Congressional Record, Volume 155 Issue 174 (Saturday, November 21, 2009)

[Congressional Record Volume 155, Number 174 (Saturday, November 21, 2009)]
[Senate]
[Pages S11907-S11967]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

SERVICE MEMBERS HOME OWNERSHIP TAX ACT OF 2009--MOTION TO PROCEED

The PRESIDING OFFICER. Under the previous order, the Senate will
resume consideration of the motion to proceed to H.R. 3590, which the
clerk will report.
The bill clerk read as follows:

Motion to Proceed to H.R. 3590, to amend the Internal
Revenue Code of 1986 to modify the first-time home buyers
credit in the case of members of the Armed Forces and certain
other Federal employees, and for other purposes.

The PRESIDING OFFICER. Under the previous order, there will be debate
until 6 p.m., with the time controlled in alternating 1-hour blocks,
with the majority controlling the first hour.
The Senator from Vermont.
Mr. LEAHY. Madam President, I am glad to see my colleague and
neighbor from New York in the chair, an extraordinarily hard-working
Member of the Senate. I am not surprised, on a Saturday morning, that
she is here.
Before I begin, I wish to state my appreciation for the kind words
from the majority leader for the Senator from Vermont. He and I have
been friends for decades. I am glad to see the work he has done in
bringing this bill to the floor. I intend to work closely with him.
Decision time is near on health insurance reform. I will vote today
to end the filibuster so the Senate can begin this important, historic
debate to improve and reform our Nation's health insurance system.
Let's not duck the debate. Let the debate begin. Let's not hide from
votes. Let's have the courage to vote. Stand up and vote on the
amendments. Let the American people know where we stand and not say:
Well, it never came up because of the filibuster. We can end the
filibuster today. We can get going. We can let every American know
where we stand.
The sentries of the status quo again have spared no effort to kick
the can down the road, as they have done before. The country suffers
when there is a failure to act on serious challenges that millions of
ordinary Americans face in their daily lives. This is a defining moment
for the Senate and for the country. I rank this along with other major
decisions such as the creation of Social Security and Medicare and the
Civil Rights Act. We have been talking about health insurance reform
for more than 70 years, before I was born. The Senate should not now
prevent a real debate on health reform by hiding behind the figleaf of
a procedural filibuster.
A bill worthy of this debate has been produced, after months of
arduous work. Opponents of reform, unfortunately, have wasted much of
the public's time by provoking arguments over their distortions about
what health reform means. Spurious rumors were spread about death
panels. One mailing opposing this bill claimed that reform would mean
denying care to people based on their voting records. How desperate can
these entrenched powers get, those who want to stop health care reform?
These are the tactics of obstruction in the service of the status quo.
Meanwhile, what the American people yearn for are constructive
solutions. They want an honest debate, not a filibuster. That is what
they deserve, and that is what we owe them.
A Vermonter came by my office to talk about health reform, as so many
have over the last several months. I hear this every time when I am
home in Vermont. If I am in the gas station putting gas in my car, if I
am in the grocery store, if I am coming out of church on Sunday, I hear
this. This Vermonter is a physician. He has a special perspective from
inside the system. He recalled stories about his father, also a very
respected doctor, who practiced in the days before Medicare. He
remembered the devastation his father felt when he was forced to turn
away elderly Vermonters because they did not have health insurance.
It may be difficult today to even imagine this, but before Medicare,
older Americans were routinely driven into poverty during their
retirement years by health expenses. Before Medicare was launched in
1964, nearly half of seniors over 65 had no health coverage and more
than one in three lived in poverty. Today, because of Medicare,
virtually everyone 65 and older has health insurance. The poverty rate
among seniors has plummeted. More than 100,000 Vermonters have Medicare
insurance.

The arguments that were made against creating Medicare may sound
familiar. Opponents of Medicare, when it first came up, tried to
demonize the plan. They claimed it would never work. How could
government run a program like this? They ignored those older Americans
living in poverty. But eventually Members from both sides of the aisle,
Republicans and Democrats, worked together. They passed a bill that is
one of the most successful and popular programs in America today.
Vermont's entire congressional delegation, which at that time was
Republican, supported passage of that landmark legislation.
Today, we have a health system with contradictions. Federal
investments in research and private investments in development have
produced modern medical marvels in the equipment, training, techniques,
and drugs that are available to many Americans. Yet in the prices we
pay, in the lack of access to basic medical care, in the loopholes and
the redtape that plague ordinary Americans in our health insurance
system and in overall results in so many categories, we get far less
for our enormous health care spending than do the

[[Page S11908]]

citizens of countries whose health care costs are only a fraction of
what ours are. Tens of millions of Americans have no health insurance
at all. Employers who want to offer health insurance to their workers
are being priced out of even having that option anymore. Self-employed
Americans must pay dearly to afford any insurance, and they can lose
their coverage at the whim of an insurance company's bureaucracy. In no
modern nation except ours are families actually driven into bankruptcy
by illness. In fact, medical expenses are one of the top reasons for
bankruptcy in America today.
In the absence of a fair and sensible health insurance system,
families, businesses, and taxpayers have been dragged along by an
inflationary curve that only worsens with time. Next year, small
businesses, already suffering from skyrocketing medical costs, will see
their premiums rise by an average of 15 percent. That is twice the rate
of last year's increases. Drug companies have boosted prices of brand-
name drugs by about 9 percent over the last year--the steepest increase
in years. All you have to do is look at the huge salaries paid to their
executives, and you know where that money is going. It is not going to
help the health care of the average American.
Can't we fashion an American-made solution so our citizens can have
high-quality, affordable care and access to basic health insurance? Of
course we can. We are Americans. We can develop that.
The bill introduced this week by the majority leader and by Senators
Baucus, Dodd, and Harkin will give millions more Americans access to
quality, affordable health care. It would end discriminatory treatment
of those who change jobs or have preexisting conditions.
I have pushed and will continue to push to accomplish the three c's
of choice, competition, and cost control, as we reform our health
insurance system.
I am encouraged that the Senate bill includes a public option that I
have strongly supported. I might say, the majority of Americans
strongly support it. I will stand with others as we make our case for
keeping it in the reform plan as part of this process.

I was proud to join Senator Brown and a core group of more than 20
other Senators who introduced a resolution affirming our support of a
public option. A public option would give consumers more choices to
select affordable and quality health insurance plans, while helping to
drive down overall medical costs through real competition in the health
insurance market.
To further enhance the advantages of a competitive market, I have
introduced the Health Insurance Industry Antitrust Enforcement Act of
2009. This would repeal the antitrust exemption for health insurance
and medical malpractice insurance providers. Closing this loophole in
our antitrust laws is long overdue, and I will offer my legislation as
an amendment to the bill to do that. Antitrust enforcement promotes
competition. It helps to lower prices and expand consumer choice.
Another factor that contributes to the rising medical costs all
Americans face is fraud within the health insurance system. The scale
of health care fraud in our system today is staggering. Studies
estimate that between 3 percent and 10 percent of all our health care
spending, both public and private, is wasted through health care fraud.
That is somewhere between $60 billion and $220 billion each year--money
we should have for health care, not going in the pockets of crooks.
To help wring this waste out of our system, Senator Kaufman and I and
others have proposed the Health Care Fraud Enforcement Act. Our bill
would toughen sentences for those who commit health care fraud,
strengthen support for prevention, investigation, and prosecution of
health care fraud, and sharpen the legal tools we need to go after this
fraud. It would prevent waste in spending. It would hold accountable
those who do the stealing. Experience shows antifraud efforts give
taxpayers a superb return on investment, with a payback of between $6
and $14 for every dollar we spend on enforcement.
I am pleased the majority leader included provisions in this bill to
address the issue of health care fraud. I will work with Senator
Kaufman and others to strengthen that bill.
Vermont has helped pave the way for some of the reforms included in
this bill, and now, for the third year in a row, Vermont has been
ranked as the healthiest State in the Nation. Vermont is one of the
earliest leaders in expanding the State Medicaid Program, under reforms
led by former Gov. Howard Dean and others. Yet under the current form
of this bill, Vermont would not share the enhanced Federal match to be
offered to other States. That would amount to a regressive policy with
adverse practical ramifications for Vermont, a State that is a leader
in expanding access to health care. I was heartened in my conversation
this morning with the majority leader when he told me he will try to
correct that problem. But we cannot correct any of these problems until
we debate the bill. Let's not hide under our desks because we are
afraid to stand up and vote and debate.
The people of Vermont have given me the honor of representing them in
the Senate for 35 years. I have joined in many debates that were
contentious yet ultimately productive. I have been on the winning side.
I have been on the losing side. But as we leaf through the pages of
history, we can read of many times when the Senate has shown its
remarkable ability to rise up to reflect the conscience of the Nation.
Those moments were forged in the crucible of national need, against the
anvil of the tempered will of the Senate's membership.
This Senate can do that again. Our dear friend, Senator Ted Kennedy,
said it so well in the letter about the health reform imperative that
President Obama read to a joint meeting of Congress. This is what
Senator Kennedy reminded us:

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

This is such a time. It is my hope and belief the Senate I love will
once again rise to the occasion.
Madam President, I yield the floor.
The PRESIDING OFFICER. The Senator from Colorado.
Mr. BENNET. Madam President, I would like to first thank the Senator
from Vermont for his excellent remarks in support of what is, after
all, just a vote to get us started on the debate on health care, a
procedural vote to allow us to be able to amend and improve the bill in
the coming weeks.
Madam President, virtually every single Member of this body in the
Senate is a Member of the baby boom generation. In my view, it is a
generation of Americans--I was born in the last year of that
generation--given more opportunity than any generation of people in the
history of this planet because our grandparents and our parents were
willing to make hard choices, understanding that part of our national
creed, part of our legacy is assuring that we are expanding opportunity
for those who come after us.
We are having this health care debate at a moment in our country's
history beset by incredible economic difficulties. This is the worst
recession since the Great Depression. But we now know even during the
period of economic growth before our economy fell into this terrible
recession that working families were struggling.
During the last period of economic growth, median family income in
the United States actually declined. As far as I know, it was the first
period of recovery in the history of the United States when median
family income actually went down. It was at the same time the cost of
health insurance was soaring--in my State by 97 percent--with the cost
of higher education in my State going up by 50 percent.
We were saying to working families: You are living in an economy with
incredible weakness, where the growth is surging ahead of a mountain of
debt, but you are not getting ahead.
Just this week, we learned that in the great State of California they
are increasing the tuition for their universities by 30 percent. The
University of California, the California system has been the envy of
the world for decades, and now it is being put out of the reach of
working families.
So we have much to do--much to do--to make sure we honor the legacy
of our parents and our grandparents. We honor the legacy of the
``greatest

[[Page S11909]]

generation'' and this generation, the baby boom generation, to ensure
that we leave behind us not diminished opportunity but more opportunity
for our kids and our grandkids.
There is much we need to do to make sure we have a health care system
that works not just for a few people but for everyone, an education
system that works not just for a few kids but for everyone, and that we
have an economy in the United States that values the contribution that
everybody can make.
My sense in this health care debate is that the people of my State--
and I know people around the country--are deeply dissatisfied with
business as usual. They hate the current system. They know it is not
working for them and their families. They know they are not able to
make the choices they need to make to have stability for their families
so they can get ahead economically.
But, on the other hand, they are deeply worried about our capacity to
make it worse. It is hard to blame people when you hear the special
interests' rhetoric coming out of Washington, DC, or when you turn on
your cable television set at night and watch what people have to say.
You can understand why people are concerned that we have the capacity
to make it worse.

But that is why I am so pleased about the piece of legislation the
majority leader has brought before us. We have never been closer to
reforming our health care system, so we can address runaway health care
costs, enact insurance reform, construct stability and predictability
in health care for families and small businesses.
The Senate legislation before us is that promising new way forward.
Coloradans, as I said, have not been shy at all about letting me know
about their views of the current system and what their concerns are
about what we might do.
Like people across the country, they know the current system does not
work for them. But they are worried, as I said a minute ago, that we
are going to make it even worse.
This bill represents a substantial improvement over business as
usual. I congratulate the majority leader for listening to not just a
small group of people but to people across the aisle, to people all
across the country in crafting this piece of legislation.
First of all, the most important principle of the bill is that it is
paid for. We already had about $5 trillion of debt when the last
President became President. We are now at $12 trillion. There has been
an unbelievable spike between 2000 and today. We have put an enormous
burden--as the father of three young girls, I feel this very personally
and very keenly--an enormous burden on our kids and our grandkids.
Our debt is now $12 trillion. Our entire gross domestic product--our
entire economy--is $14 trillion. Our deficit is $1.4 trillion, 12
percent of our gross domestic product. That is utterly unsustainable.
We know the biggest driver of our medium-term deficits is rising
Medicare and Medicaid costs, and the biggest driver of those is rising
health care costs.
This bill, unlike Medicare Part D--a very worthy program passed
during the last administration--this bill is paid for. That drug
program for seniors was not paid for. Instead of paying for it, instead
of making hard choices, what we said to our kids and our grandkids was:
You pay the bill. By the way, that is what we have said about tax cuts.
That is what we have said about the wars in Afghanistan and Iraq. We
have to put an end to this. This bill at least starts to head us in the
right direction. It does not fix our fiscal crisis, but it is an
important step forward.
As I mentioned a few minutes ago, for working families, the current
system has been a complete disaster, as their income has remained flat
or gone down, as their health care premiums have gone up by 97 percent.
Even though there is a lot of conflict out there about what the way
forward should be, about a specific policy choice here versus a
specific policy choice there, I can tell you, one thing everyone in my
State agrees with is that their health care has not improved by 97
percent over the last 10 years. They are paying more and getting less.
Coverage is getting weaker, as it gets more expensive.
Small businesses are getting crippled by the system we have today.
They pay 18 percent more than large businesses to cover their
employees, just because they are small. Sometimes people say to me:
Well, Michael, don't you know that is because the pool of employees is
smaller? It is harder to spread the risk. I say: I understand that. But
as a businessperson, from a business perspective, that is ridiculous--
the idea that a small businessperson, trying to execute their business
plan, trying to execute their vision to grow their business, is going
to spend 18 percent more for something and not get 18 percent more
productivity out of it, or not get 18 percent, in this case, better
health care coverage out of it. In fact, the reverse is true. It is
ridiculous.
By the way, one of the things that is interesting to me about this
debate over a public option is that people do not seem to understand
what is actually happening before our eyes. As the costs of insurance
are going up every year, few and fewer people are able to get insurance
through their employer, fewer and fewer employers are able to offer
insurance to their employees, which is heartbreaking for many of our
small business owners because these are family businesses that for
years have provided health insurance to their employees. They view it
as part of their pact with their employees to help them get ahead. But
they cannot do it. So they are dropping them from the rolls.
Where are these folks ending up, those who are now uninsured? Well,
two places: Medicaid, if they are poor enough, or in the emergency
room, getting covered with uncompensated care that we, the taxpayers,
are paying for.
We have a public option. It is the least intentional and most
expensive public option you can imagine. When we are talking about the
changes we are making here, we need to understand what is going on in
the daily lives of people all across our country.
The figures we have from the Congressional Budget Office show that
this bill will reduce the deficit, not add to it, will cut our deficits
over the first 10 years by $130 billion, over the next 10 years by $650
billion. That is $780 billion.
One thing we know about those numbers is they are not going to turn
out to be exactly accurate. But here is the goods news: The CBO is
unable to score the benefit of prevention. They are unable to score the
benefit of wellness. They are unable to score or focus on primary care
instead of emergency room care. There is good reason for that because
that comes down to execution--how well is the program implemented.
Those of us who are proponents of reform carry a very heavy burden to
make sure the execution is good and that we carry this through. But the
good news is, if we do a good job, we will save money.
I want to say a word about Medicare because there has been a lot of
discussion from people who are opposed to reform who are saying we are
cutting Medicare. They are saying we are hurting seniors. But what they
will not tell you is that the worst possible scenario is not taking
action now on critical Medicare reform. As I said earlier, and said in
many speeches, our Medicare Program, on its current path, is headed for
fiscal crisis.
Policy experts on both sides of the aisle have said we need to reform
our Medicare delivery system. We need to stop basing payments on every
procedure and every test. Instead, we should look at successful models
such as our own Denver Health, the Rocky Mountain Health System, and
the Mayo Clinic in Minnesota. We know they have better quality and
better outcomes, not just for seniors but for everyone.
This bill builds on what works locally. That means protecting the
guaranteed Medicare benefits for every senior, and for years to come.
It improves Medicare solvency. We make sure doctors will not see a 20-
percent cut in their payments. It makes the entire Medicare system more
affordable and will save taxpayer dollars.
Critics say no to reform. They are content with a system that pays by
the test, test after test, instead of outcomes and patient-centered
care. That approach will assure that Medicare is bankrupt by 2017. We
need to do better than that for seniors. We need to protect Medicare.
Included in this health care reform bill is a version of a bill I
introduced

[[Page S11910]]

based on great work being done in Colorado. It is called the Medicare
Care Transitions Act. We looked at the $17 billion Medicare was
spending on hospital readmissions. Currently, one out of every five
patients leaves the hospital and returns within the same month. We
looked at places in Denver and Grand Junction where the readmission
rates are 2 percent compared to the national rate at 20 percent. What
we saw was that they coordinate care. As people go from place to place,
these health care systems track where they go with a system of
electronic medical records, what medications they use, what doctors
they see. They focus on patients--on patients--when making decisions.
So when we talk about these delivery systems being unnecessary, tell
that to the 12 million Medicare seniors who got readmitted to the
hospital within the very first month they were let out of the hospital.
We owe so much more to these seniors, and we owe a lot more to the
American people.
Health care reform must stop the rising costs that are bankrupting
working families, small businesses, and our economy. If you like your
coverage, you should be able to keep it. We need to put an end to
denials based on preexisting conditions. We need to give people more
affordable options, including a public option. One thing is clear.
Business as usual cannot be an option. The debate is bigger than
politically charged issues. We have to keep our eye on the ball and not
get distracted by the same old, tired, special interest politics that
have kept us from reforming our health care system since Harry Truman
was President.
Health care reform should not be about changing our laws on abortion.
I think the House went astray when it adopted new language with
unintended consequences for women. The Senate bill already makes sure
we do not use taxpayer dollars to fund abortion. That is why I opposed
the House Stupak language.
I want to end this morning on what I am for. I am for insurance
reform. I am for making our small businesses more competitive by
reining in skyrocketing health care costs. I am for reducing premiums
for working families. I am for more consumer choice, including the
ability to voluntarily choose a public option. By the way, one thing I
have noticed is that as people start to understand they are going to be
required to have health insurance as part of this plan, what they are
saying is, I want all the options. I want a private option, a public
option, a nonprofit option. I want to be in a position to make the best
decision for my family.
I am for reform that squeezes our wasteful spending so we can reduce
our deficits in the long term. Throughout this entire debate, my focus
has been on our working families and small businesses. There is plenty
in this bill for you.
The time for talking is over. We should pass this bill. But tonight
what we should do is make sure we allow the Senate to debate the bill,
to improve the bill. There are things in this bill I want to change and
things I want to make better in the coming weeks. But I believe that if
we pass this reform, we will have taken a very important step forward
to saying we are here to honor the legacy of our parents and our
grandparents. We are here to say as one generation to the next that we
are going to carry that legacy forward and make sure we are making the
hard decisions to provide more opportunity for you, not less. This is
only one step of that.
I mentioned education earlier. I mentioned our economy earlier. My
hope is that in this debate, what we can do is begin to learn how to
set the special interests aside for the benefit of the American people.
If we can do that, there is not a doubt in my mind that we will honor
our grandparents' legacy.
Thank you, Madam President. I yield the floor.
The PRESIDING OFFICER. The Senator from Oregon.
Mr. WYDEN. Madam President, even though America has the best doctors
and the best nurses, our Nation spends too much on health care for what
it gets. Because the problem in American health care will not cure
itself, I rise in support of this motion to proceed to beginning the
debate about how to fix American health care.
Before I lay out the many provisions in Majority Leader Reid's bill
that constitute real reform, I wish to talk for a couple of minutes
about how the Senate can come together, Democrats and Republicans, to
fix American health care. I have had a chance to visit with almost
every Member of the Senate in their office on this issue, to listen to
them, and it is very clear to me that both Democrats and Republicans
have valid points. I believe my party is absolutely right in saying you
cannot fix American health care unless all Americans get good quality,
affordable coverage. If you don't cover everybody with that kind of
coverage, what happens is those who are uninsured shift their bills to
the insured folks who are already getting shellacked, and there is an
underemphasis on prevention. So my party is right that to fix this, we
have to offer all Americans secure, quality, affordable coverage.
I think colleagues on the other side of the aisle have valid points
as well. They focus on the need for marketplace forces, for choice, for
competition. I subscribe to each of these principles as well.
I think many believe it is an absurd fantasy that before the Senate
completes its work on this legislation, the Senate could actually come
together, Democrats and Republicans. I simply don't share that view.
Let me be clear: It is my intent when this bill gets to the floor to
work very closely with Majority Leader Reid and with all of our
colleagues to finally break through, to get beyond some of the
polarization, the near brawling we have seen in townhall meetings where
folks sit in opposite sections depending on their political points of
view. That is not the American way to face big challenges. This
certainly is such a challenge.
I believe fixing the economy and fixing American health care are two
sides of the same coin. We can't spend more than 16 percent of our
gross product on health care, spot our foreign competition hundreds of
millions of dollars a year, and have enough money left over to focus on
education, transportation, and domestic needs. The reason so many
Americans don't see their take-home pay go up is because health care
gobbles up all the costs in sight. So this is certainly a big enough
challenge that it demands that the Senate get beyond the fighting--near
brawling--about this subject across the land. On the basis of the
conversations I have had with colleagues, I continue to believe the
Senate can break through and produce a bipartisan bill, working with
Senator Reid, working with colleagues on both sides of the aisle.
In terms of the real reforms that are in Senator Reid's bill, some of
the most important have to do with the delivery system--the way
American health care is essentially experienced across the land. The
fact is that today's delivery system essentially rewards inefficiency.
Payments are based on volume rather than quality. In my part of the
country, we have plans like Kaiser and Group Health, and we have
actually been in the forefront of trying to move away from a system
that rewards inefficiency, rewards volume. What we have shown is that
changing these incentives pays off. People can be healthier and America
can do it for less money.
Senator Reid's bill begins to move in the direction of what we have
been doing in our part of the country for some time. His bill promotes
what are called accountable care organizations. There are also changes
in reimbursement. Probably folks on Main Street are not familiar with
what is called ``bundling.'' In effect, instead of paying for each
specific service, under bundling there is essentially one payment to
reward trying to deliver care in an integrated fashion.
We have been able to have included in the legislation incentives to
care for folks at home. The majority leader included a version of the
bill I introduced called the Independence at Home Act that is backed by
many colleagues on the other side of the aisle, and many Democrats as
well. When we think about the challenges of American health care going
forward, we certainly ought to agree it makes sense to deliver more
good quality, affordable care at home, rather than forcing the sickest
Americans to spend a big chunk of their day fighting through traffic
simply to get to a doctor's office, and we have the technologies, we
have the trained physicians and nurse practitioners to offer these
kinds of services

[[Page S11911]]

at home. I highlight the fact that this is real reform, it is in
Senator Reid's bill, and Republicans and Democrats alike are behind it.

