospitals than is even envisioned in the underlying bill. Help me understand this, Senator. How would you suggest that passes the commonsense test?

11:52 AM EST

John S. McCain III, R-AZ

Mr. McCAIN. May I say, having stood fifth from the bottom of my class at the Naval Academy, I cannot explain it. But perhaps before I turn to the Senator from South Dakota, maybe we could get a response from Dr. Coburn to that question.

11:52 AM EST

Tom Coburn, R-OK

Mr. COBURN. They are going to cut care. We are going to have more complications and worse outcomes. That is what is going to happen. Rather than changing the payment formula, which is what we should do, by rewarding quality and rewarding outcome, rather than rewarding flipping a switch, that is what needs to happen. We are going to take the same antiquated system, we are going to cut $465 billion from it, and then we are going to add, as my colleague from Tennessee said, it is 34 million people,

if they include everybody from 55 to 64 in the same program.

11:53 AM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. Is the Senator saying that whether you were at the top of your class, such as the Senator from Oklahoma or the Senator from Tennessee or the Senator from South Dakota, or the bottom of your class, as the Senator from Arizona has admitted he held down the fort, regardless of where you are on the quotient of where you stood in your class, you know what the bottom line is.

11:53 AM EST

Tom Coburn, R-OK

Mr. COBURN. Care is going to be impacted. Here is a survey of 90,000 physicians. That is more than the active practicing physicians of the AMA. More than 8 in 10 physicians surveyed think payment reform is best to improve the system for all Americans. Only 5 percent of the physicians surveyed rated the current government health care program as effective, 5 percent.

11:54 AM EST

John Thune, R-SD

Mr. THUNE. I ask my colleague from Arizona if this is what happens when you end up with one-party rule, one party trying to go this on their own. This seems to be a model of dysfunction in how to come up with a solution to one of the major problems facing the American people, dysfunctional by Washington's twisted standards. They seem to be desperately throwing things at the wall, hoping something will stick. Surely, there has to be a better suggestion coming from the other side than to expand

a program that is destined to be bankrupt in the year 2017. It is the equivalent of a ship that is sinking. It is similar to the Titanic. You will put more people on the deck of a sinking ship. Clearly, the overall objective, at least among some, and I think some have been very transparent about it--someone quoted earlier today the Congressman from New York in the other body who said this is the mother of all public options. He went on to say:

Never mind the camel's nose. We have his head and neck in the tent on the way to a single-payer system.

Obviously, there are people here who want to see a single-payer system, who want to see government-run health

care. We don't happen to believe that is the best solution for America's health care system, but the amazing thing about this proposal is, it takes a program that is destined to be bankrupt in a few short years, cuts $1 trillion out of it over 10 years, when fully implemented, and then adds millions of new people into that program. It is hard to come up with any rational explanation for what is going on here, other than that they are left with, in desperation, trying to throw something at the

wall, hoping it will stick. Is this typically what happens around here when one party tries to go on its own on something that is this consequential to America? One-sixth of our economy is represented by health care.

Essentially, what they are saying is, we want to expand that part of the economy that isn't working today, that is headed for bankruptcy, that underreimburses doctors and hospitals, put more money into that failed system, exacerbate the cost-shift problem by forcing people in the private-payer market to pay higher premiums. It seems like this creates all sorts of problems that make matters even worse.

I appreciate my colleague's leadership on this issue of pointing out what inevitably is going to happen. When you have the Washington Post editorial this morning even acknowledging the terrible problems this creates for health care and the way this is being conducted, sausage being made here in Washington, DC. Even by Washington's twisted standards, this process has become so dysfunctional, I don't know how they can recover.

One thing they could do is decide to sit down with Republicans and actually figure out some things we could do that would drive health care costs down, rather than making them go up.

11:57 AM EST

John S. McCain III, R-AZ

Mr. McCAIN. I thank the Senator from South Dakota. I have to say I have never, in the years I have been here, seen a process such as this. It is incredibly bizarre that after a year, after hundreds of hours in the HELP Committee, after how many hundreds of hours in the Finance Committee, products are here on our desks. Yet there is a meeting yesterday of the Democrats. They come out, and they don't know what the proposal is either. Apparently, there is only one Senator who knows what

the proposal is and that is the majority leader. Also, then it is OK to go home for the weekend. I honestly say to my colleague from South Dakota, I have never seen anything quite like this, especially when we are talking about one-sixth of the gross national product. Of course, already from what they know, the hospitals and doctors and others have come out in strong opposition to expansion of a program, as the Senator points out, that is going broke.

11:58 AM EST

Mitch McConnell, R-KY

Mr. McCONNELL. I say to my friend from Arizona, he made reference today to the senior Senator from Maine and her very insightful and thoughtful and correct speech a couple weeks ago about how an issue of this magnitude was historically dealt with here and how it was not being dealt with this way. She pointed out, major domestic legislation in modern U.S. history was, without exception, done on a largely bipartisan basis. That whole process, as the Senator from Maine pointed out, has

been entirely missing, as we have moved along toward developing this 2,074-page monstrosity of a bill, designed to entirely restructure one-sixth of our economy on a totally partisan basis.

I don't think that is what the American people had in mind. They want us here, as we have all indicated, debating, discussing, and amending this proposal. That is what we would like to do for as long as it takes.

11:59 AM EST

Lamar Alexander, R-TN

Mr. ALEXANDER. Mr. President, if the Republican leader will think back [Page: S12857]

when he first came to the Senate as a young aide in 1969, the year before I was a young aide in the Senate,

I can remember President Johnson, a Democrat, and Everett Dirksen, the Republican leader, dealing with the open housing legislation in 1968, a very controversial bill. How did they deal with it? The Democratic President had the bill literally written in the office of the Republican leader, with staff members and Senators trooping in and out. The country looked to Washington and said: Well, the Republican leader and the Democratic President both think it is important. They are trying to work it

out. In the end, they voted for cloture. In the end, they got the bill.

12:00 PM EST

Mitch McConnell, R-KY

Mr. McCONNELL. My friend from Tennessee is entirely correct. Right before we got here--right before we got here--in 1964 and 1965, the Democrats had overwhelming majorities, as they do now, and the civil rights bill of 1964 and the voting rights bill of 1965 passed on an overwhelming bipartisan basis. The leader of the Republicans, Everett Dirksen, was every bit as much involved in that, if not more involved in it, than even the Democrats. Republicans supported it. On a percentage basis,

a greater number----

12:01 PM EST

Mitch McConnell, R-KY

Mr. McCONNELL. An even greater percentage of Republicans ended up supporting the civil rights bills of 1964 and 1965 than Democrats. But it was a truly bipartisan landscape for our country--a landmark, important. It was widely accepted by the American people because of the broad bipartisan support it enjoyed. That is what has been lacking here from the beginning.

12:01 PM EST

Mitch McConnell, R-KY

Mr. McCONNELL. An even greater percentage of Republicans ended up supporting the civil rights bills of 1964 and 1965 than Democrats. But it was a truly bipartisan landscape for our country--a landmark, important. It was widely accepted by the American people because of the broad bipartisan support it enjoyed. That is what has been lacking here from the beginning.

12:01 PM EST

John S. McCain III, R-AZ

Mr. McCAIN. Mr. President, I ask unanimous consent that a list of physician organizations that oppose this act, representing nearly one-half million physicians, be printed in the Record.

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

Physician Organizations That Oppose Senate's Patient Protection and Affordable Care Act

To date over 40 state, county and national medical societies, representing nearly one-half million physicians, have stated their public opposition to the Senate healthcare overhaul bill, the Patient Protection and Affordable Care Act (H.R. 3590). It is time for Congress to slow down, take a step back, and change the direction of current reform efforts to ensure that it is done right!

NATIONAL MEDICAL ASSOCIATIONS

American Academy of Cosmetic Surgery, American Academy of Dermatology Association, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology Head and Neck Surgery, American Association of Neurological Surgeons, American Association of Orthopaedic Surgeons, American College of Obstetricians and Gynecologists, American College of Osteopathic Surgeons, American College of Surgeons, American Osteopathic Academy of Orthopaedics, American Society for Metabolic

& Bariatric Surgery, American Society of Anesthesiologists, American Society of Breast Surgeons, American Society of Cataract and Refractive Surgery, American Society of Colon and Rectal Surgeons, American Society of General Surgeons, American Society of Plastic Surgeons, American Urological Association, Association of American Physicians and

Surgeons, Coalition of State Rheumatology Organizations, Congress of Neurological Surgeons, Heart Rhythm Society, National Association of Spine Specialists, Society for Vascular Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society for Cardiovascular Angiography and Interventions, Society of Gynecologic Oncologists.

STATE AND COUNTY MEDICAL ASSOCIATIONS

Medical Association of the State of Alabama, California Medical Association, Medical Society of Delaware, Medical Society of the District of Columbia, Florida Medical Association, Medical Association of Georgia, Kansas Medical Association, Louisiana State Medical Society, Missouri State Medical Association, Nebraska Medical Association, Medical Society of New Jersey, Ohio State Medical Association, South Carolina Medical Association, Texas Medical Association, Westchester (NY) County Medical

Society.

--

12:02 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, I must say, some of the debate on the other side of the aisle is a little surreal. They say they want to move ahead, and then they refuse to enter into any reasonable time agreement to consider a necessary appropriations measure. I find it very impressive--I am very impressed--how the minority can maintain both that they want to move more quickly and not move at all--surreal.

I wish to also explain, despite what the claims on the other side are, that we have attempted mightily to work together on both sides of the aisle to get health care reform passed. They claim it is all one-party rule. Nothing could be further from the truth. Let me explain why.

When we began this effort over a year ago, we had many hearings. In fact, last year I think I had 10 hearings in the Finance Committee on health care reform to educate ourselves because we knew health care reform was going to be a big issue in the year 2009. So, in 2008, we had many Finance Committee hearings on all different aspects of health care. How does our system work? How do parts fit together? How does this all work? We were there to educate ourselves. We did not have a political ax to

grind. We were not trying to make points. We got the experts in and asked: How does it work? How do the different parts of our system work together?

Then we issued a white paper. It was in November of last year. It was basically a call to action, which is what we called it. It was about an 80-, 90-page paper. It was a statement of the health care options: delivery system reforms, various ways to get increased health [Page: S12859]

care coverage, various ways to help with insurance market reform--lots of different provisions.

I might say, casting all modesty to the wind, that white paper, that call to action, back in November of 2008, is probably the basis and springboard from which most of the ideas we have been debating, both in the House and in the Senate and on both sides of the aisle, come from. They basically come from there.

I might say, it has all been totally transparent. It is all on the Internet. It has all been open for everybody. Republicans and Democrats participated fully. First was the Library of Congress all-day session, both sides fully--that was over a year ago.

Since then, in 2009, this year, we have had a countless number--in the Finance Committee--of what we call roundtables, a countless number of walk-throughs, a countless number of hearings on all the various aspects of health care reform--bipartisan, fully open.

Also, I instituted something else here; that is, we got to the point where we finally got to the markup, and we put the marked up bill on the Internet, again, so everybody sees everything. We also made sure all amendments were on the Internet and fully debated by both sides--totally open, totally transparent. I prided myself on doing that.

In fact, one very well-known health journalist who works for a very major paper walked up to me and said: Max, is this a new way of doing things? Maybe you started something, Max, in being so transparent and working so much together. Do you think this is the model for the future? I said: I don't know. But it impressed him how much we tried to work together and did work together with people on both sides of the aisle.

I cannot think of a more comprehensive, more transparent, more bipartisan effort than this.

So what happened? Well, the HELP Committee had their version passed. So we in the Finance Committee worked on ours. To move the ball, I shifted it to another group--we called it the Gang of 6; three Republicans, three Democrats--to try to get a core provision together that we could take to the full committee.

We had a countless number of meetings. I have forgotten the number of days we met--I think in the nature of 30 or 40 meetings and close to 100 hours and with Republicans and Democrats to and fro. Guess what. It was very, very constructive. I wish the American public could have been an eye on the wall at those meetings and watched these meetings proceed. There were very good questions asked by Senators on both sides, Republicans and Democrats.

I highly compliment my friend from Wyoming, Senator Enzi. I highly compliment my friend from Maine, Senator Snowe. I highly compliment everybody who was there. They asked very good questions--and Senator Grassley, of course, he is the ranking member of the Finance Committee; and the same on the Democratic side--in an effort to try to find a good, solid health care reform bill.

Well, we kept working--bipartisan--working together for days, days, hours, hours. Then, unfortunately, we got to the point where--I am just calling it as I see it; one of my failings is I am too honest about things--and the Republicans started to walk away. They pulled away from the table. They had to leave.

I ask you, why? Why did that happen? The answer--to be totally fair and above board--is because their leadership asked them to. Their leadership asked them to become disengaged from the process. I know that to be a fact. Why did their leadership ask Republicans to leave and become disengaged from the process? To be totally candid, it is because they wanted to score political points by just attacking this bill. They were not here to help be constructive, to find some bipartisan solution. They

were for a while. Then, when the rubber started to meet the road, when it came time to try to make some decisions, they left and began to attack.

I think a big, unfortunate circumstance in all this--we are going to pass health care reform. It is going to pass. It is going to do wonders for the American people. We are going to dramatically reform the health insurance market. People are going to have health insurance they do not now have. We are going to help put in place delivery system reforms. That is just a fancy term for saying changing the way we reimburse hospitals and doctors in a very positive way, so we are focusing more on quality

and less on quantity and volume. This bill is going to pass. It is going to be a very good bill when it finally does pass and people understand it.

