[Congressional Record Volume 155, Number 138 (Tuesday, September 29, 2009)]
[Senate]
[Pages S9899-S9902]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                           HEALTH CARE REFORM

  Mr. ALEXANDER. Madam President, all of us were home in August. It was 
a pretty good thing we were, because the people of the United States 
had a lot to say to us about the health care bill. I think President 
Obama was very correct when he said the health care reform bill is a 
proxy for the role of Federal Government in our everyday lives.
  I think that is what we are debating here. On the one side, we have 
an effort by the majority and the President to do this massive, 
comprehensive health care reform with thousand-page bills and White 
House czars and trillions in spending and debt. That is on the one 
side. On the other side we have Republicans saying we want health care 
reform, but let's focus on reducing costs to each American who has a 
health care policy--that is 250 million of us--that is why people are 
showing up at town meetings; it is not some abstract thing--and 
reducing costs to our government, because we know that $9 trillion more 
in debt is coming.
  Mr. McCAIN. Will the Senator yield for a question?
  Mr. ALEXANDER. Yes, I will.
  Mr. McCAIN. First, concerning the costs, how do we know what the cost 
is if we don't have legislative text? I think all of us have been 
around here long enough--we have talked a lot about the 72 hours that I 
absolutely think we need. The text should be online so that every 
American--not just the 100 of us who are fortunate enough to be here--
can read it. Everybody should have the right to know what a fundamental 
reform of health care in America is all about, and they should be able 
to read the legislation if they want to.
  Just as importantly, I ask my friend, has he seen any legislative 
text anywhere? Is it true that the Finance Committee is moving forward 
with legislation regarding which there is no legislative text? And by 
the way, we find out now, according to the Wall Street Journal, Mr. 
Barthold noted in a followup letter that the willful failure to file; 
that is, to take the government option, would be punishable by a 
$25,000 fine or jail time under a section of the bill.
  I wonder how many Americans are aware of that. In fact, I have to 
tell my

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friend from Tennessee, I was unaware of it. So if we are unaware of it, 
should we not have legislative text so that Americans know what is 
being legislated in the Senate Finance Committee; and second, shouldn't 
it be on line at least 72 years so everybody would know about it?
  Mr. ALEXANDER. The Senator is right. He and I and the Senator from 
Georgia are on the HELP Committee. We worked and we spent many hours in 
June and July marking up that version of the health care bill. We 
finished our work about July 15. That bill was 839 pages. It wasn't 
even presented to us until early in September, and we still don't know 
what it costs. I wonder if the Senator from Georgia heard much about 
reading the bill and how much it costs.
  Mr. ISAKSON. The Senator from Arizona and the Senator from Georgia 
and I all sat through 67\1/2\ hours of markup in the HELP Committee on 
an 839-page bill, which was not scored and had 3 titles blank and they 
are still blank. We didn't have text during that debate on three titles 
within that bill, and what they are developing in the Finance Committee 
today, as I understand it, is concepts. The language is somewhere that 
we have not yet seen. This is too important for us to guess on and to 
take a chance on. It is most important that Congress know precisely 
what it is doing.
  Mr. ALEXANDER. Maybe the Senator from Georgia and the Senator from 
Arizona know more about this than I do, and they are debating concepts 
but they are getting down to specifics. I saw in a morning newspaper 
that Nevada was somehow miraculously taken care of in the provisions 
for Medicaid expenses. We have had Governors, both Democrats and 
Republicans, here saying if you are going to expand on Medicaid in our 
State, pay for it. What happened in Nevada?
  Mr. McCAIN. I say to my friend from Tennessee, first, it is clear 
that the Medicaid cost increases to the States will be incredibly 
large. In the original version of the bill, according to media reports, 
the State of Nevada would have, along with every other State, a 
significant Medicaid expense. So somehow now the legislation has been 
changed, again, according to media because--excuse me, the concept has 
been changed because we don't have legislative language--that 4 States 
would then have 100 percent of their Medicaid costs assumed by the 
Federal Government for as long as 4 or 5 years. That is what goes on 
with the laws and sausages business here. I ask the Senator again, do 
you--first, I ask unanimous consent that the editorial entitled 
``Rhetorical Tax Evasion'' in the Wall Street Journal this morning be 
printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

             [From the Wall Street Journal, Sept. 29, 2009]