The majority leader makes a number of long overdue changes in the
private health insurance market. In many respects, today the private
health insurance system is simply inhumane. What we have is a system
that rewards cherry picking; where the private insurance companies take
only the healthy people and send the sick people over to government
programs more fragile than they are. What we need is a very different
system where the private insurance companies compete on the basis of
price, benefit, and quality, and not who is the best at selecting out
the good risks.
Senator Reid's bill does away with the unconscionable practice of
pre-existing condition exclusions and the practice of rescission where
the insurance companies abruptly drop coverage for the sick. The bill
also does away with charging a person more simply because they are
sick, because they are a woman, or because they work in a high-risk
job.
These are very constructive insurance reforms. We are going to try to
build on those as we go forward in the legislation. Colleagues should
make no mistake about it: The insurance changes in Senator Reid's bill
are very real reform.
I wish to focus for a few minutes, though, on what I think is the
great promise of this legislation for health care in the future. Since
World War II, there has essentially been no market for American health
care. Back in the days of wage and price controls, we didn't have a way
to get good health care to Americans and we simply said we will put it
on the backs of employers. They were patriotic citizens then, like
there are patriotic citizens now, and they said, We will figure out how
to do it. We are going to have to pass on the costs in the form of
higher prices for goods and services. That probably made sense back
then. We had people essentially work at a job for 20 or 25 years, and
after their last day at work they got a gold watch and a dignified
retirement. Today, there is a very different economy. The typical
worker changes their job 11 times by the time she is 40. She needs a
different set of health care choices. She needs the opportunity to be
empowered to go into the marketplace to hold insurance companies
accountable and to get more value for her health care dollar. The
majority leader in his bill lays the foundation for this kind of
system.
He establishes a system of what are called health insurance
exchanges. They are kind of like farmers markets for health insurance.
Senator Reid has improved this so that these farmers markets, these
exchanges, could only let in good-quality plans, and under Senator
Reid's bill, it will be possible to more easily compare the plans in
these exchanges. This is something I have been interested in for years,
really going back to the days when I was co-director of the Oregon Gray
Panthers, because I think it is simply bizarre that it is possible in
other parts of American life--in a Costco store or any other big
store--to compare products, look at alternatives, have a measure of
uniformity, and not have that in American health care.
What Senator Reid's bill does is set the foundation for a marketplace
so that health care in 2009 will be dramatically different than it was,
say, 60 years ago, in 1949, when I was born. I don't see anybody
outside the Capitol driving a car from 1949, but much of American
health care still resembles the middle of the last century. Senator
Reid, through his legislation, lays the foundation for modernizing
that.
I would like to see more people in these new marketplaces, the
exchanges, more quickly. Under the estimates we have been given, only
about 10 percent of our population would be able to enjoy the fruits of
real choice and real competition. Real choice and real competition in
that marketplace is the path to holding premiums down. My goal in the
years ahead is to allow every consumer--every consumer, for example, in
New York and Oregon--to be able to deliver an ultimatum to their
insurance company. That ultimatum should be: Treat me right or I am
taking my business elsewhere. It is that simple. That is the way we do
it in every other part of American life.
By the way, that is the way it works for all of us here in the
Senate. We belong to a real marketplace. We belong to a real exchange
called the Federal Employees Health Benefits Program. If a Member of
the Senate doesn't like his health care coverage in November of 2009,
come January of 2010, that Member of the Senate can take his business
elsewhere, to another insurer that does a better job. I think that kind
of marketplace--the marketplace every Member of the Senate now enjoys--
ought to be available to everybody else in the country. I think there
ought to be public choices. I think there ought to be private choices.
I think all Americans ought to be able to have access to all of those
choices. We are not going to be able to have real insurance company
accountability, real choice, and real competition unless we make the
exchanges robust and get more people in.
To illustrate the fact that the majority leader and other leaders,
such as Chairman Baucus, are open to new ideas, just yesterday the
majority leader and Chairman Baucus and I agreed on an approach that
will allow more people to enjoy the marketplace, the fruits of a
competitive system, more quickly, when they indicated yesterday they
would support my legislation to expand access to the exchanges for
those who otherwise would have forgone having health insurance under
health reform. Let me emphasize that--letting folks get to the
exchanges who otherwise would have no health insurance at all. We have
been able to do it. According to the CBO, we will be able to add an
additional million people, middle-class folks walking on an economic
tightrope, at 10 percent or less of what it would cost to have those
people get their coverage through Medicaid or through subsidies. It is
my intent to work with the majority leader and Chairman Baucus closely
to allow others to have a chance to be part of this kind of competitive
system. I commend the majority leader and Chairman Baucus for their
commitment to work with me, as this bill goes to the floor, to expand
access to the marketplace.
Let me close with one last point. I see my colleague from New Mexico
in the Chamber, and he is a welcome addition to the Senate.
A lot of Americans listening may wonder why the Senate is turning its
attention to health care when there is so much economic hurt in our
land. The fact is, fixing the economy and fixing American health care
are literally two sides of the same coin. We have to rein in these
costs. We have to rein in these costs for Americans to have more take-
home pay, to be in a position to pay for essentials, and to allow our
workers to compete in ferociously challenging markets around the world.
It is time to move beyond the townhall brawls of this past summer and
for the Senate to work with Senator Reid and all colleagues to break
through and deal with this critical issue, the premier long-term
challenge of our time for our economy, and do it in a bipartisan way. I
urge my colleagues to vote for the motion to proceed.
I yield the floor.
The PRESIDING OFFICER. The Senator from New Mexico is recognized.
Mr. UDALL of New Mexico. Madam President, I appreciate very much
listening to Senator Wyden and his comments on health care reform. He
has been one of the leaders when it comes to working in the Finance
Committee and looking for significant reforms on health care. I look
forward to working with him in that capacity.
The health care reform we are debating today will impact every person
in this country. Whether you are searching for affordable insurance for
yourself or watching helplessly as a loved one is denied coverage,
every American stands to gain something through this historic
legislation.
In my home State of New Mexico, the people I represent don't just
have a lot to gain from this reform, they also have a lot to lose if
this reform is not enacted. For New Mexicans, the status quo isn't an
option. That is because without this health care reform our State is
expected to experience the largest increase in insurance premiums of
any State in the Union. In 2016, without this reform, a family of four
in New Mexico can expect to pay an astounding $28,000 a year in health
care premiums. That will consume more

[[Page S11912]]

than 56 percent of that family's projected income for the year.
Affordability is already one of the key barriers to obtaining coverage
in my State. Since 2000, premiums for residents have risen 110 percent.
As a result, almost one in four people doesn't have insurance, giving
us the second highest uninsured rate in the Nation.
Enactment of this reform legislation would make as many as 249,000
middle-class New Mexico residents eligible for premium credits to ease
the burden of these high costs. In addition, almost 238,000 New
Mexicans would be eligible for new private coverage through the
exchange or through their employer and another 124,000 would be
eligible for the new expanded Medicaid coverage. For the families who
already have insurance, they win too. They will likely see lower
premiums, thanks to the increased competition in the market. The bottom
line is that with this reform the vast majority of New Mexicans would
have access to quality, affordable health care for themselves and their
families.
Reform will also benefit New Mexico's small businesses. In 2006, less
than 35 percent of small businesses in my State offered coverage for
their employees. That figure means our State ranks dead last in
employer-sponsored insurance in the Nation--a dubious distinction, to
say the least. I have talked to a lot of these small business owners
over the past month. They all tell me pretty much the same thing: I
would love to offer coverage to my employees, but it is just too
expensive. They say they are having a hard time affording insurance for
their own families. To those small business owners, I say that help is
on the way. The Patient Protection and Affordable Care Act will help
you provide insurance to your employees by providing Federal tax
credits of up to 50 percent of premiums should you choose to offer
coverage.
In addition to lowering costs for individuals and families and
helping small businesses, this reform would also give our rural
communities additional tools to provide quality, affordable health care
for all of their residents.
Of the 2 million people who call New Mexico home, about 700,000 live
in rural areas. They are more likely to be uninsured and often must
travel hundreds of miles for preventive or emergency care--if they are
able to find any care at all.

In this bill, we have included pay incentives to recruit more
physicians to serve in these underserved rural areas. We will improve
dental services in rural areas, we will extend Medicare payments for
ambulances in rural areas, and we will expand the Telehealth Program so
that rural residents may receive specialized treatment not available in
their local areas.
Finally, we make sure this legislation won't result in an unfunded
mandate for our State government, which is already experiencing the
pain of budget cuts, thanks to the economic downturn. This legislation
would require the Federal Government to cover 100 percent of the cost
of the Medicaid expansion from 2014 to 2016 and 95 percent of that cost
after that.
When it comes to health care today, too many New Mexicans are living
on a cliff, teetering on the edge of financial ruin. All it would take
is an illness or job loss, and they could fall into the abyss of
medical invoices, bill collectors, and bankruptcies. For these New
Mexicans, the status quo isn't an option. This bill offers a life rope
to these New Mexicans to pull them back from the precipice. Passing it
would provide stability and security to those who have insurance,
affordable coverage to those who don't, and lower costs for families,
businesses, and government.
This is a historic moment. I urge my colleagues to join me in seizing
it. Let's begin the debate on this long-overdue legislation to reform
our broken health care system.
With that, I yield the floor.
The PRESIDING OFFICER. The Senator from New Hampshire is recognized.
Mr. GREGG. Madam President, I ask unanimous consent to be allowed to
speak in a colloquy as it evolves on our side.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. GREGG. We are joined by a number of the distinguished members of
our caucus. They have thoughts they want to express. We want to discuss
a couple of points.
Before I turn to the Senator from Missouri, I want to make a point,
because I have been listening to a lot of the discussion on the floor,
and I have participated and listened to a lot of it on television, from
my colleagues on the other side of the aisle. They continue to use this
number. They claim this bill will cost $800-some-odd billion and that
is the number that has been reached as the expenditure on this bill.
That is a totally dishonest number. That is the ultimate shell game.
That is Washington cynical politics.
Do you know how they get to that number of $800 billion as a cost of
the bill? It is a 10-year number, by the way. That is a lot of money,
$800 billion. That would run the State of New Hampshire for probably
100 years. Missouri is a little bigger, but it would run that State for
a while, and it would probably run Alabama for a little while. South
Dakota could probably run for 200 years on that. That is not the real
cost of this bill, though. That is not the cost of the bill.
The way that number was arrived at--and I think the American people
need to understand this. If that number was so dishonestly arrived at
for the number of the bill, what is wrong with the rest of the bill
that they haven't been told about? That was a 10-year score for what
the bill cost was, but they don't start spending money under this bill
until the fourth and fifth year. In fact, the cynicism exceeds that.
They couldn't get the score they wanted--they couldn't get the score
they wanted from CBO, so they moved back another year in the 10-year
cycle. They went from 4 years to 5 years as to the starting point of
most of the spending in this bill.

What they claim to the American people is the 10-year bill is going
to cost about $800-plus billion. But what they don't tell the American
people is they are not spending anything in the first 4 or 5 years of
the bill. No, they do raise your taxes throughout the 10-year period.
They do cut Medicare throughout the 10-year period. But they don't
spend the money. They don't start the programs until the year 2014,
when this bill is fully phased in.
When all these new programs, this massive expansion of entitlements
is created, brand-new entitlements, when all this new spending occurs,
this bill will cost $2.5 trillion over that 10-year period--$2.5
trillion. That is the real cost of this bill. That is how this
government is going to grow in a 10-year window as a result of this
spending.
I say to my colleagues, I think most of us understand we already have
a huge debt problem in this Nation. We are passing on to our kids a
country with so much debt they are not going to be able to afford it.
Every year for the next 10 years, without this health care bill, the
President has proposed budgets which will run a $1 trillion deficit,
every year, on average, for the next 10 years. Sometime this month, we
are going to have to raise the debt ceiling of this country because we
reached $12 trillion in debt. Then it is going to have to be raised
again because we are running up these massive deficits.
The debt owed by this country will exceed 80 percent of our gross
national product--80 percent of our gross national product at the end
of that 10-year period--and will exceed 60 percent of our gross
national product within 2 years. Those are unsustainable numbers. Yet a
bill is being proposed that is going to expand the size of government
by $2.5 trillion.
It is alleged it is paid for, and we are going to get into a
discussion in some depth because I think that is an equally cynical
number as a result of bait and switch.
I just wished to clear the air as to the real cost of this bill
because I found it uniquely cynical that it would be represented that
this bill costs $890 billion, whatever the number is. It does call into
issue the credibility of the rest of the numbers that are being thrown
out by the other side of the aisle when they use that number, which is
a 5-year number that they claim covers the 10-year cost, when they
don't do anything in the first 5 years.
I appreciate the indulgence of the Senator from Missouri. I
understand he wishes to speak and then we will go to the Senator from
Alabama and then the Senator from South Dakota and

[[Page S11913]]

then have a discussion about some of the issues, such as costs, how it
affects Medicare, how it affects small businesses, how it is going to
affect your personal insurance.
Mr. BOND. Madam President, I thank the Senator from New Hampshire. I
wish to clarify some things he said because they are truly important. I
wish to make sure everybody understands it because Senator Gregg, in
his position on the Budget Committee, as well as his other positions in
writing this bill, is intimately acquainted with the costs of this
bill.
The cost for 2010 to 2019, how much was the cost for that 10-year
period?
Mr. GREGG. That is $1.2 trillion because between the period 2010 and
2014, there are no expenditures because they don't start the programs
until 2014.
Mr. BOND. Is this the total expenditure or are these just the
expenditures that are not covered after 2014, that are not covered by
the so-called tax or revenue raisers? In other words, does this all go
onto the debt?
Mr. GREGG. No, those are total expenditures which are represented to
be offset by cuts in Medicare, increased fees, and increased taxes.
Mr. BOND. Cuts in Medicare. How much are the cuts in Medicare?
Mr. GREGG. When fully phased in, in the 10-year period, 2014 to 2023,
the Medicare cuts are $1.1 trillion.
Mr. BOND. Madam President, $1.1 trillion cuts in Medicare. How much
are the taxes and the other ``revenue raisers'' in that period?
Mr. GREGG. The taxes and fees during that period--this period, when
it is fully phased in--are approximately $1.5 trillion.
Mr. BOND. So how much will go onto the debt? How much is uncovered?
Mr. GREGG. Actually, if you accept these assumptions that we are
going to cut Medicare by $1 trillion and take that to create a new
entitlement instead of using it to help Medicare be more solvent and
then we are going to raise taxes and fees by $1 trillion--remember,
most of this is not going to come out of the wealthy. It is going to
come out of small businesses and higher premium costs to people on
insurance or it is going to come out of HI taxes. If you accept that
logic, which I find to be a bit of a reach, then it will not have any
impact on the deficit in that timeframe because they have cut Medicare
to pay for it, and they have raised all these taxes to pay for it.
Mr. BOND. My friend has been very active in the Budget Committee. How
many times have we cut Medicare, have we allowed Medicare cuts to go
into effect? I think that is a rather rare occurrence, isn't it?
Mr. GREGG. That is a fascinating question because I was chairman of
the Budget Committee the last time we tried to do something in the area
of the rate of Medicare costs because we received a directive from the
Medicare trustees that Medicare had to be made more cost-effective or
else it was going to go broke. So we suggested, when I was chairman of
the Budget Committee--and everybody in this room voted for it, by the
way--that we should reduce the rate of growth of Medicare by $10
billion on a $1 million timeframe. In other words, Medicare was going
to spend $1 trillion over a period, 5 years. We were going to suggest a
$10 billion reduction in that rate of growth which was going to be paid
for by requiring people who were getting Part D premiums and had high
income to pay for part of their premiums--people such as Warren Buffett
would not be subsidized by people working down at the local restaurant.
We did not get one vote from the other side of the aisle. We passed
it by having the Vice President sit in the chair and break the tie.
That was $10 billion over 5 years.
So I think this idea that you are going to do $1 trillion over 10
years and pay for this--first off, if you are going to reduce spending
or raise Medicare taxes, it should go to pay for Medicare solvency
because Medicare is insolvent. It shouldn't go to create a new
entitlement. Senior citizens, paying into Medicare all their lives,
should not have their money taken to start a brand-new entitlement for
other people, and that is what this bill does.
As a practical matter, we are not going to do that. We know that. We
know this is all going on the debt. Ninety percent of this is going to
end up on the debt.
Mr. BOND. I thank my colleague from New Hampshire because he has been
a very solid, consistent, credible voice. What he is pointing out today
is that the legislation we are debating has major implications for
every American family, every American taxpayer, every American small
business.
In the 1992 election, President Clinton's famous slogan was: ``It's
the economy, stupid.'' Seventeen years later, it is again the economy
that is a major issue facing the people. But this time the majority
party does not seem to be paying attention. Instead, the majority has
used its supermajority position to spend trillions of dollars that we
don't have, including a misnamed stimulus that stimulated the growth of
the deficit and the Federal Government but not jobs. We had takeovers
and bailouts of banks, insurance companies, and major auto
manufacturers. They have adopted a budget that would double the debt--
the debt our grandchildren owe--in 5 years and triple it in 10.
It is little wonder that the unemployment rate has skyrocketed,
because employers are afraid to hire. Families are seeing their budgets
strapped such as never before. But the bill before us is a crowning
achievement of the drive to destroy our economy and hope for the
future.
Just 1 year after a narrowly averted financial collapse, with
unemployment at its highest level since 1983, instead of how to create
jobs, we are debating a bill that will take over one-sixth of our
economy and likely kill jobs.

Don't get me wrong, our health care system is in need of reform. It
costs too much, too many people are uninsured, there are too many junk
lawsuits and too much defensive medicine and not enough focus on
prevention and wellness.
While we all agree reform is necessary, the American people expect us
to answer the questions: How much will reform cost and can we afford
it? Will it lower health care costs? Can you keep your current plan?
What role will the government play?
The answer to two and three on this bill is: No, it will not lower
our health care costs; no, you will not be able to keep your current
plan.
Then the question is: Who will make health care decisions? We are
seeing evidence that they have government committees that say when you
can get a mammogram, when you should get Pap screening.
Will Americans and Members of Congress have time to evaluate what is
in the legislation? We hope today, as yesterday, that we will bring out
for the American people the cost of this bill because what we are
seeing in this massive pot, 2,047 pages, is there is a lack of
commonsense reform. It is filled with costly budget gimmicks and asks
the people of America to spend over $2 trillion on proposals that will
heap a mountain of debt on our children and grandchildren.
Two trillion dollars is an almost unfathomable amount of money. But
in Washington, trillion is the new billion, and that is not the kind of
health care reform Americans want. It is not reform at all. It spends
too much, it taxes too much and it cuts Medicare too much and does not
provide reforms we need. Nearly $\1/2\ trillion in taxes will be added
on the backs of the American people, $28 billion in taxes on
businesses, which will kill jobs at a time when we have over 10 percent
unemployment and even higher if you include the number of people who
are no longer working or underemployed. These higher costs will
ultimately be passed on to American workers and consumers.
Anybody who thinks you are going to tax health care insurers, device
providers and expect that those costs will not be passed on to the
consumers--that is you and me, Madam President. The head of the
Congressional Budget Office and the Joint Committee on Taxation have
said these higher taxes are passed along, and they will land on
families, small businesses, and individuals.
It will also force Americans into a government-run health care plan.
It will ration care and limit access to lifesaving treatments and put a
bureaucrat between you and your doctor. In life, two things you can
count on are said to be death and taxes. I didn't expect to see them
both in a health care reform proposal.