But the unfortunate part is this: It is unfortunate, in my judgment, that the other side pursued a strategy of just saying no, just saying no, and attack, attack, attack. That is basically what we have heard here in the last several weeks, instead of coming up with a comprehensive alternative, instead of coming up with a comprehensive alternative health care reform package. Then it would have been wonderful if we had an honest-to-goodness, solid debate on the pros and cons of each side, the merits

of each side, a constructive dialog, pursuit, inquiry, focus on which portions of this should be put in the bill and which should not. But that did not happen. We did not have this constructive alternative provision presented to us. We had no provision presented to us--and by ``to us,'' I mean the American public--so we could debate here. But, rather, they just said no.

We have worked as hard as we could to be bipartisan. But to be honest and candid about it, the other side walked away. They walked away, and I think it is very unfortunate that happened.

Mr. President, I yield 5 minutes to the Senator from Massachusetts, Mr. Kirk.

12:11 PM EST

Paul G. Kirk Jr., D-MA

Mr. KIRK. Mr. President, before I say anything else, I wish to, once again, commend the Senator from Montana for his leadership on this historic piece of legislation. It is going to have an impact on people more widely and broadly than our Social Security system, and this will be as important a domestic piece of legislation as that. Every American who looks forward to their golden years knows what Social Security means.

The Senator from Montana has quite correctly mentioned how this legislation will have an impact on people's lives. I have only been in the Senate a short period of time, but I cannot tell you the numbers of constituents who have communicated with me about their situation in the Commonwealth of Massachusetts; whereas, in 2006, Massachusetts enacted health care reform, many of the aspects of that legislation are contained in the bill we are debating.

For the record, today the Boston Globe published a story indicating that more than 96 percent of the State's adult taxpayers had health insurance in 2008. This is close to universal coverage, and I am sure, before too long, we will be able to say we hit the 100-percent mark.

This is providing affordable insurance to people who otherwise would never have had it. When the Senator from Montana talked about how this bill would impact people's lives, I am going to tell you a story that was told to me by a family who had a situation. I will call them Daniel and Brenda. Those are their names.

They had been living without health insurance for years. In fact, Brenda said she could barely remember when they had last gone to the doctor because they did not have health insurance. But she learned about our Health Care for All on the Helpline that is in existence in Massachusetts from a close friend. Soon after she contacted it, her husband was diagnosed with a serious heart condition. With the indispensable assistance of the Helpline, her family was able to enroll in coverage they could

afford.

Brenda's husband Daniel had started to feel constant fatigue. He never imagined that someday he would need to have a strong supporting device inserted in his heart. Brenda said they truly appreciated all the assistance given to them through the Helpline. But there is more.

Brenda and Daniel recently welcomed a new addition to their family. Unfortunately, their son was born with respiratory problems and had to stay in the intensive care unit for 7 days immediately after his birth. Brenda told [Page: S12860]

us she had a hard time leaving the hospital without her newborn son in her arms. But she could also take comfort in being surrounded by top medical professionals who were dedicated to caring for her son. Here is what she wrote:

Health Care for All has been such a gift to our lives. First, my husband had no idea of the seriousness of his health issue. If it wasn't for our eligibility with the [State's new health care reform] programs, we would probably have found out about his heart disease too late. And right after came the unexpected surprise of having my son in neonatal care for a week. Both of these situations were hard to go through just emotionally. We just couldn't imagine how it could have been hard financially

speaking. That's why, and for many other reasons, we are just so amazed to be Massachusetts residents and count on the tremendous support we have been receiving from the Helpline counselors.

This is just one example of countless families I have heard from in Massachusetts.

It clearly shows how important it is to pass national health care reform and enable all Americans to have the quality, affordable health care that Brenda, Daniel, and their son were able to have.

So I wanted to bring to the attention of our colleagues in the Senate a real life story of what health care reform can mean and what will be great relief for the financial and health security to American families when we enact this legislation.

I ask unanimous consent that the Boston Globe article I mentioned be printed in the Congressional Record.

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

12:16 PM EST

Bob Casey Jr., D-PA

Mr. CASEY. Mr. President, I rise this afternoon to speak on two subjects as part of our health care debate. The first is what happens to our children. We have had an opportunity over the last couple of weeks, and will continue to have a full debate about so many aspects of this legislation. When it comes to the question of what happens to our children--and I speak of in this case poor children and special needs children--I have said from the beginning of this debate and even before the debate

began many months ago that the standard ought to be four words: No child worse off. It is a very simple standard. I think it is a standard we can meet and I believe it is a standard we should meet for the most vulnerable children in America--those who happen to be poor or suffer from or are burdened by special needs, both the impact on that child, that individual life, as well as the impact on his or her family.

The good news is that over the last couple of years, we have gotten it right with regard to children's health insurance, a program I am proud to say had a good bit of its foundation and its origins in Pennsylvania. It became a national effort in 1997 when President Clinton signed the legislation. We have had, frankly, a lot of bipartisan support for this program over many years, although we had less bipartisan support when it was reauthorized this past year when President Obama signed it into

law.

Here is what it means. The Children's Health Insurance Program, known by the acronym CHIP, has provided millions of children with health insurance coverage they would never have absent that program. We don't know the exact number as we speak today, but we are at a point now where we have in the range of 7 million or more children covered. Over the next couple of years, we will have 14 million American children covered. That is an enormous achievement, but more important than any kind of legislative

achievement, it will mean that 14 million children or their families won't have to worry about whether they get quality health care.

In the first year of a child's life, the experts tell us they should get to the doctor at least six times for a so-called well child visit. A Children's Health Insurance Program in America ensures these children receive many benefits, including dental, immunization, and preventive care. But the fact I always point to is that for six times in the first year of a child's life, he or she will get to see a doctor because they are in the CHIP program, and that has an enormous impact for that one life,

for that one family, but I would argue--and I think the evidence is irrefutable--it will have a positive impact on all of our lives, because of the impact of millions of children getting that kind of help in the early years of their life.

We know this program works. The Children's Health Insurance Program works. That is an understatement. It works well.

What we are worried about, though--what I am worried about--is that there have been people in Washington who have advocated putting the Children's Health Insurance Program in the new insurance exchange. The exchange is going to be a very positive development for our health care system and for adults, but I would argue strongly and vigorously that it is not good for kids. So we are going to be debating that maybe in a couple of years, but we want to make sure as we debate that question that we

have as much evidence to show that and put forth the reasons why the Children's Health Insurance Program should not--should not--be part of the exchange.

In terms of why we say that, the research on this question is indisputable. The director of CBO, the Congressional Budget Office, Doug Elmendorf--and we know a lot about CBO. They make determinations about this bill and about costs. CBO has said that children will have better benefits and more cost savings in CHIP than they will in the exchange.

Yesterday, an organization many people here know as First Focus released a white paper which compared Children's Health Insurance coverage versus coverage those children would get in the exchange. Here are some of the results of that research paper.

No. 1, the question of children's coverage from 2009 through 2013:

If health reform were to repeal CHIP in 2013, States would not invest in improving coverage for those children when those very efforts will be dismantled just a few years later.

It stands to reason. Why would a State go forward to strengthen a program they know is going to change as [Page: S12861]

a matter of Federal policy a couple of years later?

The increased coverage of 4 million children that is expected from passing Children's Health Insurance legislation earlier this year would be largely lost.

That whole effort that took years--years--and two Presidential vetoes, before President Obama became President, to get to continue the CHIP program and expand.

No. 2, First Focus, another one of their conclusions:

Children in most State Children's Health Insurance Plans receive coverage for all approved vaccinations, dental care and well-baby and well-child visits. This level of benefits stand in contrast to private plans, like those in the exchanges.

What is good for an adult may not be good for a child. Children are not small adults as so many advocates have said over and over. But the level of benefits that children get in CHIP stands in contrast to the provisions in private plans such as those in the exchange which often impose limits that are particularly harmful to low-income children and children with special needs.

That is conclusion No. 2 by First Focus.

Conclusion No. 3 is the following:

An actuarial study--

A recent study--

finds that children moved from CHIP to the exchange plans would dramatically increase out-of-pocket costs for those kids. Out-of-pocket costs for a child living in a family earning 225 percent of the Federal poverty level would increase by 1,100 percent--

not 1,100 dollars, but 1,100 percent--

if the Senate were to join the House in repealing Children's Health Insurance Program.

This is another reason why it is a bad idea. We want to make sure this program is strong. We know it works. We also don't want to exponentially, radically increase out-of-pocket costs.

Conclusion No. 4, premiums:

Because Children's Health Insurance keeps premiums and other out-of-pocket costs for children at low levels, the cost of health insurance exchange plans will be many times higher than that, even for just covering children.

An increase in premiums will lead to a number of children currently enrolled in CHIP to lose coverage--to lose coverage--according to the Congressional Budget Office.

No. 5, reason to do the right thing, access to pediatric providers:

Children's Health Insurance plans specifically focus on the unique health care needs of children, which is not the case in the proposed exchanges. The recent Children's Health Insurance reauthorization--

For those who watch these Senate debates, we use words such as ``reauthorization.'' My simple way of saying that is we do it again. We take an existing program, evaluate it, see if it is working, and keep doing it. That is what reauthorization is all about. But we did that earlier in the year, thank goodness, for children's health insurance.

The recent effort to continue CHIP included improvements to pediatric-specific quality measures that may get lost in the conversion of CHIP as a stand-alone program put into the exchange. We don't want to do that for kids. We want to make sure every pediatric-specific quality measure that we have in place now, all of these years later, is maintained. We don't want to injure that. We don't want to cut that back.

Finally, in terms of another item on the list of reasons, guarantee to care:

In exchange plans, some children currently eligible for the Children's Health Insurance Program may be barred--may be barred--from receiving subsidies for coverage due to the cost of employer-sponsored plans.

Once again, what is good for an adult may not be good for our kids. We have to watch this.

Moreover, the families that are eligible for subsidies and coverage through exchange plans may find coverage so unaffordable that they are left without insurance entirely.

So we don't want to send a family into the exchange who is trying to get insurance for themselves and their kids and find out that they can't cover their kids because it costs too much. We have an existing, stand-alone Children's Health Insurance Program that we know works.

This amendment I filed for this debate on health care--the children's health insurance amendment to guarantee that we keep it strong, strengthen it and continue it--the Children's Health Insurance Program has the support of over 500 national and State organizations that focus on children's health, health policy generally, social workers, children's mental health advocates, school educators, health plans in particular, faith groups across the country, and more. These 500 national and State organizations

speak volumes about why this amendment is so important. We must strengthen and ensure the continuity of CHIP in this health care reform bill. That is what our amendment is all about.

Mr. President, I ask unanimous consent to hae printed in the Record a letter addressed to me, dated December 9, from more than 500 organizations.

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

December 9, 2009.

Hon. ROBERT P. CASEY, JR.,

U.S. Senate,

Washington, DC.

DEAR SENATOR CASEY: As organizations committed to ensuring that all of our nation's children get the health coverage they need and deserve, we are writing to thank you for your commitment to making children an important priority by filing Amendment #2790 to the Patient Protection and Affordable Care Act (H.R. 3590). Your amendment builds on the provisions of the underlying bill, continuing to protect and improve the country's successful Children's Health Insurance Program (CHIP) and ensuring

that no child ends up worse off as a result of health reform. We applaud your leadership.

America's children have a lot at stake in health reform. More than eight million children remain uninsured, and more are losing employer-sponsored coverage daily. Families are just one playground accident away from medical bankruptcy. Each day a child is uninsured is a lost opportunity to strengthen our next generation, America's future. Your amendment goes a long way toward protecting and improving coverage for millions of children in low-income working families across the nation by:

Providing full funding for CHIP through 2019;

Maintaining current CHIP eligibility through 2013, and setting a floor for income eligibility for children in all states at 250 percent of poverty ($55,125 for a family of four) beginning in 2014;

Streamlining enrollment procedures making it easier for children to get coverage and keep it;

Ensuring that coverage for children remains affordable;

Guaranteeing all children in CHIP the comprehensive care they need from head to toe; and

Requiring an HHS report in 2016 that will compare coverage for children in CHIP with coverage for children in the new Health Insurance Exchange and if coverage (including benefits, cost-sharing, premiums, and other features) is comparable or better, children can be transitioned from CHIP into the Exchange in 2019.

Our nation has made great strides over the last decade in securing health coverage for low-income children of working families. We must now seize this historic opportunity to build on the success of prior efforts and the bipartisan CHIP program, and ensure that children will be better off, not worse off, as a result of health reform. Your amendment will do just that.

We offer our strong support for your CHIP Amendment (#2790). We stand ready to work with you and your Senate colleagues to achieve our common goal of reforming our nation's health care system and ensuring that all children, indeed everyone in America, have access to the health coverage they need and deserve.

Sincerely,

National Organizations.

12:28 PM EST

Bob Casey Jr., D-PA

Mr. CASEY. I will move quickly.

The second part of my remarks focuses on pregnant and parenting teens and women. We have an amendment that focuses on a group of pregnant women in America that we are not doing enough about. Neither party, in my judgment, is doing enough about them, enough about help for those women. I will come back to this maybe later today. But it is vitally important, whether we are Democrats, Republicans, or Independents, but as Americans, that we give integrity and meaning to the sentiment that is often

expressed that we care about pregnant women, that we care about a teen mother who decides to bear a child, that we are going to help her through if she makes that decision.