                         Rhetorical Tax Evasion

       President Obama's effort to deny that his mandate to buy 
     insurance is a tax has taken another thumping, this time from 
     fellow Democrats in the Senate Finance Committee.
       Chairman Max Baucus's bill includes the so-called 
     individual mandate, along with what he calls a $1,900 
     ``excise tax'' if you don't buy health insurance. (It had 
     been as much as $3,800 but Democrats reduced the amount last 
     week to minimize the political sticker shock.) And, lo, it 
     turns out that if you don't pay that tax, the IRS could 
     punish you with a $25,000 fine or up to a year in jail, or 
     both.
       Under questioning last week, Tom Barthold, the chief of 
     staff of the Joint Committee on Taxation, admitted that the 
     individual mandate would become a part of the Internal 
     Revenue Code and that failing to comply ``could be criminal, 
     yes, if it were considered an attempt to defraud.'' Mr. 
     Barthold noted in a follow-up letter that the willful failure 
     to file would be a simple misdemeanor, punishable by the 
     $25,000 fine or jail time under Section 7203.
       So failure to pay the mandate would be enforced like tax 
     evasion, but Mr. Obama still claims it isn't a tax. ``You 
     can't just make up that language and decide that that's 
     called a tax increase,'' Mr. Obama insisted last week to ABC 
     interviewer George Stephanopoulos. Accusing critics of 
     dishonesty is becoming this President's default argument, but 
     is Mr. Barthold also part of the plot?
       In the 1994 health-care debate, the Congressional Budget 
     Office called the individual mandate ``an unprecedented form 
     of federal action.'' This is because ``The government has 
     never required people to buy any good or service as a 
     condition of lawful residence in the United States.''
       This coercion will be even more onerous today because 
     everyone will be forced to buy insurance that the new taxes 
     and regulations of ObamaCare will make far more expensive. 
     Too bad Mr. Obama's rhetorical tax evasion can't be punished 
     by the IRS.

  Mr. McCAIN. This says:

       Chairman Max Baucus's bill includes the so-called 
     individual mandate, along with what he calls a $1,900 
     ``excise tax'' if you don't buy health insurance. (It had 
     been as much as $3,800. . . .)

  So American small businesses, which are hurting more than any other 
group of Americans today, the creators of jobs--are now facing a $1,900 
excise tax. By the way, the President, in response to George 
Stephanopolos, said there was no tax engaged here. I wonder how many 
Americans are aware of that and how many Americans have had the 
opportunity to know exactly not only what the costs to the Federal 
Government and the respective States are, but the costs to the 
individuals who are struggling to make it in America at a time of 
almost unprecedented unemployment?
  Mr. ALEXANDER. That is a very good point. The Senator from Georgia 
was in small business for many years before he came to the senate.
  Mr. ISAKSON. Yes, I ran a small real estate company for 22 years. We 
tried--myself and other distinguished Senators--on the floor to pass 
small business health reform 3 years ago which would have made more 
affordable and accessible health care to those independent contractors, 
the small business people. It was rejected and we could not get a 
cloture vote.
  Mr. ALEXANDER. May I interrupt for a moment? I often hear it said 
that you Republicans are not for health care too much. The difference 
is we have a little more humility than to try to take on the whole 
health care system at once and fix the whole world. We are ready to go 
step by step, and that is one of the most important steps--to allow 
small businesses to pool their resources and offer health care to their 
employees. I think the estimate is it would add maybe a million new 
people who could be insured that way.
  Mr. ISAKSON. Under outside estimates--not mine--of the 47 million 
alleged uninsured, up to 16 million would have access to insurance 
because of associated health plans and small business reform. That is a 
third of the uninsured.
  Mr. McCAIN. My friend from Tennessee brings up a good and an 
important point about some saying that Republicans have no plan. The 
fact is that the Republicans have no plan for the government to take 
over the health care system in America. That is what it is. What are we 
for? We are for going across State lines so that these small businesses 
and individuals--and the Senator from Georgia used to be one of them--
can get the health insurance policy of their choice. Why should they be 
restricted to the State they are in when perhaps there are minimum 
requirements for those health insurers residing in that State for 
coverage, which they neither want or need, and it may be in another 
State. Why don't we allow small business people to pool their assets 
together and negotiate with health insurers across America for the best 
policy they can get? And we are for medical malpractice reform and 
medical liability reform. We know doctors prescribe time after time, to 
protect themselves, unneeded and unnecessary procedures and tests. We 
all know that. That is in tens if not hundreds of billions of dollars. 
We are for medical malpractice reform. Where is it in any bill that has 
been proposed by the other side?
  We want outcome-based treatment. We want an individual who has a 
certain chronic disease to be treated on the basis of long term. We 
want Americans who have preexisting conditions to have a risk pool they 
can go to or where risk pools would be established so they can get 
health insurance, and insurers will bid on those people with so-called 
preexisting conditions, so that every American can have affordable and 
available health insurance. We are for that. We are for medical 
malpractice reform. We are for going across State lines to get a policy 
of your choice. We are for outcome-based care. We are for taking on the 
drug companies that have cut an unholy deal with the administration, 
which