[[Page S11914]]

We call this a pig in a poke. The only way to sell a pig in a poke is
to hide from Americans what their tax dollars are buying. If I were to
outline all the problems in this 2,000-page bill, we would be here
until Thanksgiving. It is sort of like a mosquito in a nudist colony--
there are so many targets to attack in this bill we don't know which
one to hit.
Let me give you just a few. As the Senator from New Hampshire pointed
out, the real cost of this bill to the American people is a whole lot
more than they admit. The majority is claiming that the bill only costs
$850 billion, but the way the majority gets to say that is because they
are pulling a great smoke-and-mirrors trick.
Even more incredible is the Democrats' claim their bill will cut the
deficit. It is a great scheme, but no one outside Washington actually
believes this health care bill will do anything but increase costs and
pile more debt on our kids and grandkids, and they are right.
Right now, as the ranking member of the Budget Committee has pointed
out, the national debt already exceeds $12 trillion. This bill will put
more on that. The true cost of the bill is not just a ``he said, she
said.'' Even the nonpartisan Congressional Budget Office acknowledges
that the majority's bill includes gimmicks that hide the true cost of
the bill.
Part of the majority's scheme to hide from Americans the true cost is
the great stunt, as the Senator from New Hampshire described, to push
back implementation of parts of the reform to 2014 but start collecting
money in taxes now. That means tax now and pay later. That sure makes
your numbers look good, doesn't it?
For example, Medicaid expansion does not begin until 2014. That is in
section 2001. Section 1311 says health insurance exchanges are not
fully operational until January 2014. Section 1323 says a public health
insurance option is not available until 2014. Most of the major
insurance reforms, however, in section 1253 take effect in 2014.
The tax on health insurance starts in 2010. That is section 9010.
Section 9009 says the tax on medical devices starts in 2010. Section
9008 says the tax on pharmaceutical manufacturing starts in 2010. That
is even worse than the Senate Finance Committee bill which initially
had it starting in 2013, but it is a great gimmick to allow them to
hide the cost of the bill. Claiming savings of $122 billion by
recording taxes over 10 years and only scoring costs over 6 years would
get an officer in a publicly traded corporation sent to jail. Move
over, Bernie Madoff. Tip your hat to a trillion-dollar scam. This is
magnificent, and that is in this bill. I am glad all Americans can read
it. They can check out the sections I cited.
Even the Congressional Budget Office has called ``bull'' on this
stunt, saying it would be difficult to maintain the savings the
majority has been touting. No wonder. And the true cost, as the Senator
from New Hampshire has pointed out, is $2.5 trillion. But it will also
be increasing taxes. In fact, everyone will be taxed one way or
another. Forget what the President promised about no taxes. Sections
9004 and 9010 will tax Americans who have insurance. Section 1501 will
tax Americans who do not have insurance--almost $8 billion. Taxes will
be placed on medical device manufacturers, section 9009; and as the CBO
has said, those taxes will be passed on in the form of higher prices
and thus in the form of higher insurance premiums.
Because of the tax on health insurers, section 9010, the CBO and the
Joint Committee have said these taxes will be passed on in the form of
higher health care premiums. Pricewater-houseCoopers says that is $487
a year per family. That is how much these taxes on the health insurers
and health payment plans will cost the average family.
Employers will be taxed. About $2 billion in new taxes will be placed
on employers who do not meet government approved health care plans.
That is section 1513. That is where American workers are going to pay
for it because that is where they lose their jobs. Headlines in the
Wall Street Journal and letters I have seen from leaders of businesses
say we are not expanding; we cannot afford to expand; we cannot afford
to take on more employees.
Why are we having a jobless recovery? Because the threats of
Washington's overspending, overcontrolling, overtaxing, and
overregulating are telling prospective employers that they are about to
hit the ditch with all the things the Government is putting on them.
For all of the taxes and mandates, according to CBO, about 5 million
Americans would lose their employer coverage. That is because the costs
would go up, the regulations would go up. Currently, 83 percent of
Americans have health insurance, and they are concerned that it costs
too much. Americans want affordable health care, but this bill raises
the cost of health care. New taxes and mandates will be passed on to
American families, the American taxpayers, and American small
businesses.
The bill still leaves 24 million Americans without insurance.
According to the CBO, the government-run plan will have higher
premiums, and the CBO said it will drive up the cost of health care.
This was supposed to lower the cost of health care. It will not do
anything of the kind.
To sum up, $2 trillion in more spending gets the American taxpayer,
in the 2,074 pages, a Federal bureaucracy that increases the cost of
health care, raises premiums, slashes Medicare for seniors, and puts
unfunded burdens on States.
Let me just make two last points: The States, according to CBO, will
get coverage for these new Medicaid eligibles for the 2 years that they
will get covered and then they will dump it on the States--$25 billion.
There is a $25 billion cost.
The Senator from New Hampshire and I were both Governors of our
States. I can tell you, States do not need that kind of burden,
particularly in their difficult circumstances.
Slashing Medicare for seniors? In Missouri, Medicare already only
pays 80 percent of the costs. More and more hospitals and doctors have
to limit the number of Medicare patients they can accept. If we
continue, and if they push through this Medicare cut, then fewer and
fewer Medicare patients are going to be able to get health care.
I hope my colleagues will listen to what the American people are
telling us and vote against the bill. That is certainly the message I
am getting from Missouri.
I yield the floor.
The PRESIDING OFFICER. The Senator from Alabama is recognized.
Mr. SESSIONS. Madam President, I thank Senator Bond. He has certainly
delineated some of the fiscal impossibilities in this bill, as has our
former Budget chairman, now ranking member of the Budget Committee,
Judd Gregg. He studied this very hard. The information he provided to
this Congress and to the American people is accurate.
I have tried to think what I should say about this bill this morning
and be realistic and honest and boil it down to its essence. The 2,000
pages that sit on that desk, how should we talk about it?
Let me just say the claim from our colleagues is that they have a
great plan to reform health care and it will fix the problems in health
care. We do have problems in health care that need to be fixed. They
are going to provide methods and additional funding and provide
millions of people with insurance who didn't have it before--although
24 million will remain uninsured. At the same time, they will save $130
billion over 10 years, and we are supposed to be grateful and say how
pleased we are that you have been able to pull off this event.
But the first reaction most American people have had, and it is a
sound one, is, wait a minute, that is pretty dubious. How can you do
that? Do you remember that song from the ``Sound of Music''? ``Nothing
comes from nothing, nothing ever could,'' sang Julie Andrews.
The result is the phrase I came up with: ``Shell game.'' Senator
Gregg used that phrase. I think that is exactly what we are talking
about. When it became obvious to everybody who could add that this
great vision, the wild chimera they had that they could do all these
things, would not work as they dreamed it, the mountebanks began their
chicanery.
In my remarks I will not attempt to point out all the manipulations
in this bill, just some of the more obvious that are inescapable.

[[Page S11915]]

First, you ask: Why do they do this? The answer is the numbers don't
add up. They cannot make the numbers do what they want them to do. So
they either have to be honest and talk about massive cuts openly or
massive tax increases. The American people are not sure about that. To
add a whole new monumental health care program at a time of colossal
financial stress in our country, with debts the likes of which our
Nation has never ever seen before, are we now going to start off on a
monumental multitrillion-dollar bill that will not pay for itself?
We have this great promise, and it is not adding up. Do they slow
down? Do they begin to think if they can't do everything they promised
in the campaign, and they would love to do, and they wanted to do, what
progress can they make step by step in a rational way that we can
afford in this time of unemployment and unprecedented deficits? No,
that is not what they decided to do.
What they decided to do is go forward anyway and call anyone who had
the temerity to say their ``emperor has no clothes,'' that they are
``Dr. No,'' they are against everything. They don't believe in any
reform.
That is kind of the idea we are hearing, and that is not correct.
The bill is just too much, it goes too far, too fast, and costs too
much. We don't have the money. The American people know this. That is
why they oppose this bill. They are not opposed to reform and progress.
They are opposed to this legislation, this 2-foot tall, 3-foot tall,
2,000-page piece of legislation.
They don't dislike President Obama, but they don't like this policy
he is trying to promote. You say: Let's have some facts about it. I
can't explain everything, but I want to share a few things.
Madam President, I ask to be notified after 5 minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. SESSIONS. A critical, essential part of fixing a broken health
care system is to end the growing problem of payments to our doctors.
Republicans and Democrats have not been good on this issue in the past,
but the problem grows worse each year. Essentially, in the balanced
budget amendment of 1997 we limited the amount of payments to doctors.
After a while it became clear the cuts were too severe, and each year
we put money back in. But the law still mandates major cuts. In fact,
today if we don't do what we call the doctor fix each year, they will
have a 23-percent reduction in reimbursements, they get paid less. This
is for Medicare. And they get paid less for Medicare than other
insurance already, so doctors are going to quit doing it if we have a
23-percent reduction in what they get paid for doing their work.
How much does it cost to permanently fix that as the medical
profession assumed we were going to do and as the President and his
team have indicated they plan to do? It costs $250 billion. That is a
lot of money. That is not a new program, this is an obligation that we
have now. Does this plan fix that? It fixes it for 1 year. So it goes
out 1 year and then the CBO score assumes the doctor payments will drop
23 percent and be 23 percent lower for 9 years.
If we add that up, that is $250 billion. It allows the folks in the
know here to manipulate the numbers and hide a $250 billion debt we
owe. We can't cut doctors that much, and we are not going to do it. We
have not been doing it, and we will fix it every year, in fact, and
that is--what I will say is, we will spend the $250 billion, and it
should be in this bill. They didn't do it.
Just a few weeks ago, they met in this secret room down the hall, and
they got to talking and said: What are we going to do about the
doctors? How are we going to fix the doctors?
We could raise taxes.
Well, we raised taxes $500 billion. We can't raise them any more. Can
we cut Medicare?
Gosh, we have cut it $500 billion. We can't do that.
What can we do? We promised the doctors fix to get them their pay.
So they offered--it would be hilarious if it weren't so serious--they
offered legislation a few weeks ago to just pay the doctors all this
money permanently, outside of the health care reform in a separate
bill, every penny of it going to the debt, unpaid for.
Even 13 Democrats couldn't swallow that. They voted no, and it
failed. But the House did it. They passed it, did they not, I ask
Senator Gregg, unpaid for? Horrible. Another $250 billion added to our
debt.
So that is a shell game. It is like you have a hole in your roof and
you don't want to spend the money to fix it, so you move across the
hall into another room and pretend the hole isn't there. Somehow you
are not going to fix it when you know you have to fix it.
They say: Don't worry. See, our plan is budget neutral. It is deficit
neutral.
If you take the $250 billion, one thing right there, it is not
neutral. It is in deficit already. It is in deficit already. You have
to watch that pea and see how it moves around in the shell. But what we
need to have a sense of is that this is a program we have never had
before. It not only adds to the debt by not fixing the doctor payments,
it raids existing programs, Medicare and Medicaid, both of which are in
serious trouble. It raids them in the first 10 years and, as Senator
Gregg said, much more later, $549 billion. And it raises taxes $493.6
billion. So it is pretty easy to say I have a deficit-neutral program
if I assume I am going to take $500 billion out of Medicare and raise
taxes $493 billion. It is budget neutral. Everybody should thank me.
That is what the paper said the other day: Budget neutral. We are so
proud of ourselves.

The American public are not buying this. They are a little bit
skeptical. Medicare is going broke. Everyone knows that. We have been
working on that for a number of years. All of us are concerned about
this iceberg in front of the Titanic which is Medicare's deficiency.
The PRESIDING OFFICER. The Senator has consumed 5 minutes.
Mr. SESSIONS. I thank the Chair.
We need to save this program before we create a new one. It is so
simple. If we are going to raise taxes $500 billion, has anybody asked
where that money should go? Should the $500 billion in new taxes go to
create a new program or maybe should it be used to put Medicare on
sound footing or maybe it should be used to pay for military
expenditures that have the highest budget in years, or maybe to reduce
the debt which, I point out to friends and colleagues, is the greatest
debt this Nation has ever seen. There has been nothing like it ever. In
2008, our debt was $5.8 trillion. In 5 years, 2014, it will be $11.8
trillion. In 2019, it will be $17.3 trillion, tripling in 10 years.
According to the Congressional Budget Office score, it does not include
money to fund the health care program.
How big are those numbers? I won't spend a lot of time on it. I will
point out that people can understand when you borrow money, this debt
doesn't come from thin air. You borrow it. China, other places loan us
money. We owe them money. That is how we get the money. And look at the
interest rate. My goodness. Alabama's budget is about $8 billion a
year; $800 billion in this year is 100 years of our budget. The
interest the United States paid on our debt in 2009 was $170 billion.
That is a lot of money. The Federal highway bill is $40 billion. All of
the Federal highway spending is around that amount. But in 10 years,
according to the CBO, we are going to be paying in that 1 year interest
of $799 billion. It is like nothing we have ever seen before. That is
why people say our spending is on an unsustainable course.
The first thing we need to do to bring spending under control is to
fix the critical problems that must be met. You don't start new
programs that are likely to spiral out of control and far exceed the
prognostications we have seen today.
I thank the Chair for the opportunity to share my thoughts. I am glad
our colleagues are here. I know others would like to talk.
I yield the floor.
The PRESIDING OFFICER. The Senator from South Dakota.
Mr. THUNE. Madam President, I appreciate the great job done by my
colleagues from Missouri, Alabama, and New Hampshire in pointing out
many of the concerns we have with regard to this bill and why we think
this is a bad direction to go.
You have heard my colleagues talk about a massive expansion of
government, tax increases, premium increases; obviously, the very
serious problem we have with our national

[[Page S11916]]

debt and the deficits we are racking up every single year, to the tune
of about $1 trillion or north of there, $1.4 trillion last year, on a
pathway to hit that target this year.
I have heard my colleagues on the other side talk repeatedly about
Republicans not having their own solution. I have to say, maybe the
reason they haven't been seeing the Republican solution is because they
have been hiding behind this voluminous 2,100-page bill at a cost of
$1.2 billion per page. Republicans--hundreds of times, if not
thousands--have come to the floor and outlined a step-by-step solution
to dealing with the health care crisis and the concerns most Americans
have which is the high cost of health care. Unfortunately, many of my
colleagues on the other side perhaps have not been able to see that
because they can't see around this $2.5 trillion expansion of the
Federal Government they seem intent on pushing through the Senate.
Republicans have talked about buying insurance across State lines,
small business health plans, tort reform, incentives for wellness and
chronic disease management. There is a whole range of things that could
be done to address the concerns of the American people about the high
cost of health care that do not involve a $2.5 trillion expansion of
the government, a 2,100-page bill, at a cost of $1.2 billion per page.
The other thing I have heard my colleagues say is we have to do
something. People in this country are dealing about the high cost of
health care. They are. We all hear it. We hear it from small
businesses, from families, and from individuals. Everybody is concerned
about the high cost of health care. In fact, a number of my colleagues
on the other side have said of all the bankruptcies that occur every
year, most occur because of the high cost of health care. Get this,
America: Under their proposal, you will go bankrupt sooner. Because
they drive the cost of health care up. They don't do anything to bend
the cost curve down.
I want to show a chart which points out what happens to the cost
curve under the Democratic plan we are talking about. The blue
represents the current cost curve. That is the increase in health care
costs we would see if nothing is done, year-over-year increases into
the future. What we would expect, if we were going to reform health
care, is that line starting to bend down a little bit so that health
care increases go down over time instead of up.
What happens? Under this proposal--and this is the CBO; this isn't
what I am saying or any of my Republican colleagues, this is what the
Congressional Budget Office says--the Democratic plan we are talking
about increases the cost of health care. It bends the cost curve up;
$160 billion more will be spent on health care if their plan gets
enacted. All those people who are concerned about the high cost of
health care today are not getting any relief under the Democratic plan.
In fact, their lives will get much worse--in particular, those who
already have health care.
There are some in this proposal who will get some subsidies to buy
insurance in a health care exchange. That affects about 19 million
Americans. But there are 182 million Americans who currently have
health care who, if this bill passes, are going to be faced with higher
taxes and higher premiums. That is the way it works. They are
ineligible to get any subsidies to buy insurance. In fact, they don't
have any more options available to them. What they are facing is higher
taxes that they will be faced with under this bill, as well as higher
premium costs.
If you are the average person who is worried about cost, which I
think most Americans are, and you are watching what is happening here
in Washington, you have to be asking yourself: What is the whole
purpose of going through a health care reform debate if, in fact, it
doesn't do anything to drive down the cost of health care?
My colleagues have pointed out that when you spend $2.5 trillion,
when you expand the Federal Government by that amount, when you raise
taxes on medical device manufacturers, on prescription drugs, on health
plans themselves, and when you cut Medicare providers and, if you
believe this, this is something that seems hard to fathom, that any of
this would ever take effect, but this $2.5 trillion is paid for in the
form of Medicare cuts and tax increases, tax increases when it is fully
implemented over a 10-year period, as the Senator from New Hampshire
pointed out, about $1.2 trillion, about $1.1 trillion in Medicare
cuts--who in this Chamber believes that $1.1 trillion in Medicare cuts
is going to occur? There was a discussion between the Senator from New
Hampshire and the Senator from Missouri about what happened a few years
ago when the Senator from New Hampshire was chairman of the Budget
Committee and proposed cutting $10 billion out of Medicare over a 5-
year period, which amounts to $2 billion a year. What we are talking
about here is $1.1 trillion over 10 when fully implemented or $100
billion a year. When he proposed cutting $2 billion a year over 5 out
of Medicare, there wasn't a single Democratic vote in support of that.
In fact, the Vice President had to come back from a trip to Pakistan to
vote on it to try and reduce Medicare by $10 billion. They are talking
about, when it is fully implemented, $1 trillion in Medicare cuts. Do
you know who that hits?
Mr. GREGG. Will the Senator yield?
Mr. THUNE. Yes, sir.
Mr. GREGG. It is important to know where that cut is proposed to
primarily fall. Is Medicare Advantage used by a number of seniors in
South Dakota?
Mr. THUNE. It is. I assume it is in New Hampshire.
Mr. GREGG. Under this plan, it will be eliminated for all intents and
purposes.
Mr. THUNE. That is where a big share of the savings is going to hit,
senior citizens, right squarely between the eyes, if they get benefits
under Medicare Advantage. In addition, $135 billion comes from
hospitals; $15 billion from nursing homes; $40 billion from home health
agencies; $8 billion from hospices. Does anybody believe all that will
happen? And if it doesn't happen, guess what, it all goes on the
Federal debt.
I thought it was interesting that last week when the President was in
Asia, the Chinese raised the issue with him about what happens if
health care reform passes. They weren't worried about universal
coverage or a public option. They were worried about what impact it is
going to have on the deficit.
According to the New York Times and their reporting on his trip:

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

They are worried about their investment because they are the biggest
buyer of American debt. What happens to all these Medicare cuts that
are proposed? We couldn't get 51 votes to cut $2 billion a year out of
Medicare a few short years ago, and they are talking about cutting,
when it is fully implemented, $100 billion a year. Does anybody believe
we will cut $15 billion out of nursing homes? I don't think so. Here we
are. How do we pay for it?
If it isn't paid for in Medicare cuts or tax increases, it all goes
on the Federal debt which is growing at over a trillion dollars a year.
This is a bad deal for the American taxpayer. It is a bad deal for
the 182 million Americans who already have insurance. They don't get
anything out of this. What do they get? Higher taxes and higher
premiums.
Listen to what CBO says: $160 billion in additional health care costs
over this time period. It bends the cost curve not down but up. That is
what we get. That is why so many business organizations have come out
opposed to this, because they know the impact it will have on small
businesses. The best way to get health care coverage to more people in
America, as long as we continue to have an employer-based health care
system, is to get people a job. People who are struggling with the
economy right now and losing jobs, the thing we ought to be doing is
figuring out how can we provide incentives for small businesses to put
people back to work, not how can we kill jobs by raising taxes on small
businesses.
That is exactly what we are doing right here. That is why every
business organization--the National Federation of Independent
Businesses, to the Chamber of Commerce, the National Association of
Wholesaler-Distributors, right on down the list--is opposed to this
bill. They know the impact it would have on small businesses and their
ability to create jobs. The best