If a woman on a college campus becomes pregnant and decides to have that child, we want to give her all the help we can. If a woman is a victim of domestic violence or other sexual violence or stalking, and through all of the horrific nightmare of that violence, [Page: S12862]

she determines that she is going to go through with a pregnancy and have a child, that we help her in the midst of that darkness, that we give her some light in that darkness. What we don't

want to have is women who are deciding to bear a child who feel all alone, who have to walk that path all by themselves.

That is what this amendment is about. I will return to it later today.

With that, Mr. President, I yield the floor.

12:30 PM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. Mr. President, I rise today to talk about the taxes that are in this bill--taxes that are imposed in 3 weeks--not 3 weeks from 6 months from now, not 3 weeks from 2014, but 3 weeks from now, January 1, 2010. Three weeks from now, on January 1, 2010, we are going to see the taxes in this bill start.

I know people are saying: Wait a minute. This bill doesn't take effect until 2014. That is what we have been talking about. It is what we have been hearing. But, no, the tax part starts in 3 weeks--January of 2010.

I have partnered with Senator Thune, who has been working on this problem, and Senator Grassley and Senator Hatch and many others who will be speaking today.

I see my colleagues from Florida, Nebraska, Wyoming, as well as my colleague, Senator Crapo, from Idaho, all of whom--Senator Crapo, of course, is waiting for a vote on his amendment, which would stop the taxes on everyone who makes $200,000 or less.

We are talking about the taxes because it is such a huge issue. Here is what is going to happen with the taxes in the bill that start in 3 weeks. Americans will pay more in insurance premiums. Americans will pay more in prescription drugs. Americans will pay more for medical equipment. Let's walk through those taxes.

In a few weeks, in January of 2010, this will begin: $22 billion in taxes on prescription drug manufacturers; $19 billion in taxes on medical device manufacturers; $60 billion in taxes on insurance companies. That is around $100 billion, which starts in 3 weeks. Then, in 2013, the taxes on high-benefit plans take effect. That is $150 billion in taxes. So for every union member who has a good plan that gives them the benefits they have negotiated for over the years, those taxes come in at 40 percent

of the benefits. That starts in 2013.

You are still saying: Wait a minute. I thought the bill started in 2014--and that is right. But the taxes start in 3 weeks, and they keep right on going. In 2013, the high-benefit plans start getting a 40-percent excise tax.

Mr. President, when the $100 billion in taxes start in 3 weeks on drug manufacturers, medical device manufacturers, and insurance companies, what happens? Premiums go up immediately, prescription drug prices go up immediately, and the medical devices--hearing aids and things people need for medical treatments--go up immediately.

We have been talking about health care reform and the need for it, and the need to make history. Yet the reform we are going to see go into effect right away is huge tax increases. I am here with many colleagues, who are so concerned about this for their constituents.

I ask the Senator from Wyoming, who is one of the two physicians in the Senate--he has been so active in this area. When the taxes go up on our insurance premiums, our prescription drugs, and our medical equipment, I ask the Senator from Wyoming, as a physician, what does he think is going to happen to the cost of health care.

12:34 PM EST

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

Mr. BARRASSO. Mr. President, I have great concern about the cost of health care for American families. We see it with our seniors certainly, as they will be seeing Medicare cuts. In this bill, there is $464 billion in Medicare cuts, but there are taxes that are going to go up, which will impact all of the people in this country.

I remember a promise the President made. He said his plan would not raise taxes one penny. He went on to say: not your income taxes, payroll taxes, capital gains taxes--any of your taxes.

We are seeing that taxes are going up, and in a way that is basically--you hate to say it, but it is a gimmick in this bill, where they are going to collect taxes for 10 years but only give benefits for 6, and it is the last 6 years.

As my colleague from Texas said, they are going to start collecting taxes--today is December 10--on the 31st of this month, 21 days from now, but the services would not be given for 4 years. That is how they get the number under $1 trillion, and it is at a time when the President makes a statement that this would not add a penny or a dime to the deficit. Eighty percent of the American people don't believe it because they know what is in front of them. They know what it is like to live their own

lives. Is this what the Senator from Texas is seeing as well?

12:36 PM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. The President said, in his address to the joint session of Congress, that this bill had to come in at a cost of no more than $900 billion. So the CBO scored the bill at $847 billion. But the Senator from Wyoming has brought up a point that is because they started scoring the bill in 2010, but the services in the bill don't start until 2014.

If you take the years from 2010 to 2019, it probably comes in at $847 billion. But if you start when the spending starts and go to 2023, the cost is $2.5 trillion.

I just ask the Senator from Nebraska if his constituents are hearing of this $2.5 trillion cost, with one-quarter of it coming from Medicare cuts and about one-quarter of it in new taxes that start next week. What does the Senator from Nebraska say about this?

12:37 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. Mr. President, the citizens from Nebraska are absolutely on to this gimmick. They know it is a gimmick. Here is what I tell the Senator from Texas: I had an opportunity, as she knows, to be their Governor for 6 years. Every year, I had to walk in front of the unicameral--our one-house system--and give a state of the State address and lay out a budget plan. If I had walked into that chamber with a budget plan with these kinds of gimmicks, they would have been rolling in the aisles

laughing at me, literally. They would have been rolling in the aisles.

I always did a State fly-around, where I visited the communities and talked about my budget vision and my legislative package, et cetera. The people of Nebraska would have run me out of the State had I tried to balance the State budget based upon this kind of gimmicky approach.

The Senator has absolutely hit the nail on the head. What we have here is a situation where those who wrote this bill--as we all know, it was written behind closed doors and nobody knew what the bill was until a few weeks ago--but those who wrote the bill said: Oh my goodness, the President has said we have to bring this bill in under $900 billion. That is what he said. How are we going to get that accomplished? So they used gimmicks. They uploaded the bill, front-end loaded the bill on the revenues,

so that starts right away. Then the benefits don't start for 3 or 4 years. So it is magic; we have made the bill come in under $900 billion.

Let me offer this thought: Who loses on this crazy accounting gimmick? Do you know who loses? The constituents we represent in the United States--not just in Nebraska. They are going to pay the taxes. They are not going to see the benefits. It is like buying a car and paying on it for 4 years but not getting the car for 4 years. They are going to pay on it.

Sadly, and most concerning to me, is that this gimmickry is going to be passed on to the next generation because, when it doesn't work, somebody has to pick up the bill. The full cost of this bill, we have come to recognize, is $2.5 trillion. This bill doesn't fit together. It doesn't pass the smell test, as we say back home in Nebraska.

My hope is that sanity will revisit what we are doing and people will say: Time out. We can't ask the American people to go along with this. We have to call a timeout and get this right.

12:41 PM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. I thank the Senator from Nebraska. I think having been a former Governor, his view is especially important. What we have heard through the grapevine--we haven't seen any new proposals, but we heard there is going to be an expansion of Medicare and an expansion of Medicaid. Medicaid, in particular, is going [Page: S12863]

to be very costly to States because they have a matching requirement for Medicaid. Many Governors are concerned about that.

I know the former Governor of Nebraska, in his background, realizes that is one of the biggest issues in a State's budget.

I know the Senator from Florida also has experience

with being in a Governor's office, being a chief of staff for a Governor. He has been very active, especially because the population of Florida has a very high rate of senior citizens. The cuts in Medicare in the bill are huge. He is on the Senate floor. I am just wondering, when we are looking at the cuts in Medicare and the huge taxes, how that will impact the State of Florida, and how he thinks we are going to have to deal with that.

12:42 PM EST

George LeMieux, R-FL

Mr. LeMIEUX. Mr. President, I thank the Senator from Texas. This is budget gimmickry. As the Senator from Texas said, as a former chief of staff who worked on trying to balance the budget because our constitution in Florida requires that, we try to figure out how much revenue we have and how much we can spend. If there were not enough revenues, we either had to cut spending or find a new source of revenues. We could not engage in this budget gimmickry.

If I may borrow an analogy from my friend from Nebraska, this is like paying for a car for 4 years before you even get to drive it. Imagine you are going to make a substantial purchase--a house or car--and they show you the house, and they say here is your mortgage payment, and you will live in the house for 10 years, but you will start paying for it today. But you can't move in until 2014. That is what this bill does.

In order to make this ``budget neutral,'' we steal $ 1/2 trillion from Medicare--health care for seniors, which seniors have paid into--and we raise taxes, which is going to increase, not decrease, the cost of insurance. When we tax pharmaceutical companies and tax the providers of medical devices, what happens? They pass those costs right along to the citizens. Not only are we stealing from Medicare, not only are we raising taxes, which will be passed on to the citizens, now we are going to

tell the States we are going to increase Medicaid.

We are hearing about this secret deal that has been put together behind closed doors. My friends are in the dark, and a lot of Democrats don't know what is going on either. They are trying to figure out what the deal is. The deal will put more of a burden on the States.

I know my friend from Nebraska knows this, being a former Governor. The American people need to know, when you increase Medicaid, the States pay the vast majority of that; and because they have to balance their budget, they will have to cut something else. So they are going to have to cut teachers or law enforcement. So we steal from seniors, steal from the States, raise taxes, and we don't cut the cost of health care for most Americans.

I am new to this Chamber, and perhaps my friend from Idaho can help me understand this. It doesn't make a lot of sense as to how we should proceed with health care reform.

12:45 PM EST

Mike Crapo, R-ID

Mr. CRAPO. No, it does not. I appreciate the comments of my colleague from Florida, all my colleagues on the Senate floor today.

As the Senator from Texas indicated, one of the items of business before us today is my motion to commit this bill to the Finance Committee to take out the taxes that the President pledged would not be in there. The President pledged that no one who makes less than $250,000 as a family or $200,000 as an individual will pay any taxes under this bill. Yet in the very first 10 years, there is almost $500 billion of those taxes, a huge portion of which falls on people who are in that category.

As has been indicated, the real implementation of the bill on the spending side does not happen until 2014. If you count the amount of taxes that start when the spending starts, it is about $1.2 trillion of new taxes. Really, the only thing that is transparent--because this was all crafted behind closed doors--the only thing that is transparent is the gimmick.

The President said, as the Senator from Texas pointed out, that he would not let a bill come across his desk and get a signature if it spent more than $900 billion. First of all, you have to say: Wow, why do we need almost $1 trillion of new spending? But when they went behind closed doors and came up with this bill, it turns out it cost around $2 trillion or $2.5 trillion.

How did they make it meet the $900 billion test? They just said: Look, let's delay its implementation for long enough that the number comes out to under $900 billion. That happened to be the year 2014. So if you don't count the first 4 years and only count 6 of the 10, then in this budget window we are working in you can get your number. It is just remarkable.

Before I ask the Senator from South Dakota about his perspective, because I know he is working with the Senator from Texas on an amendment to try to correct this gimmick, I would like to respond to one quick point I know our opposition on the other side has continued to make, and that is they actually say there are no tax increases in the bill.

How do they say that? Here is the way they say it. There are subsidies in the bill that are provided to people with low income who do not have adequate access to insurance. Those subsidies total about $400 billion in the bill in the first 10 years, which is really only 6. They count those subsidies as a tax cut. The technical term given to them is a ``refundable tax credit,'' although $300 billion of those subsidies do not go to taxpayers. The people who receive them do not have a tax liability.

But then they offset those subsidies against the taxes the rest of America will pay and say, therefore, there are no taxes in the bill.

I think that is another form of gimmickry. I ask my colleague from South Dakota what his perspective is on the types of gimmicks we are seeing and whether the American people should insist that these kinds of things be removed from the bill.

12:48 PM EST

John Thune, R-SD

Mr. THUNE. I say to my colleague from Idaho that I support his motion. I hope we get a chance to vote on it. I know right now they are scrambling to find an alternative to put up so they can have something on which to give their side political cover because they know the reason they are trying so hard is because they know this raises taxes. To say with a straight face this does not raise taxes--the American people get this. I think the gig is up. They figured out there are huge Medicare cuts

in this bill, huge tax increases in this bill. And as the Senator from Idaho pointed out, when they say these refundable tax credits are going to go back in the form of premium subsidies and there are not that many people who are going to pay, as he pointed out, 73 percent of the people who will get those premium subsidies are people who do not have an income tax liability already. Therefore, it is hard to say you are going to reduce taxes on somebody who does not have an income tax liability.

More important than that, there are still 42 million Americans with incomes under $200,000 a year, according to the Joint Tax Committee, who are going to see their taxes go up under this bill. So you literally have millions and millions of Americans under $200,000 a year. And as the Senator from Idaho mentioned, the President's promise was he would not raise taxes on anybody earning under $250,000 a year. This flatly contradicts that, flatly violates that pledge. I cannot fathom anybody coming

here with a straight face and saying: Oh, yes, this doesn't raise taxes. Of course it raises taxes.

What the Senator from Texas and I intend to do on our motion--and I hope we have a chance to vote on it and the Senator's motion--we will go back to the committee and figure this out. We want to offer a motion that we think makes sense because it aligns and synchronizes the dates of all this.

What has happened here, I would say, in a very deceptive way, is they understated the costs of the bill. My colleagues on the floor already alluded to this. They tried to get it under $1 trillion, and in attempt to get it under $1 trillion, they had to come up with budget gimmicks.