[[Page S9901]]

will give them the obscene profits, and the lobbyists, who make over a 
million dollars. We want to be able to import drugs from Canada that 
are cheaper for the American people. We want competition, as there is 
in Medicare Part D, for these patients who need it, who don't have 
health insurance.
  So we are for a number of things, but we are not for a government 
takeover of the health care system. So the next time we read that the 
Republican party does not have anything they are for, then they are not 
paying attention. There is more that we are for, but it has to do with 
competition and with availability and with affordability of health care 
in America, not a government takeover. We have seen that movie before 
in other countries.
  Mr. ALEXANDER. As I listen to the Senator, I wonder if the Senator 
from Georgia is having the same impact. Every single step he said 
Republicans are for, whether it is getting rid of runaway junk 
lawsuits, going across State lines to buy insurance, whether it is 
allowing small businesses to pool resources, or incentivizing 
prevention and wellness, they are all focused on reducing costs.
  I ask the Senator from Georgia, I thought this was supposed to be 
about reducing costs for health care premiums and costs to our 
government; but it seems to me we are talking about more billions and 
more debt and more spending and taxes.
  Mr. ISAKSON. Those are the two things Republicans don't want, which 
is more debt to bankrupt our children and grandchildren and more taxes. 
Robert from Loganville was on my teletown hall meeting a week ago in 
Georgia. We were talking about the pay-fors. He said, ``Senator, I want 
to ask you a question. The administration keeps talking about there 
being a half billion dollars of waste, fraud, and abuse in Medicare. If 
that's true, why haven't you saved it instead of using it to save 
against a national health care?''
  That is precisely right. The pay-fors they are talking about to keep 
us from going into debt are moneys that may or may not be there. They 
involve taxation and raising taxes on small businesses. Those are the 
things we don't want to do as Republicans.
  Mr. McCAIN. I ask the Senator from Georgia, do you believe, one, that 
small business people in America today are ready for an additional cost 
laid on them to provide health insurance for themselves and their 
employees? Should we not make it easier and less costly, rather than 
imposing a government mandate, which may have types of health care that 
they neither want nor need, or paying an ``excise tax,'' as is in 
Chairman Baucus's bill?
  The second point I want to ask the Senator about, of course, is this 
whole issue of what should be the government's role in health care in 
America today. We freely admit--not only admit but appreciate the fact 
that Medicare is a government program. But we also appreciate that the 
costs of Medicare have skyrocketed to the point where we now have, by 
estimates, a $31 trillion unfunded liability. In other words, our kids 
and grandkids will not have Medicare 7 or 8 years from now unless we 
fix the issue of costs.
  Mr. ISAKSON. The Senator is precisely right, because as of right now, 
Medicare goes broke in 2017. That is only 8 years from now. In this 
bill, part of the pay-fors is to raise the cost of Medicaid on the 
States to a level that would take Georgia's Medicaid payments in 2014 
by State tax dollars to be from 12 percent to 20 percent of our State 
budget. That is not the way to run a railroad.
  Mr. ALEXANDER. Going back to the point of the Senator from Arizona, I 
hear our friends on the other side say you have used scare tactics, 
saying there will be Medicare cuts. I ask the Senator, did I not hear 
the President say he was going to take a half trillion dollars out of 
Medicare for seniors? There are about 45 million seniors on Medicare 
and who depend on Medicare, and they will spend it on new programs. Is 
that not what I heard him say?
  Mr. McCAIN. That is why there is a rising sentiment, particularly 
among seniors, against this plan, the one passed through the House and 
passed through our HELP Committee and is now being formulated. Our 