[[Page S11917]]

way--best way--you can get health insurance today in America is to get
a job. This bill kills jobs.
I yield to the Senator from Louisiana.
The PRESIDING OFFICER. The Senator from Louisiana.
Mr. VITTER. Madam President, I rise to share the same sorts of
concerns as my colleague from South Dakota. I share the concerns, more
importantly, of citizens all across Louisiana who have echoed those
same thoughts to me over and over again as I have traveled the State.
Like so many of my colleagues, I have spent a lot of time these last
few months reaching out to my constituents, my fellow citizens in
Louisiana, in every part of the State.
During the August recess, obviously, there were lots of townhall
meetings around the Nation. I held 21 in Louisiana, in every corner of
the State. Since then, I have held six more townhall meetings. I
continue to do other types of outreach. For instance, yesterday--since
we had a 1-day opportunity--I flew home specifically to do a few
things, including having a roundtable of doctors, including two past
presidents of the AMA, other health care providers, small business
representatives, leaders in the pro-life community, and it was a
roundtable discussion specifically to focus on the Reid bill.
In all that process, since the August recess and even before, I have
heard certain themes over and over again, no matter where I was in
Louisiana. One of those themes was great concern about what this
Congress is thinking of doing on health care but not just because of
the significance of health care, which is vitally important, which is
personal to every American, but also because of how it fits into a
trend so many Louisianians and so many Americans are seeing over the
past year--a trend of dramatically increasing Federal Government power
and intervention and dramatically increasing Federal Government
spending and debt.
People have been passionate about health care. Again, part of that is
because that is a very personal issue, and a bill such as this affects
literally every single American. But, again, a big part of it has been
that Louisianians are also connecting the dots. They see a bigger
picture, which concerns them. Louisianians have been connecting the
dots to a government takeover of banks and insurance companies and car
companies, with the CEO of GM literally being fired and hired in the
Oval Office, and now, potentially, one-sixth of the U.S. economy
through health care.
So there is a broader concern and theme I have heard over and over,
which is an explosion of Federal Government power and intervention and
an explosion of Federal Government spending and debt. This bill,
unfortunately, does nothing except to confirm my constituents' worst
fears in that regard. It is more of the same. It is more of that theme.
It is another big dot they will be connecting in that trend, and I
share that concern.
One specific issue that goes to that concern is the so-called
government option or public option because that strikes a lot of
people, including me, as a big, open door to dramatically increasing
the Federal Government's role and dominance in health care in our
country--one-sixth of our economy. Why do I say that? I truly believe
the government option--if this bill passed or anything similar to it
passed--would be the dominant option overnight and, perhaps, the only
option in a few years.
Let me explain why. I will just point to one provision, which is the
so-called pay-or-play mandate on business. Under this Senator Reid
bill, as under previous versions of this idea, such as the Senate HELP
Committee bill, a business--virtually any business in the country--
would, for the first time, have a legal mandate, and the mandate would
be to provide health insurance up to a certain minimum defined by
Federal bureaucrats or the business would have a choice. The choice
would be, if you do not want to provide that health insurance, well,
you can write a penalty or fee check to the government instead.
What is wrong with that? Well, the penalty or fee check in this bill
is pretty much set at $750 per employee per year. How does that equate
into a business's bottom line in the choice businesses would face?
Well, businesses that do provide health insurance nationally pay an
average of not $750 per employee per year but $6,100 per employee per
year. So what sort of choice do you think that is going to present to
business? What sort of result would you expect?
In this brave new world, if the bill passes, everyone is guaranteed
coverage in some form or fashion, and business has a choice: $6,100 per
employee per year or $750 per employee per year. I think, for a lot of
small businesses under extreme competitive pressure, that is not going
to be a hard choice. It is going to be an easy choice. The result for
tens of millions of Americans who have coverage now they are reasonably
satisfied with through their employer, the result is going to be
getting dumped off that coverage, with businesses saying: Well, there
are other options now. There is the government option. Good luck. We
can't afford it. We have to be competitive. We have to go with our
bottom-line decision--$6,100 per employee per year or $750 per employee
per year. I think the clear result will be tens of millions of
Americans getting dumped off coverage they have now that they are
reasonably satisfied with.
Do not take my word for it. Other outside experts, the Lewin Group
and others, say dumping will occur and could, in fact, be massive; tens
of millions of Americans--under their analysis of a previous bill that
had largely the same provisions--over 110 million Americans. So that is
a problem with regard to ballooning Federal Government intervention,
power, domination of the marketplace.
Again, as I said a few minutes ago, another part of that theme and
concern I heard over and over was ballooning Federal Government
spending and debt. Here again, this Reid bill does nothing to allay
those fears. In fact, it does a lot to increase those fears.
There has been a lot of talk and a lot of reports of the CBO score of
$848 billion over 10 years. First of all, $848 billion is a lot of
money. That is a lot of Federal Government spending and growth. It is
hard to get your hands around that figure. What does that mean? If
someone had started spending $1 million a day when Jesus Christ was
born and kept spending $1 million a day, we would not yet be up to that
figure. So that is a lot of money.
But what is worse, that figure is artificially low. The true cost of
the bill is much greater. There are a number of budget gimmicks the
ranking member on Budget, Senator Gregg, and others have talked about
that prove that $848 billion figure is truly low compared to the full
cost of the bill.
What am I talking about? Well, the biggest budget gimmick is the fact
that the spending side of the bill does not kick in for the first 4
years. The tax side, of course, as always, kicks in immediately. So the
tax increases, the fee increases, et cetera, kick in immediately. But
the benefit spending side of the bill does not kick in for the first 4
years. So that is what will occur in the first 10 years of the bill's
life, should it be passed. Therefore, in that CBO score of the first 10
years, what the CBO is scoring is 10 years of tax increases and only 6
years of spending. So that is a huge budget gimmick which helps produce
that artificially low $848 billion or so.
In fact, we should be looking at the first 10 years of full
implementation; in other words, the first 10 years when not only all
the tax provisions are kicked in but everything on the benefits
spending side is kicked in. That is basically from 2014 to 2024. What
are the numbers there when you look at the real first 10 years, the
first 10 years of full implementation? The real numbers are not $848
billion--as big a figure as that is, spending $1 million a day since
Jesus Christ was born and you still would not be up to it--but there
the analysis is $2.5 trillion over 10 years.
Again, Louisianians see this, Americans see this as another big dot
to connect, part of a huge trend of exploding Federal Government power
and exploding Federal Government spending and debt. What does that
represent in terms of that explosion of spending and debt? It also
represents enormous new taxes, and that goes to the cost issue my
distinguished colleague from South Dakota was talking about.
When I talk to Louisianians specifically about health care--not just
these

[[Page S11918]]

broader trends and these broader concerns they are very focused on but
specifically health care; OK, we have to fix certain issues in health
care--what is the top issue? Virtually everyone in Louisiana says cost,
ballooning cost. Whether they have coverage now or they are struggling
to get coverage, the issue is cost. What can we do about cost?

Again, this bill does nothing to fix that. It makes it worse. As was
illustrated with Senator Thune's graph, it pushes the cost curve up and
not down. Part of the reason it does that is, in that $2.5 trillion of
activity there are enormous taxes, and those taxes become built into
health insurance premiums. So premiums do not go down, they go up. They
go up in a major way.
What are some of these we are talking about--again, enormous tax
increases, enormous tax increases across the board, taxes on choice and
well-being. Flexible spending which allows individuals to have a tax-
free account for medical needs, that is limited. That is downgraded and
capped at $2,500 a year. Taxes on over-the-counter medicines that many
patients' families and seniors depend on, that is a tax increase of $5
billion; reduced deductions for health expenses, again, another tax
increase; higher Medicare payroll taxes; the rate on wages in excess of
$200,000, a very large tax increase; over and over again, major tax
increases. The bill would impose $28 billion in new taxes on employers
that do not provide government-approved health care plans. There is a
tax increase of $53.8 billion, over 10 years, in terms of the Medicare
population.
So, again, there are huge tax increases that are part of that, and
that is the major reason that cost curve is not being pushed down. In
fact, it is being pushed up.
As I approach this bill, after looking at it carefully over the last
few days, my first bottom-line question is: How does it respond to
those dominant concerns I have heard over and over again from Louisiana
citizens all across the State over the last several months? What does
it do about ballooning Federal spending and debt? What does it do about
the growth of government power and intervention and the cost of health
care?
Sadly, it fails on all those accounts. It moves us in the wrong
direction on all those accounts. So I urge my colleagues to adopt a
different approach, to vote no tonight, to not move to this approach,
to adopt a far more focused, positive approach that responds directly
to those concerns of the American people.
I yield back my time.
Mr. GREGG. Madam President, what is the regular order?
The PRESIDING OFFICER (Ms. Cantwell). The Democrats control the next
hour. The Republican time is expired.
Mr. GREGG. Thank you, Madam President.
Mrs. GILLIBRAND. Madam President, I ask unanimous consent that the
next hour be under the control of the majority controlled as follows
and in the order listed: Senator Gillibrand, 5 minutes; Senator
Whitehouse, 20 minutes; Senator Landrieu, 17 minutes; and Senator
Cantwell, 18 minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mrs. GILLIBRAND. Madam President, as I rise today to speak in support
of the Patient Protection and Affordable Care Act, I wish to say that
this is truly historic legislation which I am very proud to support
which will ensure all Americans will have access to quality, affordable
health care. It will at long last make the necessary changes to contain
costs that have truly spiraled out of control, and it will make
enormous progress to address the many disparities in our health care
system that are discriminatory toward women.
The Congressional Budget Office has determined this bill will provide
coverage for more than 94 percent of Americans--98 percent when
accounting for the elderly population--while reducing the spiraling
costs of health care and trimming the deficit over the next 10 years
and beyond.
Sixty years after Harry Truman first talked about the need to
guarantee affordable, quality health care for all Americans, we are on
the brink of a historic vote to move one step closer to achieving this
goal.
In 1994, the last time we seriously considered health care reform,
opponents argued that if we reformed our health care system, health
care spending would skyrocket and health care quality and access would
decrease. The opponents succeeded in 1994, and health reform was
defeated. But in the absence of reform, look at what has actually
occurred. Since 1994, family premiums have risen by over 150 percent.
In 1993, the average annual premium for employer-sponsored family
coverage was $5,000. This year, the cost for coverage is over $13,000
per year. By 2016, family health insurance is expected to reach over
$24,000. In my State of New York, that is simply unaffordable.
Today, we spend more than 16 percent of our gross domestic product on
health care, nearly twice the average of other developed nations--an
astounding $2.2 trillion every year. What do we get in return? More
than 47 million Americans are uninsured. In 2007 and 2008, 86.7 million
Americans--1 out of every 3 Americans under 65--went without health
insurance for a period of time. Every day, 14,000 Americans lose their
health insurance.
Many of the same opponents who defeated reform in 1994 are trying to
do it again. I ask them to please consider what has actually occurred
over the last 15 years. Think about the damage that has been caused to
our economy, our families, our workers, and consider taking a stand
that is on the right side of history this time.
The bill before us lays a foundation for truly reforming our health
care system. I commend Majority Leader Reid for his work in merging the
two Senate committee bills.
This bill includes a robust public plan for which I have strongly
advocated. I believe this will increase competition and lower costs
across the system. Through a public plan and the establishment of
health insurance exchanges, the bill makes quality health care truly
affordable and accessible to everyone--all Americans. The health
insurance exchanges will streamline the system and offer insurance at
affordable premium rates, capped by income, for low- and middle-income
Americans. No longer will health care be out of the reach of millions
because of cost.
This bill also ends discrimination against women, which we have faced
in our health care system for far too long. Women shoulder the worst of
the health care crisis, including outrageous discriminatory practices
in care and coverage. The National Women's Law Center reports that a
25-year-old woman pays up to 45 percent more for the same health
insurance coverage than a man her age. Some of the most essential
services required by women are simply not covered by insurance plans,
such as childbearing, Pap smears, and mammograms. A standard in-
hospital delivery costs between $5,000 and $10,000, and much more if
there are complications. This bill ends the practice of denying health
care to those with preexisting conditions. In the current system,
pregnant women are often turned down for health care coverage because
insurance companies would rather evade this cost. Pregnancy should
never be the basis for losing coverage. In America, this sort of
institutionalized discrimination is wrong. This reform bill ends the
practice of charging women more than men and requires that these basic
health care services are included.
The bill also lays the groundwork to reward health care providers for
the quality of care they provide, not necessarily the quantity.
Hospitals and clinics across the country will model the success at
places such as Bassett Healthcare in Cooperstown in upstate New York.
It also uses new methods to reduce medical errors and prevent costly
illnesses.
Some would prefer that we continue on the current path, leaving
millions without insurance and paying for it through a hidden tax that
all insured Americans pay to cover the cost of emergency care. But the
majority of Americans think the time has now come to address this
problem and fix our broken system.
The vote today is an important step on the road to reform. In the
next few weeks, we will all have the opportunity to debate this bill
and make important modifications. I am encouraged to see improvements
from previous bills in the merged bill before us, including

[[Page S11919]]

better protections for middle-class families' benefits and increased
funding to States for Medicaid, both of which I look forward to
continuing to improve.
The PRESIDING OFFICER. The Senator's time has expired.
Mrs. GILLIBRAND. May I have an additional 30 seconds?
The PRESIDING OFFICER. Without objection, it is so ordered.
Mrs. GILLIBRAND. I thank the Chair.
I welcome the opportunity to work with my colleagues on this historic
legislation. For the next few weeks, I will work to strengthen the
provisions for States such as New York that have strong Medicaid
Programs, and I will also work to ensure that funding for our safety
net hospitals remains intact.
Now is the time to act. The bill before us provides quality
affordable health insurance for every American, reins in the high
costs, makes our system more efficient, and addresses some of the grave
disparities in the system that discriminate against women. I urge my
colleagues to join me in voting yes on the motion to proceed on this
bill.
The PRESIDING OFFICER. The Senator from Rhode Island.
Mr. WHITEHOUSE. Madam President, I had the occasion to listen to some
of the remarks of our colleagues on the other side of the aisle. It
forces the conclusion that the irony department of the Republican Party
is working overtime these days.
The criticisms of this bill are over deficit and cost. We are hearing
these criticisms about deficit from the party that, when it had control
in the Bush years, ran up over $8 trillion in our national debt--$8
trillion, the biggest spendthrifts in history, an orgy of fair-weather
debt. They didn't have any hesitation about deficits then. On the wars
in Iraq and Afghanistan, we have never heard any interest in having
those paid for on a current basis. Borrowing for wars is completely
satisfactory to them, it appears. When they had the chance to amend
Medicare, they added Part D, and they ran up the cost immensely by
providing a special protection for the pharmaceutical industry so that
it can dictate prices to the Federal Government. The Federal Government
can't negotiate with the pharmaceutical industry for Part D
pharmaceuticals. That costs the Federal Government a fortune. Do they
mind? No. They spend on deficits over and over. Now, when at last we
take on the insurance industry, suddenly they discover a concern about
deficits. Well, I would urge that based on that trajectory, these
remarks have a lot less to do with the deficit than they do with
protecting the insurance industry.
There is another clue of this as well, and that is the concern about
cost. We all, indeed, are concerned about cost. But I think the best
thing we could do about cost in health care is to pass a public option.
Why do I say that? I say that because the Director of the Congressional
Budget Office has said that changes in government policy which we
adhere to in this bill have the potential to yield large reductions in
both national health expenditures and Federal health care spending
without harming health. It is not just a possibility. He goes on to
say: Many experts agree on the general direction in which the
government must go to get those cost savings. But they conclude they
can't put a specific score on them yet for the following reason: The
specific changes that might ultimately prove most important cannot be
foreseen today and could be developed only over time through
experimentation and learning.
Now, who is going to develop those changes that will save costs while
improving the quality of our health care system over time through
experimentation and learning? The public options. There will be public
options, if the original health plan is followed, in all 50 States.
Each would have to stay within its State on balance, solvent, could not
go to the Federal Treasury to make up losses. So they have to look for
reform in order to continue to succeed. They would be 50 engines of
reform, of experimentation, and of learning.
Who is against the public options? The insurance industry, because
they don't want the competition. They love an environment in which they
are immune from the antitrust laws--almost uniquely in American
business--and in which they have incredible market share. In many
cases, there are only two dominant insurers in the entire market around
this country. So they love having these huge market shares to be able
to dictate price, to be immune from the antitrust laws, and they don't
want the competition.
Guess who else is against the public options. Our Republican friends.
It is very hard to find any daylight between the position of the
insurance industry and the position of our Republican friends.
The problem with this is that it is not just about numbers and it is
not just about statistics; it is about people. It is about people by
the hundreds of thousands, but it makes their stories better when you
actually come down to cases. So let me mention a few cases.
I talked a few weeks ago about one of my very dearest family members
who fell victim to the system when his insurance company tried to deny
him the indicated treatment prescribed by a world-class physician from
the National Institutes of Health on the grounds that it was so-called
``not the indicated treatment.'' This was an individual who had
received a devastating diagnosis. He had gone to the top expert for
that diagnosis in the country at the National Institutes of Health. He
had been told what he should do. He had been told, indeed, that was
very standard. This was not anything exotic; this was essentially the
automatic way you should treat a particular condition. When he filed it
with his insurance company, some faceless bureaucrat said: No; we know
better than the top expert at the National Institutes of Health. That
is not the indicated treatment.
From that, and from thousands and thousands of Americans who have had
their claims denied and have had insurers try to intrude between them
and their doctor and interfere with the care their doctor thinks they
need, we can tell one thing: the insurance companies do this for a bad
motivation, which is to save costs. Of all of the stories I have heard,
of all of the stories our colleagues have related here on the Senate
floor, never once has there been a story of an insurance company that
stepped in and said: Oh, wait a minute, that is not the indicated
treatment; the indicated treatment is actually more expensive than what
your doctor has indicated. Always, it is less expensive. Go figure.
I wish to share another story today about a person who is close to
me, a member of my staff. His name is Richard Pezzillo, and he has
hemophilia. He has gotten the treatment he has needed so far, but he
has been lucky, and it illustrates how luck now enters into our
equation in health care.
In 2003, after a very turbulent airplane flight, Rich unfastened his
seatbelt from the airplane, collected his things, and suddenly realized
things were going badly wrong. He started to feel tremendous pain. He
started vomiting blood. Simply wearing his seatbelt in that turbulent
aircraft had caused Rich to begin to bleed internally, inside of his
stomach, eventually requiring that his gallbladder be removed.
Rich is a kind and thoughtful young man from North Providence, RI. He
was hospitalized in very serious condition. He spent nearly 3 weeks in
the hospital. Thankfully, he received excellent treatment, and today he
works here in my Washington office. The doctors, the nurses, and the
hospital staff in Rhode Island gave Rich the best treatment. He now
leads an energetic, vigorous life and does well at a challenging job.
But the stunning part about Rich's story is his treatment and his
treatment cost--$1.5 million. At least that is what they said. If you
look at a copy of the billing sheet, you will see that the insurance
company said that his billing, here, for instance, was $366,240.
The insurance company allowed only $106,000. That is what was
actually paid, which gives you a sense of how much funny business is
going on in the private health insurance industry and in the health
care sector, when an insurance company can get away with paying about
one-third of the bill's cost.
We have heard a lot of talk about how burdensome it is for Members of
Congress to make it through a 2,000-page long health care bill. If you
actually reduce its size to the substantive

[[Page S11920]]

language--and I am elaborating on what the House bill would do, which
is about the same as ours--the substantive language is less than a
Harry Potter novel. My daughter could read Harry Potter novels when she
was 13. I don't think it is asking too much of our colleagues to plow
through a bill that represents one-sixth of our economy--when it is the
size of a Harry Potter novel. It would be a good idea.
Rather than fighting about the 2,000-page bill, how about Rich's $1.5
million health care bill? The hard truth is, Rich was able to get
lifesaving treatment because he was lucky, since he hadn't graduated
from college yet and was still covered by his parents' insurance
policy. Because he was covered, the hospital only charged his insurer
less than half of that--$106,000. What if things had been different?
What if he needed treatment a couple of years later when he wasn't on
his parents' policy and couldn't afford his own? What if he had applied
for his own coverage but was denied by an insurance company because his
illness was deemed a preexisting condition? What if Rich's father lost
his job and his health insurance along with it or what if Rich's
parents' policy had a limit on benefits, and they had to pay the rest
of the $1.5 million out of pocket?
Rich would have been a victim not just of his illness but of the
health care status quo. If he or his family had been uninsured, they
almost certainly would not have been able to afford the full care Rich
needed. Their financial future would have been irrevocably altered--
probably ruined.
Luck is no way to run a health care system. Unfortunately, Americans
need all the luck they can get when dealing with health insurance
companies that use every bit of their bureaucratic guile and financial
might to delay and deny health insurance benefits they are obligated to
provide.
For example, in March 2006, the Arizona Department of Insurance
ordered health insurance giant United Healthcare to pay fines of more
than $364,000--the largest in the department's history. Regulators
found that the company illegally denied more than 63,000 claims by
doctors without examining all of the information needed to accept or
deny a claim. It looks as if they were just on automatic pilot to deny
them.
In January 2008, California insurance regulators found that a
subsidiary of United Healthcare had committed more than 130,000
violations of law in handling claims. For example, the company
inappropriately denied more than $750,000 in claims on the grounds that
insureds had a preexisting condition. The regulators found that the
companies ``made large-scale and willful decisions to use broken
systems to process claims and respond to providers, while continually
and effectively collecting premiums.'' The total potential liability of
the company for all violations is $1.3 billion.
Last year, United Healthcare's CEO, Stephen Helmsley, made $3.2
million and holds almost $120 million in stock options.
The health care reform bill we are talking about today would right
this massive power imbalance between the health insurance industry and
ordinary Americans who are getting rolled over by it. It would empower
average Americans to take control of their health and financial future.
Rather than taking their health insurance premium dollars to the health
insurance ``casino,'' they could take them to the bank.
Unfortunately, many on the other side of the aisle wildly
misrepresent both the status quo and how reform would empower
consumers. The opponents of reform depict our bill as an Orwellian
takeover of the system.
Madam President, let me close with a story that illustrates how
ironic and completely wrong these cries of ``death panels'' or
``government interference'' really are.
In 2000, Christiane Hymel--insured by a subsidiary of Blue Cross Blue
Shield of Louisiana--scheduled an appointment for a routine physical.
During the examination, she reported to her doctor her history of back
pain and weakness in her legs over the past year and a half. Her doctor
ordered x rays of her spine and referred her to a neurologist.
The neurologist, after detecting troubling symptoms, ordered an MRI.
In accordance with her insurance policy, the doctor sent Blue Cross a
request to preauthorize the MRI. The day before the MRI was scheduled,
Blue Cross denied that request on the basis that the service was for a
preexisting condition--Mrs. Hymel's back pain.
Mrs. Hymel appealed the insurance company's decision in accordance
with the terms of her policy, but Blue Cross never processed the
appeal.
After Blue Cross denied coverage for the MRI, Mr. and Mrs. Hymel were
told that the MRI would cost about $4,000. They started saving up for
it. It took 3 months to save up the money necessary to pay cash for the
procedure, but they eventually did. The MRI showed that Mrs. Hymel had
massive tumors involving ``nearly the entire cervical and thoracic
[spinal] cord.'' She was immediately scheduled for surgery. Helpfully,
Blue Cross stepped in to deny coverage for that as well, stating it was
for a preexisting condition.
Mrs. Hymel's neurosurgeon later testified at trial:

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

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

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

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

Mrs. Hymel testified that when she first woke up from
surgery, she could not move her arms or head and she thought
she was paralyzed. She felt painful burning sensations in her
body. . . . While she was in the surgical ward, she
contemplated committing suicide. During her hospital stay,
she suffered from bowel obstruction, fecal impaction, and had
to wear diapers. Mrs. Hymel didn't see her children in the
hospital until two weeks after the surgery, and when her
children finally saw her, they were scared of her and would
not touch her. Mrs. Hymel spent approximately eight months in
a wheelchair after her surgery.
Mrs. Hymel is house-bound, she cannot take a shower, work
in her garden, ride a bike, swim, or drive, as she had
frequently enjoyed prior to the surgery. . . . Mrs. Hymel
must also take large doses of medication to relieve the
burning and shocking sensations from which she suffers. She
cannot be touched on her back or leg, because the second
something touches her lower back, it's like fireworks that go
off.