To illustrate that with a bar chart, we can see in the first 10 years of this bill--starting today and going to 2019--the spending in the early years does not show up much. That is because most of the spending gets put off until January 1, 2014. [Page: S12864]

So if we look at that first 10-year period, the spending under the bill is less than it will be when the bill is fully implemented. When the bill is fully implemented, looking at the years 2014 to 2023, it explodes the spending in the bill from about $1 trillion over the first 10 years to $2.5 trillion over the 10 years when it is fully implemented.

The reason they were able to do that is because of this sort of smoke-and-mirrors way of enacting the tax increases immediately and delaying the spending. The American people are going to end up spending $71 billion in tax increases out of their pockets, out of the American taxpayers' pockets, about $600 per taxpayer, before they ever see a benefit under this bill.

What the Senator from Texas, Mrs. Hutchison, and I are offering is a motion that would delay the tax increases until such time as the benefits begin. That, to me, seems to be a fair way to go about making public policy.

What they have done, in an effort to obscure the overall cost of this bill, is to say that 22 days from now, we are going to raise your taxes. On January 1 of this year is when most of these taxes--the taxes on prescription drugs, taxes on medical devices, taxes on health plans--all the taxes in the bill begin to take effect January 1 of next year. For 4 years, people will be paying taxes out of their pockets. I might add, because of the taxes that are going to go on all the device manufacturers,

prescription drugs, and health plans, they will get passed on in the form of higher premiums. They are going to see tax increases and premium increases before they ever see a dollar of benefits.

It is 1,483 days until the benefits under this bill kick in. That is unfair. It is unfair to the American taxpayer, it is unfair to the American people, and it is unfair to try to obscure and mask the total cost of this bill and say we are only spending $1 trillion on this bill when we know full well when it is fully implemented, the total cost of that is $2.5 trillion.

I appreciate the discussion that is being held here in pointing out the smoke and mirrors, the sort of underhanded way to try to shield the cost of this bill but also to support the Senator from Idaho with his motion that would commit this bill and get these tax increases out of here because the one thing small businesses are saying right now is we want to invest, we want to create jobs. But you cannot raise taxes on small businesses when you want them to create jobs. That is what this bill does.

The National Federation of Independent Business, the Chamber of Commerce, the National Association of Wholesalers and Distributors--all the major business organizations--have come out opposed to this bill.

The National Federation of Independent Business in a letter yesterday said: We do not support policies that increase the cost of doing business and that raise taxes. Clearly, that is what this bill does.

Our motion is very simple; that is, it simply delays tax increases until such time as the benefits begin.

12:54 PM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. I am very pleased that the Senator from South Dakota talked about what we are trying to do because it is very simple. It is very simple. The Hutchison-Thune motion to commit says, if we do nothing else, if we do nothing else in this bill, we have to be fair and transparent with the American people; that is, we do not start the taxes, we do not start the increases in premiums, increases in prescription drug benefits, increases in medical devices until at least there is an implementation

of this insurance program that we hear is going to be offered to the American people. We have not seen it, but we are told that there is going to be an insurance program that Americans can sign up for, but they are going to be paying higher taxes and premiums and costs in health care for 4 years before they ever see it. All we are saying is, let's send this bill back to committee and fix that.

It does not--as the Senator from Nebraska said earlier--pass the smell test. It does not pass the smell test in Nebraska, Wyoming, Florida, Idaho, South Dakota, or Texas. To tax people for 4 years, to raise their costs until they basically are going to say, Give me an alternative, and the alternative is, guess what: A big government takeover of our health care system. That is like saying: I am from the Federal Government, and I am here to help you. We have heard that before.

I do not think the American people will in any way believe that this bill is fair or honest with them if we start the taxes 22 days from now, as the Senator from South Dakota has pointed out, but they do not see a program. They are going to go online and say: Oh, my premiums are going up, my prescription drugs are going up; my goodness, where is the insurance program they have been talking about? They are going to go online, but, hey, there is no program.

How can we go home--I ask any of the Senators who would like to add their perspective on this--how are you going to go home and tell your constituents that your taxes start in 22 days, and maybe in 4 years, roughly, maybe you are going to see a program, and we are from the Federal Government, and we are here to help you?

12:57 PM EST

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

Mr. BARRASSO. You cannot go home and say that with a straight face. There are many rural areas in our States. People see through all this.

There are two articles next to each other in today's New York Times. One talks about the details of the secret agreement they are working on behind closed doors. It says: ``Details Are Scanty.'' Right next to it it talks about: ``For Rural Elderly, Times Are Distinctly Harder.'' These are the people who are going to see taxes going up, these are the people who are going to see cuts in Medicare.

I want to read the first paragraph because this is from Lingle, WY, a community in my State. It talks about Norma Clark, 80. It says:

Norma Clark, 80, slipped on the ice out by the horse corral one afternoon and broke her hip in four places.

I am an orthopedic doctor. I have taken care of these over the years.

Alone, it took her three hours--

These are the kind of wonderful Americans we have--

Alone, it took her 3 hours to drag herself 40 yards back to the house through snow and mud, after she had tied her legs together with rope to stabilize the injury.

This is a person who is on Medicare, and they are going to cut $464 billion from Medicare, and they are going to use gimmicks that are going to harm our people.

I have a former Governor and a former chief of staff for a Governor's office. You know in the rural parts of your community, I say to Governor, now the Senator from Nebraska, you have people like that--hard-working people who expect honesty from a government, and they are not getting it in this bill which is going to tax for 10 years and only give services for 6.

12:58 PM EST

Mike Johanns, R-NE

Mr. JOHANNS. That is such a compelling story. I want to add something to that. When you think the policy could not get more crazy and insane, you hear about this idea that they are going to expand Medicare, which is due to be insolvent in 2017. But the tragedy of that in relating it to the story you just told us is this: That will hammer our rural hospitals. Why? Because they cannot stay open on Medicare reimbursement rates. They cannot stay open on Medicaid reimbursement rates.

This poor woman who dragged herself to try to get some care all of a sudden could be faced with the possibility that the hospital she relies on will not stay open under this health care bill.

I have been to those hospitals. I have seen the struggles they are going through with Medicaid and Medicare reimbursement. Every hospital administrator tells me the same thing: We would close our doors if we had to live on that.

So what is their solution? Expand Medicaid and Medicare. You have got to be kidding me. Who are they listening to? You know what. Take this bill out to the rural areas of Nebraska. You will get an earful.

1:00 PM EST

Bill Nelson, D-FL

Mr. NELSON of Florida. Mr. President, I ask unanimous consent that the [Page: S12865]

time for debate only be extended until 2 p.m., with the time equally divided, with Senators permitted to speak for up to 10 minutes each, with no amendments in order during this time.

1:00 PM EST

Kay Bailey Hutchison, R-TX

Mrs. HUTCHISON. Reserving the right to object, I ask the Senator from Florida, it is 10 minutes and going back and forth. It is not 30 minutes allocated per side; is that correct?

1:01 PM EST

Kit Bond, R-MO

Mr. BOND. Mr. President, small businesses are the backbone of our economy. They make up 99.7 percent of all employer firms. They employ just over half of all private sector employees. They pay 44 percent of the total U.S. private payroll. They have generated 64 percent--a majority--of the net new jobs over the past 15 years. They create more than half of the nonfarm private gross domestic product, and they hire 40 percent of all high-tech workers.

Small businesses drive this economy. They are also the sector most in need of real health reform that will reduce cost and make it easier to buy insurance. It is estimated that 26 million of the uninsured are small business owners, employees, and their dependents. That is a majority of the uninsured. They continue to struggle to be able to afford health care.

Here are two examples: Jim Henderson, president of Dynamic Sales in St. Louis, has made every adjustment in the book to continue to provide health insurance to his employees. He covered both employees and their families back in the 1980s, but he is now at a point where he can only afford to provide for his employees. He pays 70 percent, his employees 30 percent. Jim is one of the very few small businesses that right now have weathered the storm despite the economy. He wants reform that lowers

cost and helps individuals better spend their health care dollars.

Unfortunately, the Democratic health care bills we have seen so far--and I guess we haven't seen all of them--won't help Jim to continue to provide his employees health care.

Kathie and Tom Veasey own True Value Hardware in Wilmington, DE, the hometown of Vice President Biden. They employ 28 people, most of whom they consider family. They cover 100 percent of the cost for their employees and half for their families. But they have seen huge increases in premiums over the years, with a 36-percent increase just this year after an employee got sick. Each year, they are forced to shop for health insurance, but they continue to have limited choices due to an uncompetitive

market.

Unfortunately, the Democratic bills won't fix the problem or help Kathie and Tom continue to provide their employees health care.

If we really want to get out of this recession, if we really want to address the problem of affordable and accessible health insurance, then the majority party needs to take a hard look at health care reform.

First of all, we need to allow small businesses to go together and purchase health care across State lines so they have true competition and so they can lower costs. We need medical malpractice reform, which would cut $120 billion to $200 billion out of the cost of health care.

However, when we look closely, the bills we see before us do not address the real health care needs, and, in fact, by imposing more taxes--and taxes which the CBO said will be passed from health care companies down to those who are paying the private bills--not only will it make health care less affordable for these small businesses, it will force many of them to drop whatever coverage they have now.

Tax equity is extremely important. An employee of a large corporation or a union member who gets health care premiums paid for by their employer or by their union doesn't have to record them as income. Small businesses, their employees, farmers, and individual purchasers need the same benefit that the employees of large corporations and union members get.

Now, instead of proposing commonsense health care solutions for small businesses, the bills we have seen coming out of the smoke-filled rooms run by the majority leader continue to heap costly new burdens on small businesses that are trying to keep their doors open. More and more it seems small businesses are under attack, and that is what they are telling us. One of the universities that visited me this past week is trying to do something to help small businesses, and I said: What is the attitude?

They say: The attitude of small business is that they are under attack by what is being done in Congress and what is being proposed by the administration.

The 2010 budget calls for tax increases on those earning $250,000 or more. For small businesses that are taxed at their personal rate--proprietorships, partnerships, and sub S corporations--these tax increases hit the returns of those small businesses, and they are taxed at the punitive rate. Higher energy taxes on businesses in the cap-and-trade plan will put many small businesses in my part of the country out of work. New taxes and new mandates in the health care bill will be passed on.

Randy Angst of Lebanon, MO, says the following about the Senate bill:

The new taxes would eliminate roughly half of my profits. It would force me to let employees go, refrain from hiring new employees and prevent me from reinvesting in my business. The mandates would be very harmful and make it much more costly for me to operate my business.

This bill--the last bill we have seen--requires a costly $28 billion new mandate on businesses that do not offer health care. Who pays that mandate? Anybody looking for a job. If you tell businesses they have to spend big money on a mandate, they cannot spend it on hiring new workers. The mandates do nothing to reduce insurance costs, and because they are focused on full-time workers, the mandate gives companies an incentive to classify more of their workers as part time.

Gene Schwartz, with K&S Wire Products in Neosho, MO, says:

We are in a recession and I am in manufacturing. The legislation would be nothing but detrimental to us. Our workforce is already down 25 percent from last year, and if this bill goes through in its current form, the new taxes and mandates will force me to make further cuts. Also, this bill will increase my costs by further raising my already sky-high insurance premiums.

This bill also includes more paperwork which is costly for a small business. Section 9006 requires that every time a business vendor sells a service or property exceeding $600 to another business, the receiving business must report the transaction to the IRS. That is an enormous new costly paperwork burden that will hit almost every business regardless of how small.

These mandates and regulations disproportionately affect small businesses and come at a high cost. According to the SBA's own Web site, very small firms with fewer than 20 employees annually spend 45 percent more per employee than larger firms to comply with Federal regulations. These very small firms spend 4 1/2 times as much per employee to comply with environmental regulations and 67 percent more per employee on tax compliance than their larger counterparts.

The bill clearly fails to bring down the cost of health care for small businesses. It fails to bring down the cost of health care at all, but it is especially hard on small businesses that can't afford coverage under the current law.

Small business owners from my State have come to me for two decades looking for more affordable ways to make health insurance available. They want to be able to provide insurance for their people. That is why I have long been a champion of small business health care reform.

Does the majority's bill include strong reform that will allow small businesses and the self employed access to more affordable, more accessible health care? No.

Does the bill include protections for small businesses that disproportionately feel the burden of increased government mandates and taxes? No.

In fact, CBO has said that this bill will increase premiums for individuals in the non group market by 10-13 percent.

Premiums for small businesses could increase by 1 percent or be reduced by 2 percent but it is easy math. If a small business cannot afford to provide health insurance now, they will not be able to afford to do so under this bill. [Page: S12866]

According to CBO, under current law families in a small group plan today pay about $13,300. In 2016, they will pay about $19,200 if this bill becomes law.

That is the wrong direction.

Health care is already too expensive for small businesses. We need to make it cheaper. It should not cost a family $19,200 in 2016 for health insurance.

This bill continues down the path of unsustainable health care costs.

In fact that is one of the main reasons the National Federation of Independent Businesses opposes this bill. They say, ``Small businesses can't support a proposal that does not address their number 1 problem--the unsustainable cost of healthcare. With unemployment at a 26-year high and small business owners struggling to simply keep their doors open, this kind of reform is not what we need to encourage small business to thrive.''