seniors and our citizens are a lot smarter than many times we give them 
credit for. They know you are not going to get $\1/2\ trillion in 
``savings'' from Medicare without there being reductions in Medicare.
  There are hundreds of billions of dollars of savings that can be 
enacted in Medicare, but why don't we start tomorrow or why didn't we 
start yesterday or why didn't we start at least at the beginning of 
this debate imposing those savings so we could have a delay in the year 
when Medicare goes broke?
  Mr. ALEXANDER. May I ask the Senator, if there are savings in 
Medicare, shouldn't it be spent on Medicare?
  Mr. ISAKSON. Absolutely.
  Mr. McCAIN. That is an excellent point. But also the fact is to root 
out this waste, fraud, and abuse is going to take time and effort and 
it is going to require some pretty hard work on our part. But we need 
to change some of the fundamentals of the Medicare system in providing 
more competition in the form of prescription drugs, in the form of 
medical malpractice liability reform, in the form of more competition 
between drug companies for Medicare and Medicaid patients. These 
reforms we are advocating have to be enacted in order to bring down the 
costs of Medicare, Medicaid, and overall health care costs in America.
  Look, it is obvious. The cost escalations that are bringing Medicare 
to a crisis are the same cost escalations everybody else in America is 
experiencing.
  Mr. ISAKSON. A lot of them are based in defensive medicine, which is 
practiced because of runaway lawsuits and verdicts. The 
administration's most recent comment about tort reform, to which the 
Senator from Arizona referred, was they want to do a study. A study is 
not what we need. What we need is action. That is one of the biggest 
contributors to the rising cost of health care we have.
  Mr. McCAIN. Or a demonstration project conducted by the Secretary of 
Health and Human Services who knows a lot about this, I admit, because 
I understand she was head of the Trial Lawyers Association for a number 
of years. I am sure that gives significant qualifications to the person 
who is tasked with this project.
  Life is full of anecdotes and experiences we have. I was down in 
Miami at the Palmetto Hospital. I spoke to a surgeon there. By the way, 
they treat a very large number of people who have come to this country 
illegally. I asked the surgeon: How are you doing on making your 
insurance payments, your malpractice or medical liability insurance 
payments?
  He said: I don't have a problem. I don't have it. I don't have it 
because I couldn't afford it and probably I am not going to get sued 
because if they sue me, they are only going to get everything I have, 
not what the insurance company has.
  We are giving physicians and caregivers the untenable option of 
either paying skyrocketing malpractice insurance premiums--in some 
cases $200,000 a year for a neurosurgeon--or as this surgeon did and 
others have done: I am not going to have insurance. That is not an 
acceptable thing to do to physicians in America or anybody in America.
  Mr. ISAKSON. The other consequence of that is the threat of it, and 
the cost of becoming a physician is driving young people to go into 
other professions. We are going to have a shortage of providers, not 
just in physicians but nurses and caregivers, if we have an overly 
regulatory system and an indefensible tort system.
  Mr. ALEXANDER. The Senators from Arizona and Georgia have raised a 
number of questions that need to be answered. How much is the expansion 
of Medicaid going to cost States in State taxes? How much of the 
Medicare costs are going to cost people on Medicare? Are individual 
premiums actually going up instead of down, which is what the 
Congressional Budget Office said. Why is there not something for 
getting rid of junk lawsuits in the bill? Why don't we have a small 
business health insurance pool?
  The point we made when we first started is if we are taking on 17 or 
18 percent of the whole economy in another one of these 1,000-page-plus 
bills, why then do the Democratic Senators vote down the amendment to 
say that