Every day that insurance companies delay or deny payment is another
day they earn interest on your premiums, adding to their profits and
adding to the funds that support their massive executive pay packages.
When Blue Cross of Louisiana failed to pay for Mrs. Hymel's MRI, it
wasn't just making a mistake, it was making a calculated decision--a
heartless, profit-maximizing decision. Christiane Hymel's story isn't
just a sad tale, it is a symptom of a disease that is spreading through
the private health insurance system.
For many Americans like Christiane and Rich, our health care system
is a casino, where a roll of the dice or spin of the roulette wheel
determines one's fate. Such an irrational and random system doesn't
comport with the society that Franklin Roosevelt described in his 1944
State of the Union:

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

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

[[Page S11921]]

turned down for that preexisting condition or whether a layoff or lack
of insurance could deny their son the treatment he needs.
Necessitous men and women are not free men and women. Let's redeem
FDR's promise by passing health care reform. Let's bear in mind, as we
go forward, the nature of the arguments that are made against health
care reform and the astonishing coincidence between the arguments made
between health care reform by our Republican colleagues and by the
barons of the health insurance industry. There seems to be literally no
daylight between those arguments.
If we are going to turn around the extraordinary spiraling costs of
health care, we are going to have to do it by reforming the delivery
system. The best way to do that is the public option. Yet they oppose
it.
Madam President, I yield the floor and suggest the absence of a
quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The legislative clerk proceeded to call the roll.
Ms. CANTWELL. Mr. President, I ask unanimous consent that the order
for the quorum call be rescinded.
The PRESIDING OFFICER (Mr. Whitehouse). Without objection, it is so
ordered.
Ms. CANTWELL. Mr. President, my colleague, Senator Landrieu, was
going to be next, but I will switch times with her. She will join us on
the floor shortly.
I want to join my colleagues this morning and talk about this
important issue of controlling health care costs. That is why we are
here. We know Americans are facing higher and higher health care costs
and that we can do something to drive down the costs of our health care
system. We know health care costs are not only strangling us, but they
are impacting our constituents, our budget, and they are leaving 47
million Americans without insurance.
Our aim is to promote better quality care and get costs under
control. Whether those costs be to consumers struggling to pay
insurance premiums or to our government, we need to make sure we are
doing all we can. Doing nothing in this debate is allowing health care
costs to continue. I want to make sure my colleagues on the other side
of the aisle who talk a lot about this legislation understand that if
we do nothing, we are going to leave the American people and our budget
in serious danger by not controlling health care costs.
As always, in this debate we must keep in mind Federal spending, and
the numbers on Federal spending are stark.
In terms of doing nothing, if the U.S. Government does nothing,
health care spending will double in the next decade. That is, we spend
about $810 billion on health care. That is one-third of our total
Federal budget. If we do nothing, Federal spending is going to go to
$1.56 trillion. That is because we are not controlling health care
costs, baby boomers are reaching retirement, and Medicaid and Medicare
costs are ballooning. One-third of our Federal budget is a big enough
bite. But if we do nothing, then our health care priorities are going
to push out other priorities of our Federal Government.
The biggest area where we could control costs is in Medicare.
Medicare is 57 percent of all Federal spending, and it is getting
bigger. By 2020, Medicare spending alone will reach $1 trillion,
doubling the $466 billion we spend today. That is to say that Medicare
spending has been doubling in the last 10 years, and if we do nothing
as our colleagues on the other side of the aisle are suggesting by not
moving forward on this legislation, then it is going to double again.
This is unsustainable because if we do not address this, Medicare is
going to bankrupt us.
The prospects are just as daunting when it comes to our Medicaid
budget because Medicaid spending over the next several years will also
double, and it has doubled in the last 10 years. States are struggling,
as many of us know, with what they can do to help sustain Medicaid
since they pay for part of that for individuals.
So we see we are in a situation where doing nothing is an
irresponsible way to go. In fact, for our constituents, they are seeing
a 120-percent increase in insurance premiums. While we are worried
about the impact on the Federal Government, they are worried about the
impact on them, on their individual budgets. That means the average
family today pays about $7,000 more per year for the same health care
benefits than they did a few years ago. If you think about that, that
means that is less money for them, less money for their families, less
money to meet the other bills in the family.
Why has this happened? If we look at what has happened in our
country, we see that wages have not gone up. In fact, during that same
10-year period of time, wages have only gone up 29 percent, health
insurance premiums have gone up 120 percent. And where has the
insurance industry been? The insurance industry has seen a 428-percent
increase in profits over the last 10 years.
That is why we need to do something about controlling health care
costs. We cannot let the American people continue to be subject to such
huge increases in premiums and then have the insurance industry walk
away with huge profits and American consumers make less and less.
What is going to happen if we do nothing, if we do not advance this
bill to control health care costs? Those same premium increases we have
seen in the last 10 years are also going to go up again. In fact, they
are projected to go up another 7.9 percent in annual growth. That is,
every year, they are going to go up another 8 percent. That is
unsustainable. That means somebody is going to be paying $10,000 or
more than what they are paying for their health insurance today for the
same health care benefits. That is why doing nothing and not advancing
this bill is just acquiescing to the fact that everybody is going to
pay more for health care.
What makes this number so scary is that it is four times the rate of
inflation over the same period. That means what we need to do is look
at general inflation, which is usually about 2 percent. But health care
inflation, as is shown on this chart, is more like 8 percent. If we do
nothing to change this, Americans are going to continue to do with less
because health care costs are demanding more and more of their budget.
What do we do about this? We certainly want to make sure that we
change the system, and that is one of the reasons I support driving
down costs by having a public option. We know that two factors are
involved: We don't have enough competition and there are very
concentrated markets in health insurance across the country. Many times
there are only one or two insurance providers providing coverage in a
market. They might have 94 percent of the market. It is too
concentrated. We know if we provide an alternative in the marketplace,
we can help drive down costs.
One provision in this bill of which I am very supportive is the basic
health plan because it lets States negotiate with private insurers for
lower costs. In my State, this program has been in place for 20 years.
It has been able to provide those who participate in the program--about
70,000 people today--a 30- to 40-percent savings if they had to buy
that plan as an individual from a private insurer. That is incredible
success in driving down the cost.
Why? I call it the Costco model because like when you go to Costco
and you buy in volume, the State of Washington, buying in volume on
behalf of those individuals, was able to drive down the cost of health
care for those individual citizens. They were able to choose between
four different plans, and they were able to get access to a very good
proposal for health care for them.
The underlying bill includes language that says you could provide
this basic health plan if States opted into it and cover 70 percent of
the currently uninsured in America. I like this proposal because it
gets us cheaper insurance for that population.
Why subsidize insurance companies by giving tax incentives to buy
more expensive insurance when what Americans want is to drive down the
cost of health care by having the same negotiating clout that big
businesses or other entities have?
I hope we can continue to work and maybe even expand this provision
to make it even more robust and to drive down costs.
What is clear is that the cost of the uninsured is adding to our
health care

[[Page S11922]]

costs. In fact, the fact there are people in America who are uninsured
is adding about $1,000 to our health care premiums overall. That is
about $43 billion a year to our health care system.
If we can change our health care system and get more people into
something such as the basic health plan, we would be able to drive down
costs, and that is why that plan is so valuable.
We should not forget that our current system, besides insurance
reform, needs provider reform. The reason why provider reform is so
important is because our current health care system is flawed. It is
driving up the cost of Medicare and health care in general because of
the payment system. Basically, the current payment system perpetuates
more spending. In fact, there is something like $700 billion in waste
in our current system. If you think about it, it is this fee-for-
service loop that I call it where you order more and you end up having
more waste in the system, you have more spending, you have more use,
and it keeps going. That is primarily because we pay doctors on volume.
We pay doctors for how many patients they see every day, and we pay
them for how many tests they order. Consequently, the cost continues to
spin out of control.
As I was saying, we spend about $700 billion on health care that we
do not need to spend. That is in duplicated tests, unnecessary
procedures, excessive insurance overhead, uncoordinated speciality
care, and preventable hospitalization.
We heard from many people during the health care debate that we have
to do something to change this system. In fact, one of the witnesses
before the health care committee said:

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

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

We think if you change the health care system, which this bill does,
to drive down costs and get better outcomes, we are going to have
better health care in America.
We can continue on the path which I think my colleagues on the other
side of the aisle want by not voting to move forward on this
legislation, we can have less coordinated care, going from specialist
to specialist without having that care coordinated and have unnecessary
tests, but then everybody in America is going to be paying for those
costs. Everybody is going to be paying higher health care premiums
because of it.
What we need to do, which is what exactly this bill sets us on a
course and path to do, is to pay for value not for volume, to pay
physicians on the value they deliver and the outcome of their patients
instead of volume.
If we did nothing else in health care reform but to change our
payment structure to focus on this premise--paying for value and not
for volume--then we would be delivering great long-term savings to our
health care system.
We have other things we need to do, and that is in the area of long-
term care and Medicaid because in our long-term care system, we are
seeing a doubling in health care costs, primarily because of long-term
care. When you think about our Medicaid budget, everybody thinks
Medicaid is this program to help the low-income population. Medicaid is
turning into a long-term care program for the elderly in America. That
is, they cannot get long-term care access so they are spending down so
they qualify under Medicaid to basically get on that system to cover
their long-term care.
We can see that right now Medicaid is paying half of its funds, and
that is an expense that is going to continue to grow.
We have made some reforms in the State of Washington to make that
cheaper. We have said let's invest in home care instead. Instead of
having everybody go to nursing homes, whether they need to be there or
not, let's focus on the long-term care system reforms that keep people
in their community and instead use the Medicaid budget to advance other
things while keeping patients at home.
I think every senior in this country would rather have their health
care delivered at home than in a nursing home, but our current Federal
system continues to reward long-term care in nursing homes instead of
in community-based care. This legislation starts us on a path to change
that direction, to move closer to long-term care community services.
We did this in the State of Washington, again, over 20 years ago and
have reaped huge benefits. If we took an individual in the system
today, the cost is only about $22,000 per individual. If we had not
reformed the system as we did 20 years ago, we would be paying $42,000
for that same individual. So we have been able to drastically cut the
amount of money we are spending on long-term care.
This legislation includes the same kind of cost control reforms in
long-term care as some States have already implemented. That is why we
have to get at controlling health care costs. If we do not control
health care costs in this area of long-term care, we are not going to
control health care costs overall in America.
What does reform mean? Why are we here today to talk about the cost
of health care and what we need to do? Why are we here talking about
advancing this legislation so we can get this debate on the floor for
the American people?
It is clear we need to have more competition through a public option,
we need smarter reimbursement rates to incentivize value, and we need
better use of Medicaid dollars.
The PRESIDING OFFICER. The Senator's time has expired.
Ms. CANTWELL. I thank the Presiding Officer. I hope my colleagues on
the other side of the aisle will consider the important cost controls
in this measure.
I yield the floor.
The PRESIDING OFFICER (Ms. Cantwell). The distinguished Senator from
Louisiana is recognized.
Ms. LANDRIEU. Madam President, I first want to commend my colleague,
Senator Cantwell, the Senator from Washington State, who has worked so
hard and so long and in such a professional way. She has been extremely
helpful to me through this process, and I want to acknowledge that and
thank her.
Before I make a statement, I also want to comment about a few other
colleagues who have been extremely helpful and supportive, not just to
me but I think to the entire Senate, beginning with Senator Harry Reid,
our leader, who, with patience and persistence and care, has led us to
a bill that is before the Senate. The question today is whether we
should proceed. I would like to say that, in my view, no other Member
of the Senate could have accomplished what he has today. I think many
Senators share that sentiment.
No. 2, I want to recognize the extraordinary work of the Senator from
Oregon, Senator Ron Wyden, who, 2 years ago, before the Presidential
election had really gotten underway, before it was really ever clear as
to who might win, Senator Wyden put down a bill called the Healthy
Americans Act, which I was very proud to support, and I still am so
proud of that effort today. That bill has the support of seven
Republicans and seven Democrats. It is a truly bipartisan effort that
would accomplish, in my view, what many Americans are asking for: a
marketplace that is fixed and reformed, more affordable choices for
individuals and small businesses and families, and a real effort to
curb the rising and alarming cost to the Federal taxpayers, given that
the percentage now of our GDP spent on health care is almost exceeding
16 percent, twice as high as any nation in the world. That is alarming.
The Healthy Americans Act went a long way to help frame my thoughts on
this debate. We are going to continue to work together through this
process.
I also thank Senator Blanche Lincoln who, because of her persistent
leadership, has pushed and prodded Members of this body to ensure that
we

[[Page S11923]]

had the time necessary to review this bill. In so doing, she helped to
assure our constituents, whether they are for or against the direction
we are moving, knew that we had the time necessary to make an informed
decision. I think I have used that time very well these last 2\1/2\
days. I have been in meetings with economists, on the phone with health
care experts, talking with people from my State as well as around the
Nation. I have used that time well and wisely. Senator Lincoln led the
charge to ensure that we had the time we needed, and I am glad to have
supported her in that effort. I know she will be speaking on the floor
later today, giving her final views on where we are. I commend her for
her leadership.
Madam President, I come to the floor today to acknowledge to speak on
the business before the Senate today, and that is the question of
whether to proceed to debate on the Patient Protection and
Affordability Act, a bill that is the best work of the Senate to date
on a subject of significant importance to the people of my State and
the country. I have decided to vote today to move forward on this
important debate.
My vote should in no way be construed by the supporters of this
current framework as an indication of how I might vote on the final
bill. My vote is a vote to move forward, to continue the good and
essential and important and imperative work that is underway.
After a thorough review of the bill, as I said, over the last 2\1/2\
days, which included many lengthy discussions, I have decided that
there are enough significant reforms and safeguards in this bill to
move forward, but much more work needs to be done before I can support
this effort.
Over the past many years, and in particular the last 6 months, I have
heard from people all across Louisiana that their insurance premium
costs are simply too high and continue to rise without warning,
threatening the financial stability of their families and their
businesses. I have also heard the pleas and cries of many people who
need health coverage but they cannot find it anywhere within reach of
their budgets.
Through months of public meetings in VFW halls, school gyms, and in
hospitals and health clinics from New Orleans to Shreveport, and in
large and small communities throughout my State, it is clear to me that
doing nothing is not an option, nor is postponing the debate.
Spirited debate and good-faith negotiations in this Senate have
produced a bill that contains some amazing and cutting-edge reforms
that will, I am hopeful, reduce costs for families and small businesses
while reducing the debt burden of the Federal Government. But these
reforms must be implemented properly and carefully, and they must be
put in place in a timely fashion.
Small business owners across the country have told me time after time
that in order to grow their businesses and create jobs, they need
affordable health insurance and they need stable and predictable costs.
Yes, they would like their costs to be lowered, and I am going to stay
focused like a laser on doing just that. But what they also need is
predictability--they need to be able to plan for the future, something
they cannot do when the cost of healthcare spikes violently from year
to year.
As we all know, today, under the status quo, small business owners
are frequently confronted with impossible choices when an employee or
employee's family member gets seriously ill. They can expect exorbitant
cost increases of up to 20 percent in their premiums when just one of
their employees gets sick. Then they are confronted with the
excruciating choice of going to that employee and those family members
and saying: I am sorry, to save my business and the other 10 employees,
we need to let you go. Here is $1,000 or $2,000 or $5,000. You are on
your own. Good luck.
That is a tragic story, painful, depressing, and it has to stop.
I appreciate the hard work of many business owners and organizations
that have helped to craft portions of this framework because they have
remained at the negotiating table. They didn't run and hide, they
remained at the table. I am asking them today to stay at this table.
Before I discuss the work that needs to be done to improve this bill,
I would like to discuss some of the points in this bill that encourage
me to move forward.
Small business owners, under the current framework of this bill,
would no longer be confronted with these kinds of volatile costs. This
bill prevents insurance companies from escalating their rates or
dropping their coverage after someone gets sick. That important change
goes a long way in stabilizing the amount small businesses will have to
pay for their health plans, and it allows business owners to do what
they do best--plan smart investments, grow their businesses, and then
help us grow our economy.
In recent years, economists have found that workers' wages have
remained largely stagnant. Why? Because employers are paying more and
more for health care that we are indirectly subsidizing through the
current Tax Code and so have less and less money to pay real wages that
workers in large and small businesses could actually take home, put in
their pockets, and spend in much more productive ways. The bill we are
debating would encourage employers to move away from high-cost benefit
plans, and instead increase the amount that working families can take
home. That is an important change from the status quo.
In addition, this bill would ensure that the majority of Louisiana
families would pay no more than 10 percent of their income for health
care. That is still high. But today families in Louisiana pay an
average of 30 percent of their income on healthcare costs. And
economists project that if we do nothing, that total will climb to 60
percent of an average family's income that will have to be spent trying
to afford health care. This bill changes that trajectory. So while some
people still think that 10 percent or 12 percent may be too high, it is
a lot better than 60 percent, which is the direction we are heading
today if we do nothing. That is real progress.
These reforms I have just mentioned are necessary and are too
important a goal for the Senate to abandon its work. But, as I have
said, there is a great deal more work that needs to be done.
I would like to mention briefly just a few of the significant changes
I would like to see be made to this bill.
No. 1, in order to increase choices for small businesses, we must
enhance and expand tax credits that are in this bill for small
businesses, particularly for business with 25 fewer employees. If we
can expand tax credits for slightly larger small businesses with
between 25 and 50 employees, that would be significant progress.
Current projections are that 96 percent of all businesses that have
more than 50 employees have coverage. That is a good statistic, and
those larger businesses have some choices. But we need to give small
businesses more choices. It is these small businesses that are leading
the country on its way out of this recession. And we need to help them
in that effort.

In addition, I will continue to fight for more tax equity for the 27
million Americans who are currently self-employed. Every chairman of
the Small Business Committee--both Republican and Democrat, I
understand, for the last 25 years--has asked for this to be addressed.
It is time to make progress on that effort now.
No. 2, in order to really deliver our promise to hold down costs for
families, we should think about focusing on ways to prevent premiums
from being excessively raised between the time this bill is enacted, if
it ever is, and the time it actually goes into effect. Many of the
provisions in this bill, because of cost considerations, which I
understand, do not go into effect until 2014. Well, today is 2009.
That's a long time between now and then, and we need to make sure that
companies do not jack up their premiums in anticipation of the market
reforms this bill will make, as we have seen the credit card industry
do in anticipation of the important reforms we made earlier in the
year. Americans cannot afford to allow that kind of predatory behavior.
Finally, I remain concerned that the current version of the public
option included in this bill could shift significant risks to taxpayers
over time unnecessarily, and I will continue to work with my colleagues
to find a better and bipartisan solution for this

[[Page S11924]]

issue. I have suggested that a freestanding, premium-supported,
competitive community option that would trigger on a date certain, if
our private market reforms fail to work, might be a possible
compromise. That would include language that Senator Snowe and other of
my colleagues have been working on for several months.
Because I am hopeful we can make progress on each of these concerns
and others through an amendment and debate process that is open and
transparent, I believe that it is incumbent upon me to allow the bill
to move to debate on the Senate floor.
I stand ready to work together with my colleagues to fashion a
principled and hopefully bipartisan compromise in the end to achieve
what the people in my State need, and what many Americans need, and
which we really have to do our best to try to give them.
Finally, I know my time is up, but I would like to ask a personal
privilege for just 1 more minute to address an issue that has come up,
unfortunately, in the last 24 hours, driven by some very partisan
Republican bloggers. So I think I need to respond and will do so now.
One of the provisions in the framework of this bill has to do with
fixing a very difficult situation that Louisiana is facing. For reasons
that are simply beyond my comprehension, some partisans have decided to
attack me for leading an effort to address a serious budget shortfall
facing my state.
The reason for this situation goes back to the disastrous hurricanes
of 2005. I am not going to review the horrors of Katrina and Rita. The
levees broke, and by the way, the courts have just ruled that the Corps
of Engineers was, as I have said from the beginning, responsible. But I
will comment more on that at another date.
But, nonetheless, in 2005 Louisiana experienced two of the worst
natural disasters in recent memory. In an effort to aid the recovery,
Congress stepped in with a massive aid package for Louisianans--thank
you--that infused grant dollars and direct assistance.
Some of necessary one-time recovery dollars, in addition to the
increased economic activity, were calculated into our State's per
capita income. The result has been that Louisiana's per capita income--
--
The PRESIDING OFFICER. The time of the Senator has expired.
Ms. LANDRIEU. I ask for 1 additional minute?
The PRESIDING OFFICER. Without objection, it is so ordered.
Ms. LANDRIEU. The result is Louisiana's per capita income was
abnormally inflated. You can understand that. There were billions of
dollars that came in from insurance and road, home, and community
development block grants.
In addition, labor and wage costs went up because there was a
constriction in the market, which any economist can tell us always
happens after a natural disaster. As a result, when we did the
calculation under the law, it made us seem as if we were a state with a
high per capita income like Connecticut and not a state with a low per
capita income like Louisiana, almost as if we had become rich
overnight. That was not the case. Our State is still as poor as it was,
if not poorer as a consequence of those devastating storms. I am not
going to be defensive about asking for help in this situation. It is
not a $100 million fix, it is a nearly $300 million fix. It is the No.
1 request of my Governor who is a Republican. He explicitly asked that
I pursue these funds. It is unanimously supported by every Member of
our delegation, Democratic and Republican. I am proud to have asked for
it. I am proud to have fought for it. I will continue to. But that is
not the reason I am moving to debate.
The reason I am moving to the debate, as I expressed in this
statement, is that the cost of healthcare is bankrupting families and
it is bankrupting our government. We cannot afford the status quo.
I thank my colleagues for their graciousness. I know I have gone over
my time, but I wanted to get that on the record. I support moving
forward with the debate and look forward to working with them to
improve it.
I yield the floor.
The PRESIDING OFFICER. The Senator from Utah.
Mr. HATCH. Madam President, I wish to express my deep concerns about
Senator Reid's bill on two very critical issues. These are not the only
things of which I am critical but I wish to focus on two issues:
coverage of abortion and conscience clause protections for medical
providers opposed to abortion.
As we can see, the Stupak compromise amendment, which was supported
by 64 House Democrats and a majority of Republicans, reads:

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

That is all it says. It should be abundantly clear to each Member of
this body. The House of Representatives overwhelmingly passed pro-life
language exactly 2 weeks ago that is markedly different from that
contained in the Reid proposal. The House provisions, in contrast to
the terribly flawed provisions in the Reid bill, contain language that
would not only safeguard the rights of the unborn but would also
prevent medical providers from being coerced into performing procedures
that violate their conscience. The Stupak-Pitts amendment was adopted
by a significant margin, 240 to 194. That represents 55 percent of the
House of Representatives, including 25 percent of the Democratic
caucus.
Even more telling happens to be two polls released this week by the
Washington Post and ABC News and CNN. They confirmed that 61 percent of
the American population do not support Federal funding for abortion.
This vote should serve as a strong signal to each Member that these
protections cannot be ignored and must be contained in any measure we
adopt. Unfortunately, the language in the Reid bill explicitly allows
what the Stupak-Pitts language would prevent. The Reid language
authorizes abortion in the government-operated health plan or the
public option and Federal subsidies for insurance coverage that include
abortion. It is not the Stupak-Pitts language.
The sanctity of life is not an issue that can be traded away for
political expediency. During committee consideration of the health
reform legislation, I offered two important pro-life amendments. The
first amendment, which I offered in both the HELP Committee and the
Finance Committee, strictly prohibited Federal dollars being used to
finance elective abortions. The second amendment provided conscience
clause protections to medical providers opposed to abortion. In other
words, we should never force people who have a conscience against
abortion to have to perform abortions or participate in abortions. This
language was based on the Hyde-Weldon provision contained in every
Labor-HHS appropriations bill since 2004. It also was included in the
House-passed bill. Both my amendments were defeated.
I notice my colleagues, Senators Brownback and Johanns, are in the
Chamber. I ask both of them: What is wrong with including the Stupak-
Pitts language in the Reid bill?
Mr. BROWNBACK. Madam President, I, first, thank my colleague for
offering these amendments in committee.
In both the HELP and Finance Committees, you said: Let's put in the
Hyde language, and both times the amendments were defeated in
committee. I appreciate my colleague raising it. Proponents of the Reid
bill will tell us the abortion funding language is essentially the Hyde
language included in the annual Labor-HHS appropriations bill. That is
plain wrong. The Hyde amendment specifically removes abortion from
government programs. The Reid bill specifically allows abortion to be
offered in two huge new government programs. The Reid bill tries to
explain this contradiction by calling for segregation of Federal
dollars when Federal subsidies are used to purchase health plans. This
segregation of funds, though, actually violates the Hyde amendment,
which prevents funding of abortion not only by Federal funds but also
by State matching funds within the same plan. Simply put, today Federal
and State Medicaid dollars are not segregated, and the Reid bill
specifically authorizes something the Hyde amendment specifically
rejects.
Mr. JOHANNS. If I might join in, it is enormously important we lay a
good record as to what this is all about and why the Hyde amendment has
been the

[[Page S11925]]

law of our Nation for so long. It is important. Therefore, I direct a
question to Senator Hatch.
Please, if you would, describe how the Hyde amendment works today.
Mr. HATCH. Today's Hyde language, which has been in every annual
Labor-HHS appropriations bill since 1976, specifically prohibits
Federal dollars being used to pay for abortions except if the pregnancy
was the result of rape, incest, or the life of the mother is in danger.
The Hyde language applies to all five of the federally funded health
care programs: Medicare, Medicaid, Indian Health Services, TRICARE, and
the Federal Employees Health Benefits Program or the FEHBP. However, it
is important to note that today there is no segregation of Federal
funds in any Federal health care program--none. For example, the
Medicaid Program receives both Federal and State dollars. There is no
segregation of either Federal Medicaid dollars or State Medicaid
dollars. States that do provide elective abortions for Medicaid
beneficiaries must do so from a completely different account; that is,
State-only dollars. No Federal or State dollars from the State Medicaid
Program may even be placed in that ``State only'' pot of money.
Mr. JOHANNS. That was an excellent explanation of what Hyde is about.
It underscores why we are so upset about the unbelievable expansion
that is going to occur if this Reid bill is passed. You mentioned the
Federal Employees Health Benefits Program. Let me take a minute to talk
about how that works because, again, I think it underscores the point
we are making today. Let me give an example. The current Federal
Employees Health Benefits Program does this. It has 250 participating
health plans that do not cover abortion. Federal employees pay a share
of the cost.
The Federal Government, through tax dollars collected, pays the
balance. So it is a mixture of Federal employees' contributions through
their paychecks and the Federal Government getting the money through
tax dollars. Federal employees cannot opt for elective abortion
coverage because taxpayer dollars are subsidizing the cost of their
employee plan. You can see how we have tried to remain true to the
distinction you talked about. As many have said during the debate, if
it is good enough for Federal employees, then why isn't it good for the
rest of the citizens?
I ask Senator Brownback, what is in the Reid bill that does not
reflect the current Hyde language? And if I could maybe direct that to
both of you or to Senator Hatch.
Mr. BROWNBACK. Well, if I could follow up quickly on the last point,
I think it is clear that if we are not going to put this in the Federal
employees benefit insurance system, then we should not put it in this
system. Yet this is a billing expansion that is taking place. The
Democratic health bill would explicitly authorize abortion to be
covered in the government option. It also mandates that there must be
abortion coverage in every insurance market in the country. This is an
enormous expansion, a radical departure from the 30-year policy that
represents the Hyde amendment. The abortion language that was included
in the bill is a huge departure from 30 years of bipartisan Federal
policy prohibiting Federal tax dollars paying for elective abortions.
The language in the Senate bill explicitly authorizes the Secretary of
Health and Human Services to include abortion in the public option and
permits government subsidies for plans that pay for abortion.
The Capps language, commonly referred to in the Senate bill, contains
a clever accounting gimmick that proponents say separates private and
public funds for abortion coverage. However, it has been proven over
and over by outside reviewers that the Capps measure would include both
abortion coverage and funding in the government-run public option as
well as for those plans in the insurance exchange. Representative Bart
Stupak, a Democrat from Michigan, explained the issue very clearly in
an op-ed he wrote yesterday. He wrote:

The Capps amendment, which is the basis of the Senate
language, departed from Hyde in several important and
troubling ways: By mandating that at least one plan in the
health insurance exchange provide abortion coverage; by
requiring a minimum $1 monthly charge for all covered
individuals that would go towards paying for abortions; and
by allowing individuals receiving Federal affordability
credits to purchase health insurance plans that cover
abortion. Hyde currently prohibits direct Federal funding of
abortion. The Stupak amendment is a continuation of that
policy--nothing more, nothing less.

I would like to ask Senator Hatch about this provision, about what we
need to talk about on the exchanges and the types of plans that will be
included in the exchanges and about how this is an expansion of the
abortion language.
Mr. HATCH. Isn't it true that one health plan must be offered in the
exchange that covers elective abortions? Isn't that a departure from
Federal policy?
Mr. BROWNBACK. The Reid health care reform bill would require at
least one health care plan to offer elective abortions in each State
health insurance exchange. However, nothing in the Reid bill ensures
that the one plan that must cover elective abortions be the plan that
is most affordable or least affordable. In other words, if I do not
wish to have a plan that covers elective abortions but all I can afford
is that plan, where does that leave me? Should my constituents have to
compromise their own moral code in order to receive health care; in
other words, that they would have to buy a plan that covers abortion?
Mr. HATCH. That is right.
Mr. BROWNBACK. Today, no Federal health program requires the coverage
of elective abortions. This is a clear departure from current law, and
I cannot imagine us forcing people to pay for insurance that covers
abortions when it is so unconscionable to so many of the American
people.
I also would like to make one other point perfectly clear. The
Stupak-Pitts compromise amendment would not prohibit the ability of
women to obtain elective abortions as long as they use their own money
to purchase these policies. I think it is important we get that piece
of it clear as well.
Mr. HATCH. I am glad the Senator did clarify that.
I say to Senator Johanns, isn't it true that the Stupak amendment,
passed in the House by a considerable margin, allows women to purchase,
with their own money, separate supplemental health coverage that may
include the coverage of elective abortions--if they do it with their
own money?
Mr. JOHANNS. I say to Senator Hatch, I am glad you raised that issue.
Yes, that is correct. Your understanding is correct. Women would be
allowed to purchase separate elective abortion coverage with their own
money.
I ask Senator Brownback, do you have a comment on that, or a
question?
Mr. BROWNBACK. Well, I think this is a key thing for us to keep in
mind, that it is true that women can purchase separately, with their
own money, use their own funds to be able to provide for their own
abortion coverage. But what we are saying here today is that we should
not have this as part of the Federal Government. We should not have it
as part of the Federal funding program. We should not be using taxpayer
dollars to fund abortions, as we have not done for 30 years. That has
been the longstanding bipartisan program. But it is not prohibited that
an individual could go ahead and buy this service on their own.
Mr. HATCH. Well, I would add, too, it is absolutely correct that the
Stupak language allows women to purchase both a supplemental policy for
the coverage of elective abortions and a comprehensive health care plan
that includes coverage of elective abortions as long as they pay for
their plan with their own money. It allows that.
Mr. JOHANNS. Let me just interject something here because I think
this is a very important point to make, following up on what Senator
Hatch just said. Some say that a person would never want to purchase a
separate rider to cover abortion. It just would not happen, they say.
But they misunderstand what the Stupak language actually allows.
Let me be clear about this. If a woman wants her health insurance
plan to provide elective abortion services, she does have the choice to
purchase a health insurance plan that provides that on the exchange.
She just has to pay for it with her own money. Am I correct in that
interpretation or have I misunderstood that?

[[Page S11926]]

Mr. HATCH. That is correct. A woman may purchase with her own funds
either a supplemental policy that covers elective abortions or an
entire health plan that includes the coverage of elective abortions.
Look, a woman has always been able to do that, and frankly, we do not
deny her the right to do that. What we say is, taxpayers should not be
paying the cost of it. They should not be called upon to pay for
elective abortions.
Mr. BROWNBACK. I say to Senator Hatch, as someone who has been in
this body for some years and as someone who has followed this issue
courageously for many years, what we are asking for, again, is just
what has been established since 1977 in this body and in the House.
Mr. HATCH. Yes. That is current law, that Federal funds may not pay
for abortion or plans that cover abortion. Now that is the fundamental
component of the Hyde language. And to be clear, the Stupak language
does not prevent people from purchasing their own private plans that
include elective abortion coverage.
Let me just change for a second here. I would like to now talk about
the conscience clause. To me, this is extremely important: the
conscience clause protections for medical providers. The conscience
clause protections in the final House bill for pro-life providers are
not included in the Reid bill. They are in the House bill but not in
the Reid bill. The House adopted language that codified the essence of
the Weldon-Hyde conscience protections, including in the annual HHS
appropriations bills since 2004.
This summer, the House Energy and Commerce Committee accepted these
protections unanimously during consideration of their bill. Let me
emphasize that point: unanimously, there was not one objection to it.
That means all members of the committee--with ideologies ranging from
the chairman, Henry Waxman, who represents Hollywood, CA, to the
ranking Republican, Joe Barton, who represents a conservative
congressional district in Texas--they all recognized the importance of
adopting this language.
In contrast, the Reid bill has stronger protections for abortion
providers than for providers who have conscience objections to
abortion. On one hand, abortion providers may not be ``discriminated''
against for performing any abortion anywhere. On the other hand, pro-
life providers must cite a particular ``moral or religious belief'' to
prevent discrimination. This is narrower than current law under Hyde-
Weldon.
Moreover, it does not extend the protections to pro-life health
plans. In other words, a Catholic health system that requires a local
hospital to stop providing abortions in order to become part of its
health system could be accused of discrimination.
What is wrong with this picture?
Let me ask Senator Johanns, don't you think it makes sense to protect
health care providers who have objections of conscience to abortion so
they are not forced to provide abortions?
Mr. JOHANNS. Absolutely. As the Senator offers this explanation about
a Catholic health care provider, it hits right to the heart of this
issue. I most certainly agree with the Senator and I want him to know
that many Nebraskans agree with him and agree with me on this issue.
I got a letter recently from a gentleman out in western Nebraska,
from a little community called Ainsworth--a great area of our State. He
wrote to me and said this:

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

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

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

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

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

The President has gone on to state on multiple occasions that he
would not support abortion in a health care bill. The President has
stated that over and over. The President has also stated on multiple
occasions--both as a candidate and as President--that it is his goal to
lower the incidence of abortion. That is what he says, not what the
Democrat-led Senate has done, though, relative to this bill, which he
has embraced. And it is not what the leadership has done in this bill.
You see, my colleagues, I see this as a radical abortion approach, a
radical piece of language. And you can go right to the bill itself, to
pages 116 to 124 of this 2,074-page bill, and you can read it yourself.
I have to tell you, there is so much about this bill that is bad
policy, but this is especially damaging. The President promised us he
would not let it happen. Do the President and the Members of his party,
who control the Senate, who wrote the bill behind closed doors, do they
really believe abortion is health care? Why didn't they just strip this
language out? Why didn't they adopt the Stupak language, which was
voted upon in the House, the Stupak compromise? Why didn't they adopt
that, knowing that 64 Democrats had signed on to that language?
What do you think about the President's commitment and his promise to
us not to use Federal dollars to fund abortions? I say to Senator
Brownback, I would like to hear his thoughts on that.
Mr. BROWNBACK. I was there that evening, along with the Senator and
Senator Hatch and almost all of the Senators, when the President was
addressing us on health care. I remember vividly sitting there and
listening to these words, the ones you just mentioned. He was very
clear, very concise; there was no fudging around on it:

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

Yes, that is specifically violated in the bill, and they had a very
simple route to change it. They could have just put the Stupak language
in that has already passed the House. That is the Hyde language that
has been agreed to by this body and others for 30 years here. Instead,
they put in this abortion-expansion language.
I will show another chart here a little bit later on. The last time
we funded abortions here was between 1974 and 1977, right after Roe v.
Wade and before the Hyde language in 1977. Do you know how many
abortions were funded annually by the Federal Government at that period
of time? If we are going back to that policy, if we are looking to go
back to that era where the Federal Government was funding it, Medicaid
funded as many as 300,000--300,000 annually. Now, I would ask
everybody, pro-choice or pro-life, do you want your taxpayer dollars to
pay for 300,000 abortions a year? I do not think anybody wants to see
us do that.
President Clinton we all remember very clearly saying often that he
wanted to make abortion safe, legal, and rare. Adding 300,000 does not
do that.
So the President took the time, in a carefully tailored and vetted
speech that all of us were there to hear--the Presiding Officer, as
well; it was nationally televised in prime time--to tell Congress the
words we have quoted here today and to make that specific promise. And
that promise is broken in the Reid legislation before us today. We sat
there in the House Chamber and heard him say those words. Our
constituents watching the speech at home heard those words. I have to
believe these are the kinds of broken promises that are making our
constituents lose their trust in government.
But the fact is, as so many people have pointed out, abortion is very
much in this health care bill. Many Democrats and Republicans
acknowledge this. Mr. Stupak, whom I have quoted several times, is just
one of them.
If we want to do more than just pay lipservice to lowering the
incidence of abortion, we need to oppose the motion to proceed, and we
should have had the Stupak compromise language included in the bill in
the first place since the President clearly stated he did not want
Federal dollars to be used for the funding of abortion.

[[Page S11927]]

Consider the fact that when Federal funding is not available for
abortion, fewer abortions occur. When Federal funding is available, as
we have seen in the past, thousands more will occur.
As shown on this chart, here is why the Hyde amendment is so
important. The administrators running the Medicaid Program funded, as I
noted, over 300,000 per year. That is almost 1 million abortions paid
for by the country's taxpayers out of their pockets when the Hyde
language was not the law of the land. That was until the Hyde amendment
was enacted in 1976 because the American people disagreed with being
forced to pay for abortions. Whether they are pro-choice or pro-life,
they did not want taxpayer dollars to go for this.
One other example of government ushering abortion policy through
health care legislation is when the Commonwealth of Massachusetts
recently passed its State-mandated insurance, Commonwealth Care. They
failed to include an explicit exclusion of abortion, like Senator Hatch
tried to get in committee or like they had in the House language, the
Stupak language, so abortions there were funded immediately in
Massachusetts. In fact, according to the Commonwealth Care Web site,
abortion is considered covered under ``outpatient medical care.''
The Federal Government should not go down this road. The President
made a commitment to the American people, and the Democrat-led Senate
has failed to include that commitment in this bill. They included
radical language that will increase the incidence of abortion.
I say to Senator Johanns, don't you think it makes sense to protect
health care providers, when we look at that issue here, who have
objections of conscience to abortions so they are not forced to provide
abortions?
Mr. JOHANNS. Absolutely. It absolutely makes sense. I say to Senator
Hatch and Senator Brownback, one of the things that has been very
remarkable to me--this bill just came out, as you know. It was behind
closed doors for weeks and weeks and came out in the middle of the
night, actually.
Mr. JOHANNS. Madam President, pro-life groups weighed in on this bill
immediately. For all of the complexity, for all of the definitions, for
all of the buried language, they saw immediately what this bill was all
about. Pro-life groups across the board have opposed the provisions of
this legislation. No pro-life group has taken the bait. They represent
millions of Americans across this great country.
Let me, if I might, take a moment and quote from what they have said.
The National Right to Life Committee--and again I am quoting--says
this:

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

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

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

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

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

Concerned Women for America said the following:

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

Senator Hatch referred to polls. The polls indicate the majority of
Americans do not want their tax dollars paying for elective abortions.
According to that CNN/Opinion Research Corporation survey, 6 in 10
Americans favor a ban on the use of Federal funds for abortion. It also
indicates that the public may also favor--literally favor--legislation
that would prevent many women from getting their health insurance plan
to cover the cost of abortion even if no Federal funds were involved.
This poll indicates that 61 percent of the public oppose the use of
public money for abortions for women who cannot afford the procedure.
I have to ask the question of Senator Hatch: When will we listen to
the American people on this important issue?
Mr. HATCH. I ask Senator Johanns, have you seen similar polls
indicating that a majority of Americans do not want their taxpayer
funds used for paying for elective abortions? Have the Senator seen
those national polls?
Mr. JOHANNS. I have. We have seen the polls. We have gotten letters
from our constituents. Consistently, in poll after poll, we can see
what the American people are saying. They do not want their tax dollars
to fund abortions.
Mr. HATCH. Madam President, let me ask a question to both Senator
Brownback and Senator Johanns. I know my constituents are very upset
about the possibility of their tax dollars being used to pay for
elective abortions. I even brought a few of their letters down to the
floor so I could read them. If you don't mind, I wish to read them. Can
I take a few minutes to do that?
Mr. BROWNBACK. Please do.
Mr. HATCH. These are just a few. We have all kinds of letters. I
thought I would mention a few of these since they are on point here, as
far as I am concerned.
Here is one from a woman, a Ph.D., the President of AUL Action,
Charmaine Yoest:

Dear Senator: On behalf of Americans United for Life, AUL
Action, I write to express our strong opposition to the
Senate proceeding to Majority Leader Reid's health care
reform bill, the Patient Protection and Affordable Care Act.
Majority Leader Reid's bill does not include the Stupak-Pitts
language added to H.R. 3962, which is necessary to prevent
Federal funding of abortion. AUL Action will score against
all votes to proceed to this bill because it does not contain
the Stupak-Pitts language. Majority Leader Reid's bill
explicitly allows the Secretary of the Department of Health
to include abortion coverage in the ``community health
insurance option'' and allows Federal subsidies to go to
private insurance plans that include abortion coverage. In
addition, the bill also requires that at least one private
plan in each exchange provide coverage for all abortions. The
passage of a health care reform bill without language
explicitly excluding abortion coverage and funding is
unacceptable to pro-life Americans. We strongly encourage you
to vote against all procedural motions to move to the
majority leader's bill, including cloture on the motion to
proceed.
Sincerely,
Charmaine Yoest, Ph.D.,
President and CEO of AUL Action.

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

Dear Senator: As an American with a growing disdain for the
heavy handedness and disregard for the wishes of the American
people, I adamantly oppose any plan brought to the table that
would require me to pay for abortions with my tax dollars.
Any government-run health care system with this provision is
bad for America and violates the deep convictions of many
Americans. Furthermore, I am infuriated by Senate Majority
Leader Harry Reid's deceptive course of action in secretively
creating his own version of a health care reform plan. Reid's
underhanded tactic diminishes the opportunity for public
debate and scrutiny which flies in the face of our
legislative process. I strongly oppose Harry Reid's health
care overhaul plan to nationalize our system. I urge you to
oppose any nationalized health care bill and any plan
containing an abortion mandate.

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

Hello, Mr. Hatch. I am writing for 4 registered voters in
my family which include my husband, my parents, and myself.
We are very concerned about the Federal health care
legislation. We believe that it must support several of our
beliefs. We believe that life must be respected and cared for
from conception to natural death. As such, we do not want any
of our tax dollars going to abortions or euthanasia. We have
a desire for the continued support of the Hyde amendment of
1976. Our family supports charities which provide counseling
and material goods needed by families who have an unplanned
pregnancy. We want to support them in having the baby and
caring for themselves and the child. We do this by donating
things that are needed by the mom-to-be during her pregnancy.
We also have donated furniture and other things needed by the
baby. These have been given to Birthright--a program
supported by donations. We want access to health care for
all. This includes fair treatment of our immigrants. We do
not want any of their health care that they may be receiving
right now to be taken from them. In the

[[Page S11928]]

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

Whether you agree with every word of these, they are interesting.
Here is another one:

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

Then she has a PS:

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

Then she lists the names of her parents.
Here is another one:

Dear Senator Hatch: I am a registered Democrat strongly in
favor of health care reform. I am also committed to
protecting the unborn and to safeguarding the conscience of
each health care provider who is uncomfortable with providing
abortion services. During floor debate on the health care
reform bill, please support an amendment to incorporate long-
standing policies against abortion funding and in favor of
conscience rights. If these serious concerns are not
addressed, the final bill should be opposed. Genuine health
care reform should protect the life and dignity of all people
from the moment of conception until natural death.

Another one.

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

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

One out of every three babies conceived is a victim of
abortion, a tragedy that has claimed more millions of
innocent lives since the Roe v. Wade Supreme Court decision
legalizing abortion on demand. Every abortion is a gruesome
act that ends an innocent human life and cannot be tolerated
in a civil society. The pro-abortion lobby is seeking to hide
abortion funding into virtually every piece of ``must-pass''
legislation, including continuing resolutions, budget and
authorization bills, so-called ``economic'' bills, and even
the Defense authorization bill. I urge you to actively oppose
and, if necessary, filibuster all attempts to use the budget
to force Federal funding of abortion and abortionists and to
pack the courts with activist, pro-abortion judges.