This bill also imposes new taxes and fees, like the $6.7 billion per year tax increase on health insurance companies.

Yes, the majority wants to sock it to the insurance companies.

Well, guess what. The insurance companies are going to pass the costs along to consumers.

Small businesses cannot self-insure, they must purchase products available in the marketplace. That is why CBO has found that increased costs due to fees being passed on to the consumer will be more pronounced for small businesses. NFIB has also said this new tax will fall almost exclusively on small businesses.

This bill just does not help small businesses.

I know the argument my colleagues on the other side offer.

They say they provide a tax credit to help small businesses.

What they don't say is that this is a bait and switch.

First of all, in order to get the full credit, you cannot have more than 10 workers who get paid an average of $20,000.

After that, the credit begins to phase out for each employee you have above 10. It also phases out for each $1,000 increase in average wages above $20,000. If you have 25 employees or you pay more than an average wage of above $40,000, you don't even get the credit.

The real kicker is that the full credit is only available for 2 years after the exchange takes effect. Then that is it.

A small business will either have to offer an employee health insurance--which will really not be any cheaper than it is today--or they will have to pay a fine. Or an employee can go into the exchange as an individual where insurance will cost 10-13 percent more.

Let us examine a realistic situation using Jim from St. Louis as an example.

As I mentioned before, the small business tax credit is filled with thresholds and variations that make it of limited value for the few small businesses that are eligible to claim the credit.

The full value of the credit, which is equal to 50 percent of the business owner's costs, is available for small businesses with 10 or fewer workers that pay their employees an average annual wage of $20,000 or less. But the credit also starts to phase out as the employer adds employees or gives raises, so the entire credit is gone if the employer has 25 or more employees and pays them an average wage of $40,000 or more.

Jim has six employees and his average annual wage is about $39,000. Jim has to ask if he meets the two threshold questions before he can determine whether he gets the tax credit. He passes the first test, since he only has six employees. But Jim's credit is reduced because he has paid his employees too much in wages.

Today, Jim's health care costs are $30,540. If he qualified for the full value of the credit, his annual health care costs would be $15,270--about half of what he pays now.

But the value of his small business tax credit is directly related to wage, so the value of Jim's credit is reduced to $763 based on the formula. That is a small fraction of his health care costs and wouldn't even cover the cost of hiring an accountant to figure out how much the credit is worth.

Because Jim is already so close to the highest average wage to be eligible for any credit at all, this means if he gives his employees a well-earned and well-deserved raise, he will lose the credit altogether.

In these tough economic times, the government is encouraging small business owners like Jim to create more jobs, but if they create too many or pay people too much, then the government will reward them by taking away their small business tax credit.

And even worse, the phase-outs mean that Jim has a disincentive to hire more workers.

So this bill completely misses the mark for small businesses.

Mr. President, our small businesses are struggling. We owe more to this critical sector of our economy which is responsible for half of the private-sector jobs and employees than a bill that mandates taxes and fails to provide real health care reform.

In a recent letter to Senator Reid, the NFIB outlines how the bill will adversely affect business owners.

When evaluating healthcare reform options, small business owners ask themselves two specific questions. First, will the bill lower insurance costs? Second, will the bill increase the overall cost of doing business? If a bill increases the cost of doing business or fails to reduce insurance costs, then the bill fails to achieve their No. 1 goal--lower costs.

In both cases, the Patient Protection and Affordable Care Act (H.R. 3590) fails the small business test and, therefore, fails small business.

They further say in the letter:

Despite the inclusion of insurance market reforms in the small-group and individual marketplaces, the savings that may materialize are too small for too few and the increase in premium costs are too great for too many. Those costs, along with greater government involvement, higher taxes and new mandates that are disproportionately targeted at small business and are being used to finance H.R. 3590, create a reality that is worse than the status quo for small business.

It is worse than the status quo.

Mr. President, it is time to stop attacking small business and work on real reform. We should defeat this proposal that does not make insurance more affordable, is a massive government intrusion into health care and that will pay for new entitlement programs on the backs of our small businesses.

Let us put this debate in context. If small businesses do most of the hiring, and we are counting on them to help lead us out of the recession, why would we want to increase their costs of doing business and make it less likely they will hire new workers?

President Obama hosted a Forum on Jobs and Economic Growth last week, where he invited ideas to jump start job growth in our sluggish economy.

Now, he and the majority are considering a new plan to jump-start job growth using ``unspent'' or returned TARP funds. Have they forgotten that it is all borrowed money, and thus deficit spending, in the first place?

Let me submit that the bill before us will hurt job creation.

Before practicing medicine, doctors often take an oath, the Hippocratic Oath, where they promise to refrain from doing harm. I would like to see Congress and the President take the same oath.

How can you on the one hand legislate new taxes on businesses in the name of health reform--coupled with new energy taxes in the name of climate protection--and on the other hand ask businesses to generate new jobs? It cannot be done. Massive tax increases and job creation are mutually exclusive.

Employers who face uncertainty regarding new, oppressive taxes and mandates are not going to want to sink money into new jobs. It is that simple.

We should think about the harm we will do to small businesses through this legislation and instead work on commonsense reforms that have bipartisan support.

Mr. President, I ask unanimous consent to have printed in the Record the letter from the National Federation of Independent Businesses.

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

NATIONAL FEDERATION

OF INDEPENDENT BUSINESS,

December 8, 2009.

Senator HARRY REID,

Majority Leader, Hart Senate Office Building, Washington, DC.

Senator MITCH MCCONNELL,

Minority Leader, Russell Senate Office Building, Washington, DC.

DEAR SENATORS REID AND MCCONNELL: As the Senate continues to debate the future of comprehensive healthcare reform, the National Federation of Independent Business, [Page: S12867]

the nation's leading small business association, is writing in opposition to the Patient Protection and Affordable Care Act (H.R. 3590).

When evaluating healthcare reform options, small business owners ask themselves two specific questions. First, will the bill lower insurance costs? Second, will the bill increase the overall cost of doing business? If a bill increases the cost of doing business or fails to reduce insurance costs, then the bill fails to achieve their No. 1 goal--lower costs.

In both cases, the Patient Protection and Affordable Care Act (H.R. 3590) fails the small business test and, therefore, fails small business. The most recent CBO study detailing the effect that H.R. 3590 will have on insurance premiums reinforces that, despite claims by its supporters, the bill will not deliver the widely-promised help to the small business community. Instead, CBO findings report that the bill will increase non-group premiums by 10 to 13 percent and result in, at best, a 2 percent

decrease for small group coverage by 2016. These findings tell small business all it needs to know--that the current bill does not do enough to reduce costs for small business owners and their employees.

Despite the inclusion of insurance market reforms in the small-group and individual marketplaces, the savings that may materialize are too small for too few and the increase in premium costs are too great for too many. Those costs, along with greater government involvement, higher taxes and new mandates that are disproportionately targeted at small business and are being used to finance H.R. 3590, create a reality that is worse than the status quo for small business. The shortcomings of the Patient

Protection and Affordable Care Act include:

A New Small Business Health Insurance Tax

Unlike large businesses, which self-insure and find security under the blanket of ERISA, most small businesses are only able to find and purchase insurance in the fully-insured marketplace. The Senate bill includes a new $6.7 billion annual tax ($60.7 billion over 10 years) that falls almost exclusively on small business because the fee is assessed on the insurance companies. CBO's most recent study reinforces those costs will ultimately be passed on to their consumers, leaving the cost to be

disproportionately borne by small business consumers in the individual and small-group marketplace whose only choice is to purchase those products or forgo insurance altogether.

A New Mandate That Punishes Employers, Employees and Hinders Job Creation

Employer mandates fail employers and employees in two ways. First, mandates do nothing to address the core issue facing small business--high healthcare costs. Second, mandates destroy job creation opportunities for employees. The job loss, whether through lost hiring or greater reliance on part-time employees, harms low-wage or entry-level workers the most. The employer mandate in H.R. 3590 sets up potentially troubling outcomes for this sector of the workforce. The multiple penalties assessed

on full-time workers will most certainly result in a reduction of full-time workers to part-time workers and discourage the hiring of those entrants into the workforce who might qualify for a government subsidy, hardly an outcome that contributes to a greater insured population.

A Poorly-Structured Small Business Tax Credit

As structured, the small business tax credit will do little, if nothing, to propel either more firms to take-up coverage or produce greater overall affordability. Due to its short-term temporary nature and the limitations based on the business' average wage, its benefit is, at best, a temporary solution to the long-term cost and affordability problem. A tax credit that is poorly structured is not going to provide sustainable and long-term relief from high healthcare costs, and the recent CBO

finding that the tax credit would benefit only 12 percent of the small business population illustrates its lack of effectiveness.

A Benefit Package That Is Too High a Hurdle for Small Business

NFIB has voiced concern over establishing a benefit threshold that is too high a price tag for small businesses to meet. Small businesses are especially price sensitive. They need purchasing choices that provide the flexibility in coverage options that reflect their marketplace and business needs. If Congress doesn't adjust the actuarial value standards in the legislation, what may be affordable this year may be unaffordable next year. As a result, small business owners will be at risk of having

to drop coverage due to cost increases that outpace their healthcare budgets.

Destructive Rating Reforms and Phase-In Timelines That Threaten Affordability for All

NFIB supports balanced federal rating reforms that protect access and affordability, regardless of an individual or group's health status. However, the excessively tight age rating (3:1) in H.R. 3590 will increase more costs than it will decrease, and make coverage unaffordable for the very populations that are most beneficial to the insurance pool--the young and the healthy. Independent actuaries have analyzed the negative impact of such tight bands and have indicated that there will be devastating

effects to the long-term viability of a pool without action to correct this rating imbalance.

Additionally, to prevent volatile spikes in insurance premiums, also known as ``rate shock,'' federal rating reforms must be appropriately applied to all marketplaces and phased in over a responsible period of time. If this is not done, then certain plans, including ``grandfathered plans,'' will utilize different rating practices when underwriting risk, which can create adverse selection issues. Those selection problems will have a striking negative impact on the new exchanges--exchanges that

are meant to improve, rather than decrease, affordability for small business and individuals.

National Plans That Provide Limited Promise for Success

Leveling the playing field for small business starts with allowing uniform benefit packages to be purchased across state lines. If done right, this can provide a greater security that, as people change jobs and move from state to state, they can keep the benefit plan that meets their healthcare needs. National plans would be particularly helpful for states with smaller populations and where consumers lack a robust marketplace with choice and competition for private plans. Specifically, the state

``opt-out'' language in the Patient Protection and Affordable Care Act would create more disincentives than incentives for carriers to embark on these new opportunities. If the national plan section is not significantly restructured to make national plans a viable option, then these new opportunities will never materialize for small business.

Threatens Flexibility and Choice for Employers and Employees

Small employers need more affordable health insurance options and new alternatives for employers to voluntarily contribute to individually-owned plans. Provisions also need to be structured to insure that options are widely available to both employers and employees. The simple cafeteria plan language in H.R. 3590 excludes the owners of many ``pass-through'' business entities from participating in these arrangements. If owners are unable to participate in the plan, they will be less likely to

provide insurance to their workforce. Finally, small business needs the freedom and flexibility to preserve options that are already proven to work. Prohibiting the use of HSA, FSA and HRA funds to purchase over-the-counter medications, along with the $2,500 limit on FSA contributions, diminishes that flexibility and threatens to further limit the options employers have to provide meaningful healthcare to their employees.

New Paperwork Costs on Small Businesses

The cost associated with tax paperwork is the most expensive paperwork burden that the federal government imposes on small business owners. The Senate bill dramatically increases that cost with a new reporting requirement that is levied on business transactions of more than $600 annually, leaving small business buried in paperwork and increasing their paperwork compliance expenses.

An Unprecedented New Payroll Tax on Small Employers

Since its creation the payroll taxes that fund the Medicare programs have not been wage-based and are dedicated specifically to funding Medicare. The Senate bill changes the nature of the tax and creates a precedent to use payroll taxes to pay for non-Medicare programs.

The Absence of Real Medical Liability Reform

NFIB strongly supports medical liability reform as a means to both inject more fairness into the medical malpractice legal system, and to reduce unnecessary litigation and legal costs. Taking serious steps to adopt meaningful medical liability reform is a significant step toward restoring common sense to our medical liability litigation system. It also is especially critical to improving access to healthcare for those living in rural areas, where it is becoming increasingly difficult for those

in need to locate specialists such as OB/GYNs and surgeons.

The Creation of a New Government-Run Healthcare Program

A government-run plan will drive the private healthcare marketplace out of business. Private insurers will be unable to compete in a climate where the rules and practices are tilted in favor of a massive government-run plan. This means millions could lose their current coverage. This will decrease choice and increase costs. On both accounts, the government-run plan will leave small business with a single option--the government-run plan, which is the exact opposite outcome small businesses want

from healthcare reform.

There is near universal agreement that, if done right, small business has much to gain from healthcare reform. But if it is done wrong, then small business will have the most to lose. The Patient Protection and Affordable Care Act, which is short on savings and long on costs, is the wrong reform, at the wrong time and will increase healthcare costs and the cost of doing business. NFIB remains committed to healthcare reform, and urges the Senate to develop common sense solutions to lower healthcare

costs while ensuring that policies empower small [Page: S12868]

business with the ability to make the investments necessary to move our economy forward.

Sincerely,

SUSAN ECKERLY,

Senior Vice President,

Public Policy.