[[Page S9902]]

the bill needs to be online for 72 hours so we and the American people 
can read it? Shouldn't we read the bill we are voting on, and shouldn't 
we know how much it costs before we start voting on it?
  Mr. McCAIN. The Senator is exactly right. Again, wouldn't it be nice 
for our constituents--by the way, many of them come to the townhall 
meetings with a sign that says ``Have you read the bill?''--to let them 
read the bill too. Wouldn't it be nice if every American citizen who 
wanted to could go online and read the legislation and give us their 
ideas and thoughts as to how we could make it better?
  May I mention--I hate to keep coming back to this issue of medical 
liability--a PricewaterhouseCoopers study says defensive medicine could 
cost us as much as $200 billion annually. If we are interested in 
savings, why don't we go right at that? Do we need a demonstration 
project someplace around America? I don't.
  May I mention one other point, and I would be interested in my 
colleagues' views on it. This proposal also levies new taxes on medical 
devices. Why in the world would we want to do that? Medical devices and 
the best technology in the world are developed in America, but they are 
very expensive as they are. Why would we want to levy new taxes on 
medical devices when we know very well that if the insurance company is 
paying for them, the insurance company passes on those increased costs 
to the insured, thereby increasing the cost of health insurance in 
America. Why would we want to do that?
  Mr. ISAKSON. It is raising the cost to the consumer because a lot of 
those types of things that are being taxed are purchased 
discretionarily and are not covered. They are paid for out of the 
pocket of the consumer. When you tax the medical device, you are just 
raising the cost of the medical device to the consumer.
  Mr. McCAIN. What the other side is trying to do is expand government, 
expand coverage, and yet, at the same time, reduce costs. You cannot 
square the circle. That is why they keep bumping into--every time there 
is a new proposal and to make things more expansive and more available, 
they run into escalations in costs and how we are going to pay for it.
  I believe our constituents, again, have figured it out--a reestimate 
of a $7 trillion to $9 trillion deficit over 10 years, a some $700 
billion stimulus package that may have stimulated Wall Street but, 
frankly, in my view from being home a lot, has not stimulated Main 
Street and is not having an effect on unemployment in America, to say 
the least. The neighboring State of California now has 12.2 percent 
unemployment. They cannot get to where they want to go without 
increasing that deficit and debt burden that we are laying on future 
generations of Americans.
  I wish they would sit down with us. I wish we could sit down 
together, start from the beginning, knowing what we know--we have all 
been well educated by this process--knowing what we know now, knowing 
what we can do to reduce health care costs in America and make it 
affordable and available. Unfortunately, as we watch the machinations 
going on in the Finance Committee, that has not happened yet.
  Mr. ISAKSON. I completely concur with the Senator from Arizona and 
the Senator from Tennessee. There is common ground, but you have to be 
willing to find it. So far that has not been the case. When we get to 
that point, we can solve a lot of the American peoples' problems. Just 
ramming through something we cannot read, we cannot quantify, we cannot 
score is not the way to go about it.
  Mr. ALEXANDER. If there is one point we would want to make, it is 
this. It is such an ambitious program. The stakes are so high. This is 
no abstract debate. The reason people are turning up at town meetings 
is because this is about their health care insurance and also whether 
your government is going to go broke in the next few years, dumping a 
lot of burdens on our children and grandchildren.
  What we are saying is we need to read the bill and know how much it 
costs before we start voting on it. We need to read the bill. It needs 
to be online 72 hours. That is a modest request, it seems to me. That 
is a short period of time. Then we need to know how much it costs. Does 
it raise our premiums or lower them? Does it cut your Medicare, or does 
it not cut your Medicare? Does it increase the national debt, or does 
it not increase the national debt? We need to know the answers to those 
questions. It would be the height of irresponsibility for us to begin 
debating a bill that affects 17 percent of the economy at a time when 
our debt is going up so rapidly without having, one, read the bill and, 
two, knowing exactly what the nonpartisan Congressional Budget Office 
tells us every provision costs.

  Mr. McCAIN. Can I tell my friend, if the American people are able to 
know the details of this legislation, I think they would be surprised 
to know that the new taxes--the medical devices, the prescription drugs 
and other tax increases--they begin in the year 2010, 3 years before 
the provisions in the bill for ``reform'' are implemented. So for the 
next 3 years, the cost of health care and health insurance goes up due 
to the new taxes and fees, but the so-called reforms are not 
implemented--why did they do that?--so that the actual costs, as we 
cost it out over a 10-year period, are disguised by beginning the taxes 
and not implementing the reforms, which then the Congressional Budget 
Office can give a cost estimate which is less than, frankly, what it 
actually is if you put the reforms in at the same time as the tax 
increases.
  That is a little complicated, but I think Americans need to know 
that.
  Mr. ISAKSON. My only comment in closing is simply this: The Senator 
is exactly right. Once this horse is out of the barn, you can never put 
him back in. We have to get it right to begin with. We need to go back 
to the drawing board, have a bill we can read, and a bill we can 
afford.
  Mr. ALEXANDER. I thank the Senator from Arizona and the Senator from 
Georgia. They said what we believe. We need to stop, start over, and 
get it right. Above all, we--it seems such a basic thing to say it is 
almost embarrassing to say it on the Senate floor--we need to make sure 
we read the bill before we vote on it, and we need to make sure we know 
what it costs before we vote on it. Those two things are minimum 
requirements.
  From the Republican side, we want to reduce health care costs, and 
rather than try a comprehensive health care reform of the whole system, 
we would like to work step by step in the direction of reducing costs 
in order to re-earn the trust of the American people. Senator McCain 
and Senator Isakson have outlined a series of steps ranging from 
eliminating junk lawsuits against doctors to allowing small businesses 
to pool their resources, all of which would help reduce costs. I thank 
the Senators.
  I yield the floor. I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. Warner). The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. McCAIN. I ask unanimous consent that the order for the quorum 
call be rescinded.
  The PRESIDING OFFICER (Mr. Casey). Without objection, it is so 
ordered.

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