I thought I would read a few of those interesting letters to set a
tone here. I have received all kinds of letters, but I chose a few, at
random, to read on the Senate floor this afternoon.
Mr. BROWNBACK. I was recently at a Veterans Day parade in
Leavenworth, KS, and I had a number of people coming up to me opposed
to the health care bill. I had one come up to me and say they were in
favor of it and all the rest were opposed. It starts on the basis that
it is fiscally insane what we are considering doing with $12 billion in
debt, and then we are going to add a multitrillion-dollar entitlement
program on top of this. The Federal Government is hemorrhaging money.
Why on Earth would we do that? Then they are scared about what else is
in the bill, and then this feature comes up as well.
Finally, Senator Johanns was putting in statements from various
groups, and I ask unanimous consent that this statement from the United
States Conference of Catholic Bishops be included at the end of our
colloquy.
The PRESIDING OFFICER. Without objection, it is so ordered.
(See exhibit 1.)
Mr. BROWNBACK. The Catholic Bishops issued this yesterday and said
this:

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

SCHIP, which Senator Hatch helped to get started--

the Federal Employees Health Benefits Program--

that Senator Johanns spoke about--

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

This is the Catholic Bishops, generally in favor of health care
reform, and they are saying this fails on this account and must not be
in this legislation and can't be considered as part of health care
reform.
Mr. HATCH. I ask Senator Johanns, where do we go from here? We are
going to have a cloture vote at 8 o'clock tonight on the motion to
proceed. What would be the advice on that?
Mr. JOHANNS. I thank the Senator. Let me, if I might, before I
address that, tell my colleagues how proud I am to stand here with
these two champions of this issue, Senator Brownback and Senator Hatch.
They have a remarkable history of every time they had an opportunity
standing strong on an issue that I must admit is not the most popular
issue in Washington, DC, to promote, and I admire their courage.
To address the relevant question of the day, the Stupak protections,
that compromise that was reached in the House, it is not in this bill.
Of course, since it is not in this underlying bill, this Reid bill,
it is very unlikely to be in the final bill. I wish somebody could
disprove this. But, very simply, there aren't enough pro-life Senators
to break this provision and get the Stupak amendment passed on the
Senate floor if we propose it as an amendment--and I am sure it will
be--there just aren't enough.
That is why I have been making the case over the last 48 hours that
the motion to proceed is the key vote on abortion in the health care
debate. The most important pro-life vote that a pro-life Senator will
cast, I believe, in the entire time they are here is on this motion to
proceed. I have seen all the arguments from many, saying this is a
procedural vote; that there is nothing to worry about; that it just
begins debate, and we might potentially vote this bill down, and we can
do some amendments and some tweaking.
But the facts suggest otherwise. The Congressional Research Service
has looked into this. Between the 106th and 110th Congresses, there
were 41 cases, according to the Congressional Research Service, in
which the Senate approved a motion to proceed and then proceeded to a
vote on the final bill. Do you know what the end result of those 41
cases were, when the motion to proceed was approved? It was 40 times
out of 41--about 97 percent--went on to receive final approval. In
other words, all but one passed into law.
This suggests to me this vote tonight at 8 o'clock on the life issue
is very well determinative. Some of my colleagues also argue if we
don't like the bill, we should not block the opportunity to amend it,
and they say let us proceed.
I don't believe, if you are truly pro-life as a Senator, you can make
that argument. Here is why: Everybody in the Senate knows what it will
take to amend the Reid bill on something like this. It will take 60
votes. It is the way the Senate operates. It will take 60 votes. Again,
I say to Senator Hatch and Senator Brownback, I wish I could count 60
pro-life Senators. I wish I could do that. But by anybody's count, I
believe--mine included--there aren't 60 here.
I believe if you are pro-life, every opportunity you get to stand for
the life issue, you must stand for that issue. These truly are our most
vulnerable citizens. I feel very strongly that at 8 o'clock, when we
are gaveled to a vote, we need to stand up on this issue--this life
issue--or there is a 97-percent chance it is lost.
I will conclude my thoughts on this by saying this: There were many
strong and courageous pro-life Democrats in the House. I watched that.
That was remarkable. Can you imagine the pressure they were put under?
This evening, we just need one--not many, just one Democrat--who will
come here and say I am pro-life. If we don't stand together tonight,
this bill will radically expand abortion, and I cannot live with that.

[[Page S11929]]

Mr. HATCH. I thank the Senator for his remarks. I thank both Senators
Brownback and Johanns.
Before coming here, the Senator was the Secretary of Agriculture. He
is from Nebraska. By any measure, he is a very sincere, dedicated, and
principled person. We all know that, and I think the world of the
Senator.
I appreciate standing on the Senate floor with the Senator to chat
about this matter. Senator Brownback, without question is a leader in
this body in protecting the rights of the unborn. It is one of the
things I most love about him. There are many things that cause all of
us to hold the Senator from Kansas in very high regard and esteem. He
is principled and dignified about it. He is friendly to everybody. But
the Senator doesn't mince words when it comes to standing up on these
very important issues.
Look, all we are saying is, let's protect the Hyde language. You do
that with the Stupak-Pitts language. What is wrong with including that
language? All we want to do is not have federal funds pay for abortion.
The vast majority of people in this country feel that way too.
Second, why should people of conscience, who really and sincerely
believe that abortions are wrong, be forced to participate in abortions
in any way, shape, or form? Unfortunately, this bill could lead to that
forced participation. I just do not understand what is so difficult
about including the same language included in the bill passed by the
House of Representatives. What is so problematic about our body doing
the same?
If you are a nurse, doctor, health care practitioner, Catholic
hospital, or an LDS hospital out of Utah, if we have the Stupak-Pitts
conscience protection language passed by the House, you cannot be
forced to participate in abortions. These are highly religious people
with highly religious motivations who have made this the greatest
country in the world. If we do not change this language in the Reid
bill, there will be Federal funding of abortion, and there will be
people who could be pushed toward participation in abortion.
Mr. BROWNBACK. It has been my pleasure to join Senators Hatch and
Johanns on this effort. I have worked with both of them in many
different capacities and jobs.
This is as serious a pro-life vote as I have seen. If this gets
passed, the Federal Government will be funding somewhere north of
300,000 abortions a year. If it was 300,000 back in the 1974-to-1976
timeframe, with the growth in U.S. population, you are probably looking
at north of that number of Federal taxpayer dollars funding abortions.
I cannot imagine many people in this country being satisfied about that
kind of number taking place. I can't imagine that. But that is our past
experience when the government funds abortion.
Those are the numbers we are talking about. I note, too, the country
has a longstanding ethic and moral code. We are a moral people, and we
have been from the outset. Some people say this or that, but a big part
of that has been that basic moral code, that basic thought within the
Judeo-Christian ethic that we respect life. This goes back to when
Moses talks to the people about going into the Promised Land. He is
giving his last lecture to the Jewish people before going into the
Promised Land. In that last lecture--Moses doesn't get to go in
himself, but he gets the people together. They march for 40 years in
the wilderness. He knows he is not going in, but they are, and he gives
a lecture.
Deuteronomy 30:19 says something that is applicable here:

This day I call heaven and earth as witnesses against you
that I have set before you life and death, blessings and
curses. Now choose life, so that you and your children may
live.

This is in the fundamental ethic and background of our country. That
is what we have to choose today. Do we choose life or death? Choose
life, so that you and your children might live.
As Senator Johanns notes, we just need one vote on the other side to
change this, and this language gets pulled out and Stupak gets put in.
Just one vote. If we cannot get to 60--and you have to get there--and
that one person says: I am not going to do it, unless you put Stupak in
this, it changes. We need just one to choose life, and it will change.
It has been a pleasure to join with both Senators today.

Exhibit 1

United States Conference

of Catholic Bishops,

Washington, DC, November 20, 2009.
U.S. Senate,
Washington, DC.
Dear Senator: On behalf of the United States Conference of
Catholic Bishops (USCCB), we strongly urge the Senate to
incorporate essential changes to the Senate's health care
reform bill to ensure that needed health care reform
legislation truly protects the life, dignity, consciences and
health of all. We especially urge the Senate to act as the
House has in the following respects:
Keep in place current federal law on abortion funding and
conscience protections on abortion;
Protect the access to health care that immigrants currently
have and remove current barriers to access; and
Include strong provisions for adequate affordability and
coverage standards.
The Catholic Bishops of the United States have long
supported adequate and affordable health care for all. As
pastors and teachers, we believe genuine health care reform
must protect human life and dignity, not threaten them,
especially for the most voiceless and vulnerable. We believe
health care legislation must respect the consciences of
providers, taxpayers, and others, not violate them. We
believe universal coverage should be truly universal, not
deny health care to those in need because of their condition,
age, where they come from or when they arrive here. Providing
affordable and accessible health care that clearly reflects
these fundamental principles is a public good, moral
imperative and urgent national priority.
Sadly, the legislative proposal recently unveiled in the
Senate does not meet these moral criteria. Specifically, it
violates the longstanding federal policy against the use of
federal funds for elective abortions and health plans that
include such abortions--a policy upheld in all health
programs covered by the Hyde Amendment, the Children's Health
Insurance Program, the Federal Employee Health Benefits
Program--and now in the House-passed ``Affordable Health Care
for America Act.'' We believe legislation that violates this
moral principle is not true health care reform and must be
amended to reflect it. If that fails, the current legislation
should be opposed.

Protecting Human Life and Conscience

Specifically, we urge you to include the House-passed
provision that keeps in place the longstanding and widely
supported federal policy against government funding of
elective abortions or plans that include elective abortions.
In the aftermath of the overwhelming and bipartisan House
vote for the Stupak-Smith-Ellsworth-Kaptur-Dahlkemper-Pitts
Amendment, there has been much misunderstanding of what it
does and does not do. This amendment does not change the
current situation in our country: Abortion is legal and
available, but no federal dollars can be used to pay for
elective abortions or plans that include elective abortions.
This provision simply keeps in place existing policy and
allows Congress to honor the President's commitment that ``no
federal dollars will be used to fund abortions.'' The
amendment does not restrict abortion, or prevent people from
buying insurance covering abortion with their own funds. It
simply ensures that where federal funds are involved, people
are not required to pay for other people's abortions.
Thus far, the pending Senate bill does not live up to
President Obama's commitment of barring the use of federal
dollars for abortion and maintaining current conscience laws.
The bill provides federal funding for plans that cover
abortion, and creates an unprecedented mandatory ``abortion
surcharge'' in such plans that will require pro-life
purchasers to pay directly and explicitly for other people's
abortions. Its version of a public health plan (the
``community health insurance plan'') allows the Secretary of
HHS to mandate coverage of unlimited abortions nationwide,
and also allows each state to mandate such abortion coverage
for all state residents taking part in this federal program
even if the Secretary does not do so. The bill seriously
weakens the current nondiscrimination policy protecting
providers who decline involvement in abortion, providing
stronger protection for facilities that perform and promote
abortion than for those which do not. The legislation
requires each region of the insurance exchange to include at
least one health plan with unlimited abortion, contrary to
the policy of all other federal health programs. Finally,
critically important conscience protections on issues beyond
abortion have yet to be included in the bill. To take just
one example, the bill fails to ensure that even religious
institutions would retain the freedom to offer their own
employees health insurance coverage that conforms to the
institution's teaching. On these various issues the new
Senate bill is an enormous disappointment, creating new and
completely unacceptable federal policy that endangers human
life and rights of conscience.

Immigrants and Health Care Coverage

We support the inclusion of all immigrants, regardless of
status, in the insurance exchange. The Senate legislation
forbids undocumented immigrants from purchasing health-care
coverage in the exchange. Undocumented immigrants should not
be

[[Page S11930]]

barred from purchasing a health insurance plan with their own
money. Without such access, many immigrant families would be
unable to receive primary care and be compelled to rely on
emergency room care. This would harm not only immigrants and
their families, but also the general public health. Moreover,
the financial burden on the American public would be higher,
as Americans would pay for uncompensated medical care through
the federal budget or higher insurance rates.
We also support the removal of the five-year ban on legal
immigrants accessing federal health benefit programs, such as
Medicaid, the Children's Health Insurance Program, and
Medicare. Legal immigrants, who work and pay taxes, should
have access to such programs if needed. Removing the ban
would help ensure that legal immigrants, who were widely
praised in past immigration debates for their many
contributions and for playing by the rules, will still have
access to health care.

Accessible and Affordable Health Care

The Catholic bishops have advocated for decades for
affordable and accessible health care for all, especially the
poor and marginalized. The Senate bill makes great progress
in covering people in our nation. However, the Senate bill
would still leave over 24 million people in our nation
without health insurance. This is not acceptable.
The bishops support the expansion of Medicaid eligibility
for people living at 133 percent or lower of the federal
poverty level. The bill does not burden states with excessive
Medicaid matching rates. The affordability credits will help
lower-income families purchase insurance coverage through the
Health Insurance Exchange. However, the Senate bill would
still leave low-income families earning between 133 and 250
percent of the federal poverty level financially vulnerable
to health care costs. Overall, the average subsidy provided
for in the Senate bill is $1,300 less than the average
subsidy in the House bill. Improvements to the bill should be
made so that low-income families have reasonable out of
pocket expense for health care.
Immediate reforms are included in the bill that should be
helpful in providing relief to the uninsured and
underinsured. Additionally, reforms that will strengthen
families and protect low-income and vulnerable people such as
eliminating denial of coverage based on pre-existing
conditions including pregnancy; eliminating life time caps;
offering long-term disability services; and extending
dependent coverage to uninsured young adults--are significant
steps toward genuine health care reform. We urge the Senate
to maintain these provisions.
These moral criteria and policy objectives are not marginal
issues or special interest concerns. They are the questions
at the heart of the health care debate: Whose lives and
health are to be protected and whose are not? Will the
federal government, for the first time in decades, require
people to pay for other peoples' abortions? Will immigrants
be worse off as a result of health care reform? At their
core, these health care choices are not just political,
technical, or economic, but also moral decisions. This
legislation is about life and death, who can take their
children to the doctor and who cannot, who can afford decent
health care coverage and who are left to fend for themselves.
Our appeal for health care legislation that truly protects
the life, dignity, health and consciences of all reflects the
unique perspectives and experience of the Catholic community.
Our hospitals, clinics, and long-term care facilities provide
quality health care to millions. Our dioceses, institutions,
and ministries purchase health care for many thousands of
employees and their families. Our emergency rooms, shelters,
clinics, and charities pick up the pieces of a failing health
care system. Our Catholic moral tradition teaches that health
care is a basic human right, essential to protecting human
life and dignity.
For many months, our Bishops' conference has been working
with members of Congress, the Administration and others to
fashion health care reform legislation that truly protects
the life, dignity, health and consciences of all. Our message
has been clear and consistent throughout. We hope and pray
that the Congress and the country will come together around
genuine reform.
Sincerely,
Bishop William F. Murphy,
Diocese of Rockville Centre, Chairman, Committee on
Domestic Justice and Human Development.
Cardinal Daniel DiNardo,
Archdiocese of Galveston-Houston Chairman, Committee on
Pro-life Activities.
Bishop John Wester,
Diocese of Salt Lake City, Chairman, Committee on
Migration.

Mr. HATCH. Madam President, I yield the floor and suggest the absence
of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The assistant legislative clerk proceeded to call the roll.
Mr. FRANKEN. Madam President, I ask unanimous consent that the order
for the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. FRANKEN. Madam President, I ask unanimous consent that the next
hour be equally divided between the following three Senators: Franken,
Lincoln, and Levin.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. FRANKEN. Madam President, I rise today to express my strong
support for the Patient Protection and Affordable Care Act.
I commend Leader Reid, Chairman Harkin, Chairman Baucus, and Senator
Dodd for their leadership that has brought us to this critical point.
We are on the verge of passing legislation that will do more than any
bill in recent history to make our country healthier, our economy more
stable, and our working families more secure.
Make no mistake, this bill will change. There will be amendments to
it that will make it an even better bill. There may be amendments that
make it less to my liking and, therefore, a less good bill, to my point
of view. But the final bill will make health care available to more
tens of millions of Americans. It will make health insurance more
secure for all Americans who have it and will put an end to the
unsustainable trajectory that we are now on with the cost of health
care, and will avert an otherwise inevitable catastrophe to our health
care system and our economy.
The reality right now is that we are denying millions of Americans
their shot at the American dream because of our irrational health
insurance system.
Right now, if you have been sick, insurance companies can refuse to
cover you or charge you ridiculous premiums. If you get sick, your
insurance benefits can run out when you need them the most.
Right now, people without insurance do not get preventive care.
Instead, they go to the emergency room when they cannot hold out any
longer. This is the least-efficient and most expensive way to deliver
care, and those of us who do have insurance pay for it. It costs every
insured family more than $1,100 a year in additional premiums to pay
for those who don't have health insurance.
Right now, if you are a woman who has had a C-section or if you have
been a survivor of domestic violence, health insurance companies can
arbitrarily decide not to cover you. That is because having had a C-
section or being a survivor of domestic violence is considered by many
insurance companies to be a preexisting condition. That is wrong.
What is even more egregious is that while millions of Americans
struggle to pay for health care, insurance executives continue to make
obscene salaries. From 2000 to 2007, a period of 8 years, Americans saw
their premiums almost double. During that same time, we saw more than 6
million more Americans become uninsured. During that same time,
insurance company profits rose 428 percent--428 percent. That is all
you need to know to understand why we have to pass this bill--428
percent in 8 years. No wonder the insurance companies are fighting this
bill. Of course they don't want to be subject to antitrust laws. They
are making outrageous profits by gouging American families. Make no
mistake, that is what this is about.
This bill will change all that. It will fundamentally transform how
health insurance works in this country. This bill guarantees secure
coverage that will be there for Americans and stay there when they need
it the most. This is not going to help just individual Americans; it is
going to help small businesses too.
There are urgently needed changes that will go into effect the day
the President signs this bill into law. Effective immediately,
preventive services, such as colonoscopies and cholesterol tests, will
be covered by all insurance plans at no cost. This will make prevention
a priority, not an afterthought. We will detect cancers earlier and
stop chronic diseases, such as diabetes, in their tracks. Not only will
this save innumerable lives, it will lower the long-term cost of health
care for all of us. This is one of the key

[[Page S11931]]

ways health care reform transforms our system of sick care into a true
health care system.
Effective immediately, any new health insurance plan will let your
children remain on the family policy until they are 26. That is big.
Say you are a parent whose kid has been ill in the past, maybe she had
asthma and she just graduated, say, from the University of Minnesota.
Your daughter is just out of school, and she wants to find a job. We
all know this is a big enough challenge in this economy. While she
plans for her future, the last thing she should have to worry about is
how she is going to get health insurance.
The good news is, after health care reform, she will have secure
coverage until she gets on her feet. She can either stay on your plan
until she is 26 or once the exchange is up and running, she can
purchase an affordable plan through the exchange.
Also, effective immediately, we will hold health insurance companies
accountable by making them give rebates if they spend more than 20
percent of premiums toward profits, marketing, or administration. I am
proud to have championed this safeguard with my colleagues, Senator
Rockefeller and Senator Whitehouse.
The current reality is, most of us do not know where our health
insurance premiums go. It is challenging enough to understand a billing
statement from your health insurer, much less track where your money is
being spent. We are going to change that.
Thanks to Senator Jack Reed, the Senate bill also requires
transparent reporting of how health insurance companies are spending
your money. This transparency is especially important as we cover an
additional 3l million Americans under this bill. We know from their
profit margins that right now insurance companies are price gouging.
But clear reporting will help us hold them accountable for every dollar
we invest in health insurance.
Based on our experience in Minnesota, I know we can do even more to
rein in marketing, wasteful administrative costs, and profits in health
insurance. In the coming weeks, we will debate this bill, amend it, and
make it even better. I will be pushing to require an even higher
percentage of your premiums go toward actual health care.
The reason I believe we can provide higher quality care without
excessive profits is because Minnesota already does it. We are
distinguished by the fact that 90 percent of Minnesotans are served by
a nonprofit health plan. These plans outperform their national peers
and are able to put an average of 91 cents of every premium dollar
toward actual health care services--91 cents out of every dollar.
In other plans throughout the Nation, you may find less than 60
percent of your premium is put toward health care. The rest is for
overhead, marketing, and profits. By taking the profits out of the
health insurance industry--not taking them out but lowering them to a
reasonable level--Minnesota health plans do a better job of helping our
residents live healthier, longer lives. As we begin debating this bill
on the Senate floor, it is essential that health insurance companies
get the message loudly and clearly that their top priority must be
serving patients, not creating more and more profits, not a 428-percent
increase in profits in 8 years.
Under the Senate bill, we will stop insurance companies from denying
you coverage or charging you more because of preexisting conditions.
This will end the egregious industry practice of discriminating against
survivors of domestic violence. Insurance companies also will no longer
be able to charge women more for their health coverage just because
they happen to be a woman.
We will ban lifetime caps and end unreasonable annual limits on your
benefits. These insurance market reforms will help Americans, but they
will be particularly life changing for families such as the Battersons
who live in Bloomington, MN. Linda Batterson has three daughters. She
owns her own business, and her husband Bud is a realtor.
The Battersons have some relatively minor health problems--asthma,
allergies, and back problems. But because health insurance companies
can charge them more based on their health history, their only health
care option in Minnesota is a high-risk pool. This year they are paying
nearly $21,000 for health care--$21,000 for their insurance. This is
not a Cadillac plan. Neither the Battersons' businesses nor their
family can sustain these costs.
But the good news is, the Battersons will get relief under our bill.
They will be able to go to the exchange and find an affordable plan.
Health insurance companies will not be able to charge the family more
because of their health history. If companies are going to raise rates,
they will have to publicly disclose and justify any increase.
I think we can all agree that one group of Americans who suffer under
our current system is small businesses. Across Minnesota--from Bemidji
to Spring Valley--I have talked to small business owners who want to do
the right thing. They want their workers to be healthy, but they cannot
afford the current unpredictable and skyrocketing rates.
In Minnesota, we have 92 percent of our State covered, and we have
invested resources to create the MinnesotaCare Program to make sure
low-income residents are covered. But even with all this success, the
uncontrolled cost of health insurance is forcing us to tighten our
belts and make sacrifices that no American should have to make, such as
small businesses having to choose between laying off workers or
dropping health insurance for everyone.
I am pleased to tell you this bill will bring real relief to small
businesses across our country. We will even the playing field so small
businesses can do the right thing for workers without sacrificing their
bottom line. This will make them competitive with large employers and
with companies from overseas so they can attract the best and brightest
workers.
Right now, small businesses are often priced out of the markets. They
may be lucky to find just one or two carriers willing to cover their
workers. So the first important change that health care reform can
bring is choice of plans for small businesses. They will be able to
participate in the exchange which will offer them a choice of reliable
plans. This coverage will be less expensive and provide better coverage
than what is available today.
Right now, if you are a business with, say, 15 employees and 1 of
them gets sick or has a baby, your premiums are going to go up
dramatically. That is because your risk pool is 15. But when you choose
from policies on the exchange, your risk can be pooled with hundreds or
even thousands of other businesses. That is the whole point of
insurance, to spread the risk over the greatest number of people.
The second key benefit for small businesses is tax credits to help
business owners purchase coverage. Effective immediately, these credits
will ease the burden on small business owners who offer coverage but
are being squeezed in the current market. For business owners who have
not been able to offer insurance, the tax credits will provide a new
incentive to begin covering their workers, keeping the workforce
healthy and productive.
Today I have touched on just a few elements of the health care reform
bill. I will be back. I have touched on insurance market reforms and
provisions tailored to the needs of small businesses. But this just
scratches the surface. The public option will bring much needed
competition, and the incentives for high-quality care will make us all
healthier. Taken together, these elements will bring our country into a
new era in which high-quality and affordable health care is a reality
in this country.
Passing national health care reform this year is my top priority
because I have listened to Minnesotans across my State. They have told
me loudly and clearly that the current health insurance system is not
working for them, and they have told me they want access to care. I
have heard them.
They want to know they can start a small business without worrying
about the cost of health insurance because one of their kids has a
preexisting condition. They want to know they will have health care
when they need it the most. They want insurance companies to prioritize
health services over profits. They are looking for us to fulfill our
promise to pass comprehensive health care reform this year.