1:09 PM EST

Kit Bond, R-MO

Mr. BOND. Mr. President, I have a couple of other comments I wish to add.

We have now learned that there is a new proposal coming out of the back rooms--the smoke-filled rooms. Every time something new is thrown up on the wall, we stand around with a great deal of interest to see whether it sticks. When you look at this one, I don't believe it sticks. I think it stinks.

If you read the Washington Post's lead editorial today, its headline is ``Medicare sausage? The emerging buy-in proposal could have costly unintended consequences.''

Mr. President, I ask unanimous consent to have printed in the Record, after my remarks, the Washington Post article.

1:12 PM EST

Roland Burris, D-IL

Mr. BURRIS. Mr. President, over the past several months, I have come to the floor of this body many times to speak about the urgent need for comprehensive health care reform. I have said that our bill must accomplish three goals in order to be effective: It must bring competition to the insurance market--competition to the insurance market--it must provide significant cost savings to ordinary Americans, and it must restore accountability to an industry that has run roughshod over the American

public for far too long. I would like to focus on this last point with my remarks today.

We need real accountability in the insurance market. After almost 100 years of debate about health care reform, this Senate stands on the verge of making history. There are many good elements in the legislation that is before us today, but without accountability, any reform measure would be toothless and inconsequential. If we don't give the American people a chance to hold their insurance providers accountable, quality care will continue to elude certain segments of our population. We can't

stand for this any longer. We must prevent insurance companies from discriminating against people by charging them higher rates or denying coverage because of certain conditions.

Everyone knows it is hard for uninsured patients to get quality medical care. Under the current law, in the case of catastrophic injury or illness, anyone admitted to the emergency room should receive equal treatment to save their life. Shockingly, Harvard researchers have found that this is not the case. They examined 690,000 individual cases over 4 years and found that uninsured patients are nearly twice as likely to die in the hospital as patients with similar injuries who do have insurance.

And even after these results were adjusted to account for age, race, gender, and the severity of the injuries, they found that the uninsured were still 80 percent more likely to die than those with health coverage, including Medicaid.

I just had a delegation of physicians in my office. I listened to their comments in reference to wanting us to make sure we passed a health care reform bill this session. One of those physicians began to relate to me the story of his brother, who was employed but was without health insurance. At 41 years old, he died of cancer because he waited too long to try to get treatment. And because he was uninsured and no one would treat him, that took his life at the young, tender age of 41.

So this new evidence is conclusive, and it is truly disturbing. The poor and the uninsured suffer disproportionately under our current system. In the most advanced country on Earth, there is no excuse for this stunning inequality.

Big corporations know there is a lot of money to be made out of the poor and they do not hesitate to rake in large profits and their expenses. These companies exploit minor technicalities [Page: S12869]

to deny coverage to people who are sick. They use gaping holes in the system to refuse treatment for those with certain conditions. That is because they do not see patients as real people who need help, they see them as numbers in the corporate ledger. They see risk

and expenses and lower dividends for their shareholders. That is why we need to prioritize patients over profits. That is why we need to extend coverage to more people and make these companies accountable for the first time in decades.

If we pass insurance reform with a strong public option it would be illegal to deny coverage because of a preexisting condition. For the first time in many years, ordinary Americans would be able to shop around if they are paying too much, or they are not being treated fairly. Costs would come down, coverage would improve, and lives would be saved.

Let us pledge ourselves to this cause. Let us make sure every American can get the treatment they need in the emergency room regardless of their income, need, or the insurance coverage they have. We must not fall short in this regard. We must not settle for anything less.

I yield the floor.

1:18 PM EST

Chuck Grassley, R-IA

Mr. GRASSLEY. Mr. President, my friends on the other side of the aisle have consistently stated that this 2074-page Reid bill, according to the Joint Committee on Taxation, is a net tax cut. I want to put emphasis throughout my remarks on the word ``net.''

Yesterday a chart was used to illustrate this point. This chart had multiple bars with dollar figures. For example, in 2019 the chart showed a $40.8 billion net tax cut. My Democratic friends said this number came from the Joint Committee on Taxation, a very responsible, intellectually honest group.

Unfortunately, the chart my friends were using was not entirely clear on how they came up with this net tax cut for Americans. So it was natural for most of the fellow Senators and the country at large to wonder how my Democratic friends got this number. They said show me the data.

To clear up any confusion, right here is the Joint Committee on Taxation table that the Democrats relied on to claim that the Reid bill results in a net tax cut. Here it is. We can see the negative $40,786, for example. That is the figure that was used. As the chart indicates, these dollar amounts are in the millions, so $40,786 million. The Joint Committee on Taxation says it this way: This means negative--the negative mark there--negative $40.8 billion.

My friends on the other side unfortunately did not explain what was going on here. It appears my friends simply made an assertion that they hoped many of us and those in the media would believe. But I cannot let my Democratic friends get off the hook this easily. Why? Because the entire story is not being told, so let me take a moment to explain.

First, in simplest terms, where you see negative numbers on this chart, the Joint Committee on Taxation is telling us there is some type of tax benefit going to the taxpayers. So this group and these groups here, wherever there is a negative here, those are tax benefits to the benefit of the taxpayers.

For example, families making $50,000 to $75,000 have a negative of $10,489 in their column. This means the Joint Committee on Taxation is telling us that this income category is receiving $10.4 billion in tax benefits.

I hope you will listen closely. When we see a negative number on this chart, the Joint Committee on Taxation tells us there is a tax benefit so, conversely, where we see a positive number the Joint Committee on Taxation is telling us that these taxpayers are seeing a tax increase. I have actually enlarged those numbers, the number of tax returns and the dollar amounts where there is a positive number for individuals and families. Again, these positive numbers indicate tax increase.

My friends have said that all tax returns in this chart are receiving a net tax cut. If that were so, why aren't there negative numbers next to all of the dollar amounts listed? Because not everyone in this chart is receiving a tax cut, despite what my friends have said. Quite to the contrary, a group of taxpayers is clearly seeing a tax increase and this group of taxpayers in middle income is seeing tax increases.

I didn't come down to the floor to say my friends on the other side of the aisle are wrong. After all, you can see here the negative $40,786 million figure they used is right there, out in the open. What I am doing is clarifying that my Democratic friends cannot spread this $40.8 billion tax cut across all the affected taxpayers on this chart, and then say that all have received a tax cut.

You want to know why. Because this chart, produced by the nonpartisan Joint Committee on Taxation, shows that taxes go up for those making more than $50,000 and families making more than $75,000. It is right here in the yellow, as you can see.

The numbers obviously do not lie. I say the nonpartisan Joint Committee on Taxation, I think everybody agrees, is very intellectually honest. So let me give you my read on what the Joint Committee on Taxation is saying here as evidenced by the figures on the chart.

First, there is a group of low- and middle-income taxpayers who clearly benefits under the 2074-page bill that is before the Senate. They benefit from the government subsidy of health insurance. This group, however, is relatively small.

There is another much larger group of middle-income taxpayers who are seeing their taxes go up due to one or a combination of the following tax increases: the high-cost plan tax increase, which actually is a brandnew tax; the medical expense deduction limitation, which used to be 7.5 percent, and now before you can deduct you have to have 10 percent of your income be medical expenses or you don't deduct anything, so that is a tax increase; and then a Medicare payroll tax increase, where everybody

is going to pay--well, everybody over a certain income is going to pay an additional half a percentage point or, if you are self-employed, pay 1 percent more of payroll tax. In general, this group is not benefiting from the government subsidy. After all, how can a taxpayer see a tax cut if they are not even eligible for the subsidy?

Also, there is an additional group of taxpayers who would be affected by other tax increase provisions in the Reid bill that the Joint Committee on Taxation could not distribute in the way people are distributed on this chart. These undistributed tax increases include, among others, the cap on Federal savings--flexible savings accounts. Then there is a tax on cosmetic surgery.

My friend from Idaho, the author of the amendment before us, Mr. Crapo, recently received a letter from the Joint Committee on Taxation stating that this additional group exists and many in this group will make less than $250,000 and, hence, have a tax increase that is not accounted for here and also a tax increase if they are under $250,000. That is a violation of the President's promise in the last campaign that nobody under that figure would get a tax increase--only people over $250,000.

So you see, my Democratic friends cannot, No. 1, say that all taxpayers receive a tax cut--I have proven that here--and, No. 2, say that middle-income Americans will not see a tax increase under the Reid bill.

I yield the floor.

1:28 PM EST

Max Baucus, D-MT

Mr. BAUCUS. Mr. President, some of the charges from the other side of the aisle have taken us down some detours to essentially try to distract us from some of the main points of this legislation. I want to take a few moments to discuss one of the key features of the bill and that is insurance market reform.

The bill would change the way insurance companies do business in America. Sometimes I think this reform is part of the reason some on the other side are fighting this bill so hard. Our bill will end the practice, widespread today, of insurance companies denying coverage altogether, or charging someone an exorbitant amount of money if they have some preexisting condition, something in their health history which is an issue. Our bill would make those changes right away. They start going into effect

in 2010. That is, the prohibition on companies denying coverage for preexisting conditions or [Page: S12870]

health care stats, and right down the list, would take effect right away, 2010.

We all have countless numbers of examples, either directly or through friends or relatives of small insurance companies that either denied insurance coverage or you have to pay much greater increase in premiums because of a preexisting condition, whatever it may be, of something. It is wrong, flat, outright, 100 percent wrong. This bill stops that, stops those practices by insurance companies.

I think it is important that we not get sidetracked by some other very important matters but keep focused on what this legislation does. It reforms the health insurance industry.

What else does our bill do with respect to reforming the health insurance industry? It would prohibit lifetime limits on payments to people who get sick. Right now, insurance companies limit how much they pay out to people when they get sick. They have lifetime limits, annual limits. No matter how sick you are, some catastrophic coverage you have, the insurance company says: Sorry, we are putting a limit on it. That is not right. Sometimes people have conditions that require a lot more attention,

more hospitalization, more attention by doctors. Our legislation would prohibit lifetime limits on payments to people who get sick.

Our bill also prohibits unreasonable annual limits. These are limits that insurance companies impose on policyholders. This reform would apply in both the group market and the individual market. What does that mean, that gobbledygook. It implies that for everybody, whether you are an individual or whether you are working for a company, this would take effect 6 months after enactment. That is pretty important. A lot of people have insurance policies with limits, where the insurance company will

only pay so much to an individual or during the person's lifetime or in any year. It is not right because some conditions require a significant increase in payments or coverage for the person.

Our bill would require any insurance plan that provides dependent coverage for children to continue to make that coverage available until the child turns age 26. We know that is a problem today. Often, in a State, once a child turns 21 or 22, that person can't find health insurance. In today's economic recession, with unemployment so high, it is kind of hard for kids to find jobs, and that is how they would otherwise get their health insurance. We say family coverage covers your child until the

child turns age 26. This reform would take effect 6 months after enactment.

In addition, when the exchanges are up and running, our bill would prohibit insurance companies from discriminating against consumers because of health status, generally. Sometimes the insurance industry says it is not a preexisting condition, but you have not been healthy lately so we will not give you insurance. No longer can insurance companies refuse to sell or renew policies because a person gets sick. If you pay your premiums, the insurance company has to renew your coverage.

When the exchanges are up and running, the legislation before us today would limit the ability of insurance companies to charge people much more just because of their age. That is what they do today. Sometimes, depending upon the State, the insurance company is able to charge somebody much more for the same coverage because of that person's age. Right now it is not at all unusual for insurance companies to charge more than five times as much just because a person is, say, age 55. Our bill would

prohibit insurance companies from charging more than three times as much because of age. In some States, there is no limit whatsoever. In my State of Montana, we have no limit. Some States have five. We are saying down to three.

When the exchanges are up and running, our bill would prohibit insurance companies from charging women more than men. Think of that. Some insurance companies charge women more than men. That is not right. This is also a widespread practice among insurance companies that is charging women more than men. It is just plain wrong. Our legislation would stop that.

Health insurance reform also means real insurance market reform. It means real change in the way insurance companies do business. No longer will insurance companies be able to build their business by cherry-picking only the healthiest and the youngest. That is what they do today, especially for individuals, to some degree, in smaller organizations. No longer will they be able to insure only those who don't need insurance. We bring real reform. It would make insurance much more fair, and that

is literally a matter of life and death.

As a recent Harvard study reported, people without insurance are 40 percent more likely to die prematurely than people with private insurance. Think of that. People without insurance are 40 percent more likely to die prematurely than people with private insurance. Tens of thousands of Americans die each and every year because they do not have insurance. Is that America? That doesn't sound like the United States we are all so proud of, where we allow tens of thousands of Americans to die each

and every year simply because we have not set up a system for them to have health insurance. That is something we stop in this bill.

I suggest the absence of a quorum and ask unanimous consent that the time be charged equally against both sides.

1:41 PM EST

Chuck Grassley, R-IA

Mr. GRASSLEY. Mr. President, I have said, for the last 2 days, I was going to speak on the Dorgan amendment, a bipartisan amendment to allow the importation of drugs into the United States. I haven't done it until now, so I am glad to rise in support of this bipartisan amendment to add provisions of the Pharmaceutical Market Access and Drug Safety Act to this bill. That legislation is the result of a collaborative effort by Senators Dorgan, Snowe, McCain, and this Senator to finally

make drug importation legal.

I have, for a long time, been a proponent of drug reimportation. In 2000, 2002, and 2003, I supported an amendment permitting the importation of prescription drugs into the United States from one country, Canada. This amendment is much broader than only Canada.

In 2004, the late Senator Kennedy and I worked together on a bill that would authorize drug importation, but it did not survive the partisan politics of this Chamber. I then introduced my own comprehensive drug importation bill in 2004. That was S. 2307, the Reliable Entry for Medicines at Everyday Discounts Through the Importation with Effective Safeguards Act. The REMEDIES Act is what the acronym finally spells out. In 2005, I combined my bill with a proposal sponsored by Senators Dorgan

and Snowe. In 2007, we reintroduced a version of that legislation with the hope that our combined efforts would finally lower the cost of prescription drugs for all Americans. That is what we are still working together to do this very day. I thank Senator Dorgan for his leadership.

This time around, I should be confident that this effort will finally pass. Historically, Democrats claim to be champions of holding the big pharmaceutical companies accountable. Now we have a Democratic supermajority in the Congress and a Democratic President who has supported drug importation in the past. I am not as confident as maybe I should be. That is because the White House has participated in some back-room negotiations since the last time this legislation was brought before the Senate

and then Senator Obama supported it. Behind closed doors, the Democratic White House found new friends in the pharmaceutical industry. Last summer, the head of the pharmaceutical lobbying group bragged that drug manufacturers had negotiated a ``rock-solid deal''--those are their words--with the present administration.

An article in the New York Times detailed the administration's deal with big drug companies. This quote comes from the New York Times:

Foreseeing new profits from the expansion of health coverage, big drug companies are spending as much as $150 million on advertisements to support the President's plan.

But in 2008, when President Obama was campaigning for the position he now holds, he promised that:

[Page: S12871]

We'll take on drug and insurance companies, hold them responsible for the prices they charge and the harm they cause.

Certainly, the President knows that a great way to hold drug companies accountable is to allow drug importation. In fact, in 2004, when he was a candidate to be a Member of this Chamber, he challenged his opponents to support drug importation. He said at that time:

I urge [my opponent] to stop siding with the drug manufacturers and put aside his opposition to the re-importation of lower-priced prescription drugs. .....

But, unfortunately, it has been reported that during backroom negotiations at the White House, the big pharmaceutical companies have convinced the President to drop his strong support for drug importation.

The New York Times reports that:

On July 7--

Meaning this year--

Rham Emanuel, [President] Obama's chief of staff ..... assured at least five pharmaceutical companies during a White House meeting that there would be no provision in the final health care package to allow the reimportation of cheaper drugs. .....

I thought we were going to hold drug companies accountable. I thought health care reform was supposed to drive down the cost of health care, including the cost of prescription drugs for all Americans. The Dorgan amendment is a commonsense, bipartisan approach to achieve both of these goals. Drug importation achieves these goals without imposing arbitrary fees, and without flexing the muscles of the Federal Government.

I have always considered this a free trade issue. I know most people see it as a health issue, and it is a health issue. But I come at it from the point of view that there are only a couple items Americans cannot buy in this country from anyplace else in the world they want to buy it. One class is pharmaceutical drugs, the other class is Cuban----

1:47 PM EST

Chuck Grassley, R-IA

Mr. GRASSLEY. So I see this as a free-trade issue. Imports create competition and keep domestic industry more responsive to consumers. In the United States, we import everything consumers want. So I ask again, why not pharmaceuticals? That is why it is a trade issue for me as much as a health issue. Consumers in the United States pay far more for prescription drugs than those in other countries. If Americans could legally and safely access prescription drugs outside the United States, then drug

companies would be forced to reevaluate their pricing strategies. They would no longer be able to gouge American consumers by making them pay more than their fair share for research and development.

It is true that pharmaceutical companies do not like the idea of opening up America to the global marketplace. They want to keep the United States closed to other markets in order to charge higher prices here.

Based on the reports I just read, it seems that the White House has already sided with the drug manufacturers and promised them the ability to continue to gouge American consumers, otherwise known as the status quo.

The debate is not over. With the Dorgan amendment, prescription drug companies will be forced to be competitive and establish fair prices in America. The drug companies will try to find loopholes in order to protect their bottom line.

The Dorgan amendment would make such action illegal. It would not allow manufacturers to discriminate against registered exporters or importers. It would prohibit drug companies from engaging in any actions to restrict, prohibit, or delay the importation of a qualifying drug.

The Dorgan amendment would give the Federal Trade Commission the authority to prevent this kind of abuse. It develops an effective and safe system that gives Americans access to lower prices. Our effort goes to great lengths to ensure the safety of imported drugs. The Dorgan amendment requires that all imported drugs be approved by the FDA. It puts in place a stringent set of safety requirements that must be met before Americans can import drugs from that country.

The amendment requires all exporting pharmacies and importing wholesalers to be registered with the FDA and inspected. It gives the authority for the FDA to inspect the entire distribution chain for imported drugs. It sets very stringent penalties for violations of the safety requirements in this bill, including criminal penalties and up to 10 years imprisonment.

We need to make sure Americans have even greater, more affordable access to innovative drugs by further opening the doors to competition in the global pharmaceutical industry.

If my colleagues on both sides of the aisle are serious about bending down the cost curve of health care inflation--and doing it in that direction, the right direction--then they will support the Dorgan amendment, a bipartisan amendment.

I yield the floor.

1:51 PM EST

Sherrod Brown, D-OH

Mr. BROWN. Thank you, Mr. President.

I echo the comments of the senior Senator from Iowa. He is exactly right about the Dorgan amendment. There are a lot of reasons, as he pointed out, why the Dorgan amendment makes sense for the American people.

It makes sense for taxpayers because we pay way too much for prescription drugs as taxpayers. It makes sense for government programs--whether it is TRICARE, whether it is Medicare, whether it is Medicaid, whether it is the Federal Employees Health Benefits Program. It makes sense for small businesses and large businesses alike who are paying too much for prescription drugs. And it makes sense for seniors and all Americans who are paying too high a price for prescription drugs out of their pockets.

It also makes sense in terms of, sort of, internationally as to what we do on the buying and selling of prescription drugs.

I was part of these discussions in the House where we had the same amendment. We would pass it, and then it would die in the Senate, or things would happen in the conference committees or whatever, where the drug companies really did exert their influence over the Congress and with the President during the Bush years.

But one of the arguments they always make is to question the safety of these drugs, that these drugs coming from Canada or these drugs coming from France are not safe, as if they did not have a food and drug administration as efficient and effective as ours in terms of protecting the public.

But what sort of shoots a hole in that argument is how many American drug companies--over and over and over, and in increasing numbers--how many American drug companies are importing ingredients especially from China.

Senator Kennedy, 1 1/2 years or so ago, asked me to chair an oversight hearing with the Health, Education, Labor, and Pensions Committee on this issue of what is happening when these American drug companies are increasing their outsourcing of jobs, particularly to China. It was in response to what happened in Toledo, OH, among other places, where a number of Americans died because of contaminated heparin.

Heparin is a blood thinner drug that is a very important drug to keep people healthier and live longer and live better. But some of the ingredients for heparin were made in China, and the drug company is not able to trace back, if you will, the supply chain, where they are getting their ingredients. They know they get them from China. The American drug companies--whether it is Pfizer or another drug company--when they outsource their production to China, may know where the plant is that puts

all these ingredients together, but they cannot trace back--or at least they will not tell us or cannot tell us--all their ingredients. So they may get this ingredient from Wuhan, and this ingredient from Shanghai, and that ingredient from a rural outpost in Hebei or Henan Province, but they cannot tell us exactly where they come from. So no wonder these drugs are not as safe as they should be.

So if they were interested in drug safety, it would not be that they would stop us from drug importation because we know if we buy it from France or Canada or Germany, they have a food and drug agency, an FDA equivalent, [Page: S12872]

that keeps

their drugs safe. They know that. It is all about protecting their profits. There is simply no doubt about that. Their profits get to be bigger because they make some of these drugs in China.

So let's not have it both ways. Let's not say we cannot import drugs safely into this country--when they are exporting jobs, as so many other industries are doing, to China, exporting jobs to little villages where they manufacture these ingredients. They end up in America's medicine cabinets. Let's not talk out of both sides of our mouths, as the drug industry is doing.

A couple other comments about the underlying bill and how important it is we move on this legislation. There are more than 400 people every day--in Defiance, OH, in Gallipolis and Zanesville and Saint Clairsville and Cadiz and all over my State--400 people every single day who lose their insurance.

Every day my friends on the other side of the aisle delay, every day they offer amendments and then will not let us vote on them, and stand up and object to even voting on things, every day they try to filibuster, every day they put up another hurdle, 400 more people in my State lose their insurance. It is about 1,000 people in this country every week--1,000 people in this country every week--who die because they do not have health insurance. It is 45,000 people a year, so 900-some people every

week in this country die because they do not have health insurance.

A woman with breast cancer without insurance is 40 percent more likely to die than a woman with breast cancer with insurance. I heard President Bush, in Ohio, maybe a couple years ago, say every American can get health care. They can go to an emergency room. Well, a woman suffering from breast cancer, who did not get a mammogram because she could not afford it, did not get the kinds of tests she should have because she did not have a doctor she could afford to pay, and because she did not have

insurance--the emergency room does not do those kinds of things. Even if she got sick, the emergency room would not take care of her until she was almost dead. Then she could go into the emergency room and they will take care of her in her last few days or her last few weeks of life.

That is not the way we should do health care. This kind of delay, hearing these kinds of delaying actions, these kinds of delaying tactics, these kinds of ``we can't pass this,'' ``chicken little,'' ``the sky is following''--every day we have Republicans coming down here saying ``the sky is falling,'' and it simply is not.

I want this bill to be bipartisan. I am a member of the Health, Education, Labor, and Pensions Committee, as is my friend, Senator Roberts from Kansas, who is in the Chamber. During that markup in June and July, we passed 160 Republican amendments. Some of them were major, some of them were not so major. But this bill had a bipartisan flavor to it.

It is only on the big questions--the role of Medicare, the role of the public option--some of the bigger questions, where there are philosophical differences; the same reasons that back in the 1960s, when Medicare passed, it was passed almost only by Democrats because Republicans did not agree there should be a major role in government in our health care system.

So it is a philosophical difference. It is not so much partisan as that. So even though there are many good Republican ideas in this bill, on the big questions there is that difference.

So, Mr. President, I think it is so important--when I hear that many Ohioans, every day, lose their insurance, this many Americans, every week, die because they do not have insurance--to pass this legislation.

Mr. President, I suggest the absence of a quorum.

1:58 PM EST

Pat Roberts, R-KS

Mr. ROBERTS. I will try it again. I thought it was worked out.

I ask unanimous consent for the second time that the order for the quorum call be rescinded so I may be--

2:03 PM EST

Chris Dodd, D-CT

Mr. DODD. Mr. President, I ask unanimous consent that over the next 30 minutes, the time be equally divided with 15 minutes for the majority and 15 minutes for the minority for debate purposes only.

2:04 PM EST

Pat Roberts, R-KS

Mr. ROBERTS. I thank the President. I rise today to talk about health care in general and the latest proposal to come out in the form of the so-called compromise, if there is no objection. I wish to talk about the latest proposal to come out from what some of us have determined is the majority leader's behind-closed-doors effort for the compromise on the government-run health insurance plan. I will admit very readily I do not know all of the details of this plan, although I hope to in the very

near future. I think most of my friends across the aisle are in the same boat and we are all getting our information from the Post, the Times, and the rest of the catch-up media.

But this is the compromise, as I understand it: The majority leader will drop the government plan in exchange for two major policies: first, a national insurance plan run by nonprofit insurance companies and supervised by the Office of Personnel Management; and second, a massive expansion of Medicare to tens of millions of people age 55 and older.

Putting aside the first policy which, frankly, I don't understand how it could possibly work, I cannot believe anyone is seriously considering expanding Medicare as a compromise to the government-run or so-called public option. It doesn't take a genius to see that a huge expansion of Medicare is, as one single-payer advocate in the House dubbed it, ``the mother of all public plans,'' further quoting: ``An unvarnished and complete victory'' for advocates of single-payer health care and socialized

medicine. That is a very strong quote, but that is the way it was.

In other words, this is not a compromise to the public option--it is worse. Maybe we need to remind ourselves why moving toward more government control of our health care system is such a bad idea. We need look no further than our current government-run insurance plans, Medicare and Medicaid, for examples. Government-run insurance plans currently control nearly half of the market. With the government's power, they have the ability to set payment levels for doctors and hospitals and home health

care agencies and even hospices and all other health care providers, not based on the actual costs those providers incur when treating patients, but instead based on whatever arbitrary spending target the budget crunching bean counters determine the government can afford.

To paraphrase one observer: These types of global government budgets transform patients from sources of revenue over which providers compete to attract and serve, into sources of cost for the government to avoid, shunt off, and treat as cheaply as possible. That is not right. This has clearly been the result in the Medicare Program, often heralded as the best of all of the government's health care programs.

So to review: Medicare has been on an ever shrinking path toward bankruptcy for years. The latest reports [Page: S12873]

from the Medicare trustees say the hospital insurance trust fund will go broke within the next 8 years. The program has $38 trillion in unfunded liabilities. How has the government responded? By severely underpaying Medicare providers and denying Medicare patients' claims. Medicare only pays doctors around 80 percent of their costs, and hospitals

even lower.

Privately insured Americans pay a hidden tax of nearly $90 billion a year to make up for these underpayments. But even that hasn't been enough to keep some providers in business and able to afford to accept Medicare patients. Medicaid is even worse. Medicare is also a huge denier of claims. I think many of my colleagues would be surprised to hear that Medicare denies claims more often than most private insurance companies. In fact, in 2008, Medicare had the highest percentage and the highest

number of denied claims in the country. Think about that when you hear some Senators demonize private insurance companies for denying claims. Medicare is even worse.

This bill already exacerbates these Medicare problems by cutting almost $ 1/2 trillion from this already woefully underfunded program. Now we are considering adding even more people. This is a sinking ship with no lifeboats, and we are adding more folks to the deck.

By underpaying health care providers and denying claims, Medicare already rations health care. Expanding Medicare to tens of millions of new people as envisioned by this compromise we hear about will take government rationing to a whole new level. Because as the government takes over more of the health care system and becomes responsible for more of the increasing costs of that system, the only way it will be able to afford this commitment is to ration health care. As I have said countless times

before, this bill gives the government all the tools it requires to ration care.

From Comparative Effectiveness Research, to the independent Medicare advisory board, to the new powers granted to the Centers for Medicare and Medicaid Services, CMS and the U.S. Preventive Services Task Force, this bill puts the rationing infrastructure into place. The U.S. Preventive Services Task Force's recent change to its guidelines pertaining to mammograms was a perfect illustration of how your health care will be rationed under this bill. For those who don't know, the task force recently

reversed its longstanding advice that women should start getting regular mammograms to detect breast cancer at age 40.

Why is this important? Because under this bill, the recommendations of this task force will carry the weight of law for both government-run--i.e., Medicare--and private insurance. If the task force recommends a particular treatment or a particular set of patients, then Medicare and private insurers must cover it. If it doesn't, they don't.

What do you think will happen to treatments and tests that don't get the task force's recommendation? They simply will not be covered. That is how the government will hold down health care costs, by rationing access to treatments and tests such as mammograms.

Some government-controlled health care systems such as the one that exists in the United Kingdom are much more explicit about rationing. The rationing in this bill, quite frankly, is not as honest. Since Americans would never stand for the government explicitly rationing their health care, the authors of this bill had to come up with a pseudoscientific justification for rationing, and that justification is the main feature of this bill: Comparative Effectiveness Research, or CER.

Very generally, it is very simple. CER is the comparison of two or more treatment options to see which one is better. Sounds great, right? Except when you realize that CER is not being conducted for the purpose of improving patient care but for the purpose of saving the government money instead.

I read the CER section of the bill and I remember my amendment on CER and the distinguished chairman of the HELP Committee was very helpful, and said he would study it overnight. Because I had the word ``prohibit'' in the amendment we got into a great debate on what prohibit means. I thought it was pretty clear but, unfortunately, that was dropped from the bill, from the HELP Committee bill. We tried that again in Finance. It didn't work. We would like to try it again if we have time.

This bill establishes a CER institute to conduct this research for the purpose of justifying government rationing of health care. CER will be the golden ring of rationing.

So what we have here is a recipe for disaster: a bill that already significantly weakens the woefully underfunded Medicare Program and lays the foundation for a rationing infrastructure, plus a ``compromise'' that apparently will pour millions of more people into the program.

In the no-holds barred search for a proposal that can attract 60 votes, I don't understand how any Senator can support this idea.

This is just another Trojan horse, another incremental step toward the single-payer system. Again, as one House Member in the leadership observed:

This gets not only the camel's nose under the tent, but his whole head and neck, too.

It is another step toward socialized medicine and increased government rationing of health care.

The American Hospital Association, American Medical Association, and the Federation of American Hospitals are finally taking notice of the advice they are receiving from their State and local hospitals and doctors. They, finally, have seen the light and have come out in opposition to this deal at least.

I urge my friends across the aisle to resist this latest misguided attempt at deal making. The consequences are too dangerous.

There is an awful lot of cactus in this health care world. I don't think we need to sit on each and every one of them.

Before yielding back my time, I truly thank the distinguished Senator from Connecticut for his comity and allowing me to make these debate comments. I thank the acting Presiding Officer in his effort to be bipartisan.

I think we will have a sad day in this body if one side or the other gets into a situation where we do not allow people to make remarks on not only the pending bills and specifically on the general issue of health care.

2:19 PM EST

Pat Roberts, R-KS

Mr. ROBERTS. Mr. President, I agree with the Senator. I point out that in the specifics of the bill, I think it says shall not, in regard to cost containment on Medicare A and B, but the rest is encouraged. That is where we get into problems because CER is the blueprint on how we allot health care dollars in this country.

I might mention to the Senator, I had a chart on what CER recommended, and it had a figure of a humpback whale and how much money we would be devoting to different age groups. If you are 60--and, by the way, the average age of the Senate is 62--you are out of luck. If you are 70, you better get something fixed real quickly before this bill passes. That is my point. I thank the Senator for his comments.

2:20 PM EST

Chris Dodd, D-CT

Mr. DODD. Mr. President, I thank Senator Roberts for his amendment in the HELP Committee to protect patients by preventing rationing of health care. That is in the Senate bill. That was language we adopted, I say to my friend from Vermont. It was a Roberts amendment that was adopted in [Page: S12874]

our markup that prohibits any rationing of health care in our bill. I thank him for that.

I yield the floor.

2:20 PM EST

Bernie Sanders, I-VT

Mr. SANDERS. Mr. President, when Republicans controlled the White House, the Senate, and the House, they had the opportunity to do something about the health care disaster in America. From 2000 to 2008, some 7 million Americans lost their health insurance. Where were the Republicans? During that same period, health care costs soared in America. Small businesspeople found themselves unable to provide health care to their workers.

Where were our Republican friends? I am delighted they are down on the floor every single day criticizing an effort to try to improve the situation. But it might have been a little better if they were here 8 years ago, bringing forth their ideas. But they were not.

Having said that, let me suggest that in the midst of this health care crisis, in which 46 million Americans have no health insurance and health care costs are soaring and, as the President indicates, that will double in 8 years if we do nothing, at a time when 45,000 Americans this year will die because they don't get to a doctor when they should, when close to 1 million Americans are going to go bankrupt from medically related bills, we need real health care reform.

That is something that I, and I know many other Members in Congress, have been fighting for for years. More than anything, I wish to see us pass strong health care reform. I must express a disagreement with some of my colleagues on the Democratic side, who think we are on the 2-yard line, we are almost there. I don't think so. I think there are a number of problems that remain in this legislation that have to be resolved. I wish to touch on a few of them.

One of the parts of this legislation is that, finally, we are going to add some 30 million Americans to health care insurance. That is a good thing. About half of them will be added to an expanded Medicaid--a huge expansion of Medicaid. But here is my concern. Right now, our primary health care system is extremely weak. Everybody knows we don't have enough primary health care doctors. We know that Medicaid, today, is on wobbly legs as it tries to take care of the people who access that program.

I am not quite sure how you add 15 million more people to Medicaid if you don't have a primary health care infrastructure to accommodate their needs.

In this regard, I have fought very hard for authorization language in the Senate to greatly expand community health centers and the National Health Service Corps, for which we will train and make sure that we have the primary health care doctors, dentists, and nurses we need, desperately need.

In the House bill, there is language introduced by Representative Clyburn, supported by the Democratic leadership, that would provide $14 billion over a 5-year period to expand community health centers, enable tens of millions more to access health care, and make sure we have the primary health care doctors and dentists we need.

It would be a cruel hoax to tell people they now have health insurance--Medicaid or another program--but not create a situation by which they can get into the doctor's office. I fear that may happen. I am going to fight as hard as I can to make sure we have the primary health care infrastructure we need. That means, in the Senate, adopting

the language that currently exists in the House bill for $14 billion over a 5-year period--money which, according to a variety of studies, will pay for itself as we keep people out of the emergency room and keep people from getting sicker than they otherwise should be and ending up in a hospital. This makes a lot of sense. Community health centers have had wide bipartisan support. We have to support the House language.

On another issue, I found it interesting that my friend from Kansas, a moment ago, was denouncing the United Kingdom's health care system, denouncing socialized medicine, single payer. Well, I got a little confused by my Republican friends, who have been in Congress, saying: We love Medicare. My word, do we love Medicare. We are very angry that those Democrats are trying to cut back on that.

Republicans who, year after year, wanted to privatize Medicare, this week they love it. If they love it so much, why don't they join us in trying to expand Medicare and address some of the problems in Medicare? Let's work together.

Last week, we were criticized, but now, I guess, the tune has changed a little. Get your act together, my Republican friends. Either you continue the line you have had for many years about detesting Medicare because it is a single-payer health care program, a government health care program--that is what it is, a single-payer government health care program. You have been on the floor defending it all week long, until a couple days ago.

I support Medicare. In fact, what I believe and am fighting for is a Medicare-for-all, single-payer program because, at the end of the day, I disagree with many on this side of the aisle. I think, at the end of the day, the only way you are going to provide comprehensive universal health care to all Americans, in a cost-effective manner, is through a Medicare-for-all, single-payer system, which ends the hundreds of billions of dollars of bureaucracy and waste engendered by the private insurance

companies.

One of my concerns, as we seem to be hurtling down the finish line, is I don't know who is going to be able to offer amendments. I have an amendment that speaks to what millions of Americans want, including the Physicians for a National Health Program--17,000 doctors, mostly primary health care doctors but not exclusively. They want to see this country have a Medicare-for-all, single-payer system. I understand I am not going to get very many Republicans supporting that amendment--or any Republicans.

I also understand I will get few enough Democrats supporting that amendment. In the years to come, we are going to have a Medicare-for-all, single-payer system. I want that debate on the floor of the Senate. I have offered an amendment and I want to have that debated. I don't need 20 hours or 5 days. I would love to discuss that issue with my Republican friends.

Democrats, I think it is an amendment that has a right to be offered and it should be. I understand that will not pass. I will tell you what could pass and what could have Republican support, it is the provision I have been working on that at least says that in our Federalist system, where each State learns from other States, at least give States the option. If the Governor or the legislature wants to go forward with a single-payer model; maybe it works, maybe it doesn't work. I have the feeling

if one State--whether it is Vermont, California, Pennsylvania, States that have strong single-payer movements, a lot of support for that concept--if one State does it well, then other States will be saying we want the same thing. It is a cost-effective way to provide comprehensive health care to all our people.

I want to touch on another issue, where I think my colleagues in the Senate are wrong and my former colleagues in the House are right. This is an issue the occupant of the chair has worked on with me. We held a press conference this morning. It is to understand this legislation is going to cost between $800 billion and $1 trillion.

How do you get the money? Well, the Senate bill contains a tax on health insurance benefits. I think that is wrong. I think that is regressive. It is called a tax on Cadillac plans. Given the soaring cost of health care in America today, what may be a Cadillac plan today will be a junk car plan 5 years from now. Millions of Americans are going to be forced to pay taxes on their health care benefits or else their employer will cut back on those benefits, and they are going to have to pay out of

their own pockets. That is wrong. It is a regressive and unfortunate and unfair way to raise the revenue we need.

Our friends in the House did the right thing. They said that millionaires should be asked to pay a little bit more in taxes to make sure we expand health care coverage in this country. I support what our friends in the Senate and the House did, and I disagree with what is in the Senate bill. There will be a poll coming out this afternoon in which 70 percent of the American people, as I understand it, disagree with the tax on [Page: S12875]

health care benefits. They

understand that is a tax on the middle class.

Let's be clear. We are in a terrible recession now. Working families are struggling. It is wrong for us to propose a tax on health care benefits, which in a few years will be impacting millions of middle-class workers. We should follow what the House has done and say to people at the top--millionaires who have received huge tax breaks under President Bush--that they have to pay a little bit more in taxes so we can provide health care to all our people.

There is a lot in the bill in the Senate that makes a lot of sense to me. I congratulate Senator Dodd and Senator Baucus and all those people and their staffs who have worked so very hard on this bill. We have 31 million more people who will get insurance. There is insurance reform dealing with preexisting conditions. We made progress in disease prevention. There are a lot of good things in it.

I want to be very clear: I do not think we are at the 2-yard line. I think a lot of work has to be done to improve this bill. We need to, as I mentioned a moment ago, make major improvements in primary health care. We need to change how we fund many parts of the expansion of insurance and do away with the tax on health care benefits. We have to give States the option, the flexibility to go forward with a single-payer system if that is what they want to do.

Also, I hope very much that this afternoon we will vote and adopt the reimportation prescription drug legislation championed by Senator Dorgan. It is an absurdity in this country that we remain the country that pays by far the highest prices in the world for prescription drugs. When I was in the House, I was the first Member of Congress, as I understand it, to take Americans over the Canadian border. Back then--10, 15 years ago--women were able to purchase the breast cancer drug Tamoxifen

for one-tenth the price they were forced to pay in the United States. I know the drug companies are very powerful. I know they have a lot of influence in this institution. But I hope we can do the right thing and provide affordable medicine to all Americans through reimportation. And I hope we can adopt that amendment.

I did want to say I have some very serious concerns about this legislation, and I hope they will be addressed in the coming days and weeks. I very much want to be able to vote for this bill, but I am not there now, not by any means.

I yield the floor.