[[Page S11932]]

I look forward to working with all of you to make this a reality.
I yield the floor.
I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The bill clerk proceeded to call the roll.
Mrs. LINCOLN. Madam President, I ask unanimous consent the order for
the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mrs. LINCOLN. Madam President, I have asked for this time today not
only to address my colleagues in this body but to speak directly to my
constituents at home in Arkansas. After many months of debate on health
care, we are nearing yet another important step in a very deliberative
process. Today we are voting on whether to continue to discuss how to
improve health care in America or to stop the debate.
I personally have carried the mantle to improve health care for
Arkansas throughout my public service, like many of my colleagues and
so many others as well who have worked hard on this issue. Over the
last several decades the advance of medical technology and our Nation's
changing demographics have placed new demands on our health care system
that it is not designed to meet.
Our vote later this evening is not the first step toward making the
necessary adjustments in health care, nor will it be the last, without
a doubt. The Finance Committee on which I serve and which is led so
ably by my good friend from Montana, Chairman Baucus, has produced what
I still describe as the most responsible approach to health insurance
reform. We deliberated for more than 22 months, incorporating
recommendations from experts all across our great Nation and proved,
through our bill, that America can achieve unprecedented health
insurance reforms that expand coverage, reduce cost, and provide
stability for those with existing coverage.
We accomplished these goals without posing long-term risk for
taxpayers. It was not a perfect bill. We never see perfect bills around
here, quite frankly, but I can honestly say I will fight hard so our
final product will more closely resemble the commonsense, deficit-
reducing plan we produced in the Senate Finance Committee.
At times like this I think it is very important for each of us to
remember the very reasons we began this debate. Small businesses and
working families are reaching the breaking point financially because of
the relentless rise in health care costs. Nationally, our economic
recovery will only be slowed by the inflationary cost of health care.
Taxpayers and the insured are already bearing the cost of medical
treatment for the uninsured at the most expensive point of delivery, in
our emergency rooms. Health care in America today is a model that waits
until people get sick rather than focusing on the wellness, prevention,
and good management of illness that keeps people out of the hospital
and from having the most costly care needs.
Our current health care system wastes money and is so inefficient
that the United States spends more than twice as much per person while
insuring a smaller portion of our population than the average spending
in 29 other industrialized nations. There simply are not enough health
insurance options available to most Americans today when in at least 17
States, including my home State of Arkansas, only one insurance company
controls more than half the insurance market, and in at least 22 States
still only two carriers control half or more of the market.
Patients and doctors are routinely making treatment decisions with
little or no objective information about which treatments are more
effective. American capitalism is based on choice and competition
because when these elements are present, consumers can most always find
the best value for their money. That is not true in health care. So by
creating health insurance exchanges through which small businesses and
individuals can choose from a menu of private plans, we can enhance
cost transparency, create head-to-head competition, and allow market
forces to reduce prices.
These are facts. These are facts, and whether we are Republicans or
Democrats or independent, I believe we can agree on most all of them. I
know the great majority of Arkansans believe these facts and want to
see us accomplish these reasonable goals.
For months now, groups from outside my State have assigned various
motives to my deliberations on health care and tried to define the
meaning of my vote. According to the last tally, there has been more
than $3.3 million worth of media ads that have been purchased in my
home State of Arkansas by groups from outside of our State--certainly
none by me--and most with my name in the ad. Still, I have continued to
approach this issue as I always do. These outside groups seem to think
this is all about my reelection. I simply don't think they know me very
well.
I am focused on my opportunity to influence the final version of
health care legislation in a way that most helps my State. That is why
the people of Arkansas sent me here. They sent me here because they
know I am going to work hard to do the best job possible and to do the
right thing; to stand my ground on my principles.
I have avoided the extremist claims from the left and from the right
and tried to pull the commonsense solutions from among all the policy
options so that we get health care reform that benefits Arkansans and
all Americans. That is our job in this body, to represent our States in
this unbelievably historic body, the Senate.
The truth is, this issue is very complex. There is no easy fix, and
it is imperative that we build on what is already working for health
care in America and not turn away from the problems we face. We keep
building until we can truly say one day that all American citizens will
have access to quality and affordable health care. In order to improve
upon and build upon what we already have, I do not support the creation
of a so-called robust, government-administered public plan.
I believe we should work to make sure we do not expose American
taxpayers and the Treasury to long-term risks that could occur over
future government bailouts of a public plan. Rather than create an
entirely new government-run health plan to compete with private
insurers, I support health insurance reform that focuses on changing
the rules of our existing employer-based private health insurance
system. I believe we should change the current rules that permit
insurance companies to bully their customers and cherry-pick healthy
patients, so we can force them to compete with each other.
My first loyalties are with the people of Arkansas--not insurance
companies, the health care industry, or my political party. In fact, I
authored an amendment during consideration of legislation in the Senate
Finance Committee which limits taxpayers' subsidies for health
insurance companies that pay their top executives millions in salaries.
Responsible health insurance reform should ensure that insurance
executives are not receiving a personal windfall, and that companies
they work for are not receiving excessive tax breaks while at the same
time profiting from government requirements on consumers to buy
insurance.
The reason we are having this vote is because our Republican
colleagues object to beginning debate and consideration of amendments
on health care legislation. Although I do not agree with everything in
this bill, I have concluded that I believe it is more important that we
begin this debate to improve our Nation's health care system for all
Americans rather than simply dropping the issue and walk away. That is
not what people sent us here to do.
Attempts by the National Republican Party and other conservative
groups to portray this as a vote for or against this particular health
care reform bill are untrue and deliberately misleading. The vote
tonight will mark the beginning of consideration of this bill by the
full Senate, not the end. Republicans have sought to revive their
political party by opposing any real solution to our Nation's health
care crisis. In fact, this vote for or against a procedure that allows
us to begin debate on health care reform is nothing more and nothing
less. Put simply, those who vote yes on this vote believe our Nation's
health care system needs reforming, and they are ready to have an
honest and open debate in the Senate about how to best achieve that
reform.

[[Page S11933]]

I am not afraid of that debate, nor am I afraid of coming before this
body to say what I believe is the most important thing we can do to
reform health care. I hope none of us are. Our country needs us too
desperately now to be making good decisions and moving forward.
I will not allow my decision on this vote to be dictated by pressure
from my political opponents, nor the liberal interest groups from
outside Arkansas that threaten me with their money and their political
opposition; the multitudes of e-mails and ads we have received,
unbelievable types of threats about what they are going to do and how
they are going to behave. The fact is, I am serious about changing our
health care system, as most Arkansans and most Americans are. I am not
with those who seek to avoid the debate, nor with those who use
political attacks to achieve their narrow goals. I will vote in support
of cloture on the motion to proceed to this bill.
But let me be perfectly clear. I am opposed to a new government-
administered health care plan as a part of comprehensive health
insurance reform, and I will not vote in favor of the proposal that has
been introduced by Leader Reid as written. I, along with others, expect
to have legitimate opportunities to influence the health care reform
legislation that is voted on by the Senate later this year or early
next year. I am also aware there will be additional procedural votes to
move this process forward that will require 60 votes prior to
conclusion of the floor debate. I have already alerted the leader and
my colleagues that I am prepared to vote against moving to the next
stage of consideration as long as a government-run public option is
included. The public option, as a part of health insurance reform, has
attracted far more attention than it deserves. While cost projections
show that it may reduce costs somewhat, those projections don't take
into account who pays if it fails to live up to expectations. If, in
fact, premiums don't cover the cost of the public plan, it is taxpayers
in this country who are faced with the burden of bailing it out.
Our colleagues cannot ignore the growth in the Federal Government
since the year 2000. I can assure you that the American people have not
ignored it. According to the American Institute for Economic Research,
government spending grew by 55 percent under President Bush. As he was
leaving office, government launched a massive bailout of Wall Street.
Then it was the domestic auto manufacturing industry that needed
taxpayer funds to survive. And finally, in order to revive a dying
economy, it took a government economic recovery package to save or
create hundreds of thousands of jobs. We can argue about the necessity
of these unprecedented steps, but we need not argue about the
impression they have made on the American people. We should be stopping
the growth of government, not expanding it more. Without the public
option, we could still force private insurance plans that participate
in the exchanges to provide standard benefit packages that are easy to
compare and more fairly priced. We will be bringing millions of new
customers to the exchanges so insurers should be motivated to lower
prices and be competitive.
I have pledged to dialog with Leader Reid regarding my concerns that
remain about this bill. I look forward to continuing that dialog on
improvements that I believe are necessary in order to meet the
challenge. I will be asking my colleagues to consider these additional
important changes I believe will improve our chances for real health
insurance reform and that can also enjoy the support of most Arkansans
and most Americans.
Some of these include that the legislation remain deficit neutral,
now and in the future, and curbs future cost, that it protects Medicare
beneficiaries for seniors and extends solvency of the Medicare Program,
that it improves accessibility and affordability of health insurance
for employees and owners of small businesses and the self-employed
through access to health insurance exchanges and tax credits, that it
enhance choice and competition of health insurance plans for small
businesses and individuals without the inclusion of a government-run
public option, and that it build our Nation's health care workforce and
ensure continued access to quality health care providers, especially in
rural America.
Today I know I will ultimately be held accountable by my constituents
in Arkansas for all of my votes on health care, not the National
Republican Senatorial Committee, not by other groups from outside my
State that continue to engage in a conversation they have begun. I know
my decision to support the upcoming cloture vote on the motion to
proceed is not my last nor only chance to have an impact on health care
reform.
I am optimistic and encouraged about the step we are preparing to
take in the Senate, to amend and craft a bill that will improve access
to quality, affordable coverage options for the residents and
businesses of my State who desperately need relief, a bill that
improves the quality and efficiency with which we deliver health care,
all without adding to our Nation's deficit and while lowering the cost
of health care over the long term. I am committed to using every power
of my office to achieve success on this issue by enacting meaningful
reforms that will benefit the people of Arkansas and our Nation.
I have spent the last several months in a passionate dialog with my
constituents about health care reform. It was not only in townhall
meetings where I heard from Arkansans. I had hundreds of conversations
with many of them in groups and one-on-one conversations. They may not
be in agreement about solutions, but I can assure my colleagues that
each Arkansan I speak to expects us to roll up our sleeves and get this
right. We can. Following the vote tonight, the bill that will be laid
before us will not be the only possible solution. I know my decision to
support cloture on the motion to proceed is not my last or only chance
to have an impact on overall health care reform. My strongest hope is
that each of us can lay political fortunes aside and make the tough,
commonsense choices our constituents expect of us, whether you are a
Democrat or Republican, and look at what we face and the challenges of
our Nation. Make sure that as we are working toward an end result, that
each of us is working as hard as we can to come up with a pragmatic
solution that our constituents expect of us. We may not get this
opportunity again in our lifetime.
Today I am thinking about the Arkansas working family who can't pay
their mortgage because of their sick child's medical bills. I am
thinking of the Arkansas small business owner who told me that more
than 20 percent of the cost of running his business now goes to health
insurance for him and his workers. I am thinking about the 450,000
Arkansans who have no health insurance. I am not thinking about my
reelection, the legacy of a President, or whether Democrats or
Republicans are going to claim victory in winning the debate. I hope
all of my colleagues join me in looking forward to working with the
leader and all of our colleagues in the days and weeks ahead as we
strive to solve a problem whose solution is long overdue.
I yield the floor.
The PRESIDING OFFICER. The Senator from Michigan.
Mr. LEVIN. Madam President, in a few hours we will take an important
step on the road to health care reform. Our vote will come after months
of analysis and debate and years of growing concern on the part of our
constituents that the American health care system is in need of
fundamental reform. Two Senate committees have approved reform
legislation. We will vote later today on whether to open debate on a
third one which merges the two produced by the Senate Finance and HELP
Committees. Much time and attention has been focused on the provisions
in this legislation which will expand the number of Americans who are
covered by health insurance, a goal I wholeheartedly share. But a
compelling reason for reform and a major reason to vote in favor of
allowing the Senate to debate health care reform is the serious and
worsening signs that for those Americans who have health insurance, our
health care system is no longer working as it should.
Increasingly, Americans with health insurance are at catastrophic
financial risk, if they get sick. Increasingly, working families with
insurance are unable to afford the escalating premiums they face to
maintain their

[[Page S11934]]

often inadequate coverage. Increasingly, businesses large and small
that offer health insurance to their employees are buckling under the
crushing weight of spiraling costs for their employees. Increasingly,
families find that caps on their coverage leave them exposed to
devastating medical bills. And increasingly, arbitrary insurance
company practices that boost their own profits are shortchanging
Americans, denying coverage because of preexisting conditions, and
searching for ways to deny patients the treatments they need and have
paid for through their premiums.
Democrats are not alone in pointing out these problems. The
Republican leader himself has said:

Every Republican in Congress supports reform.

That is the Republican leader who said that every Republican in
Congress supports reform. He did not say many Republicans. He did not
say most Republicans. Every single Republican in both Chambers of
Congress, the Republican leader tells us, wants to reform the health
care system.
How will any reform happen, reform proposed by Democrats or by
Republicans or by anybody? Only when this body can bring a bill to the
floor of the Senate for debate and amendment, only when we work with
our colleagues in the other Chamber to resolve differences between
legislation approved by the Senate and that approved by the House, only
when Congress sends the President a bill he is prepared to sign into
law. Speeches will not reform health care. Polls and cable television
shout fests, none of that will reform health care. We, the Members of
the U.S. Congress, and we alone, can reform health care.
We must listen to constituents, advocacy groups, physicians,
insurers, health care experts, economists and anyone else with
constructive ideas. Ultimately, it is we who must act. To do that, we
must begin to debate here on the floor of the Senate the many complex
issues that must be resolved. That is all today's vote will do, give
the Members of the Senate the chance to come together in a sincere
effort to work together, resolve our differences, and address an issue
on which there is, we are told, even by the Republican leader, general
agreement on the need for reform.
Two Senate committees have already spent months seeking the proper
ways to reform the health care system. The Senate Finance Committee has
held over 50 meetings on health care reform legislation in the last
year. The Health, Education, Labor and Pensions Committee spent 13 days
marking up its legislation. So we have made progress. We are at least
in position to do what this body was designed to do and is supposed to
do: deliberate and decide.

The minority opposes the legislation we are trying to bring to the
floor for debate and amendment. They say they do not like the bill. But
why deny the Senate the opportunity to debate the subject of health
care reform? Why prevent us from considering it? Why not offer
amendments to the bill if you do not like it or offer a substitute
measure for it?
There are parts of the bill in which I would like to see changes. I
would like to make health insurance even more affordable for working
families, and I am willing to require that those earning more than
$250,000 a year, for instance, pay a higher and, in my view, more fair
and more appropriate tax rate to make that greater affordability for
working families possible.
Income data shows that in recent years only the wealthiest 10 percent
of Americans have seen any real increases in income and that those
increases are concentrated in the wealthiest 1 percent of the country,
while the vast majority of Americans have lost ground. At the same
time, most Americans are coping with falling income, they have been hit
with massive increases in health insurance premiums. So I am willing to
support an increase in upper income tax brackets to end that
unfairness.
Other sources of revenue, such as ending the abuse of offshore tax
havens, can and should go toward doing other things we should be doing
in this bill. For instance, I am concerned that the annual fee on
insurance providers contained in the merged bill would treat nonprofit
and for-profit insurers the same way. Millions of Michigan residents
receive their insurance from Blue Cross Blue Shield of Michigan, a
nonprofit company, which is the insurer of last resort in our State,
providing coverage to residents who cannot find it elsewhere. We need
to find ways to reform the insurance market without negatively
impacting the not-for-profit insurance companies that are the insurers
of last resort and that provide high levels of coverage in return for
the premiums they collect.
On these and other issues, I will continue to study the details of
the legislation, discuss them with colleagues and constituents, and I
will support improvements where needed. What I will not do is vote to
block efforts to reform a system that simply is not working well for
those who have health insurance, as well as for those who do not.
The need for reform is generally acknowledged. How can we then not
open debate? How can we not discuss, offer amendments, consider
alternatives, make changes, and vote on reform legislation? That is the
only path to health care reform. There is no other way. And for those
who proclaim their belief in the need for reform to stand in the way of
that debate is, at best, starkly inconsistent.
A vote against even opening debate is a vote in favor of the status
quo, which my constituents and the vast majority of Americans can no
longer afford. They can no longer afford it because it is bankrupting
them, in many cases literally bankrupting them. A study this year,
published in the American Journal of Medicine, found that in 2002, 62
percent of all individual bankruptcies in the United States involved
medical costs.
That is a tragedy. You should not be forced into bankruptcy because
you get sick. But it gets worse. Three-quarters of those bankruptcies
involved people who had health insurance when they got sick. Let me
repeat that. In the United States, almost two-thirds of all
bankruptcies are linked to medical costs, and three-quarters of those
bankruptcies occurred even though the debtor had health insurance. That
is adding absurdity to tragedy and demonstrates the inadequacy of
health insurance for those who are covered.
We must act to reform a health care system so broken that it crushes
Americans under a mountain of debt. One of my constituents, a Kalamazoo
man, had what he thought was adequate health care coverage when 3 years
ago he needed surgery to replace two sections of his aorta. But his
coverage left him an out-of-pocket cost of nearly $40,000. That is the
sum that stood between this man and lifesaving surgery. Financially
devastated by the costs, he declared personal bankruptcy. He wrote to
me:

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

He is right.
We must act to reform a health care system so broken that it leaves
the mother of a young Michigan State University student worried that
her daughter will not get the care she needs. This 24-year-old student
has insurance. Yet when she began to have unexplained seizures, her
coverage would not pay for all the tests needed to determine their
cause. Even after declining some prescribed tests because she could not
afford them, the young woman's doctors eventually discovered the cause
of her seizures: a brain tumor. This mother worries that her daughter
will lose her insurance, will be forced to declare bankruptcy, and that
the family will have to find some other way to cover the massive
expense of her lifesaving care--all while coping with the other
financial strains hitting her family and so many others. The mother
writes:

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

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

[[Page S11935]]

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

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

And she said:

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

Reflecting on her experience, this minister writes:

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

She is right.
The legislation the majority leader has brought forward will do much
to ease the hardship on millions of Americans. It has benefits for
those who already have insurance through their employer, with steps to
rein in skyrocketing premiums and to reduce the risk of financial ruin
for those who have health insurance.
In addition to helping those with private insurance, this legislation
provides important benefits for seniors covered by Medicare. Medicare
beneficiaries will receive free preventive care benefits, and the bill
will reduce the enormous costs many seniors face when they fall into
that doughnut hole, so-called, in the Medicare Part D prescription drug
program. Because of these important improvements in care for seniors,
AARP has recommended that Senators vote in favor of beginning debate on
this bill tonight.
The legislation also contains important provisions to improve
information technology in the health care sector, pushing for uniform
billing practices and developing standards that will lead to the
computer systems of health care providers being able to talk to the
computer systems of insurance companies, reducing mountains of
paperwork and other inefficiencies that drive up health insurance
premiums.
Americans who move from one employer to another will no longer face
the risk of being denied coverage at their new job because of a
preexisting condition.
We must allow debate to begin. If we act, millions of those who
already have insurance at work will benefit. If we act, millions
without insurance will get it, along with help to pay for it, so we can
end the current wasteful situation in which emergency room care--vastly
more expensive than primary care through a family doctor--is used for
nonemergency purposes by those without health insurance.

We can only accomplish these things if we vote today to begin debate
on this legislation. We can only accomplish these things if we are
willing to honestly and vigorously debate the best ways to achieve it.
So I urge our colleagues not to close the doors of this Chamber to
debate on one of the most urgent problems Americans face. I ask our
colleagues to allow the Senate to begin deliberations on health care
reform and not to turn away from the opportunity and the responsibility
before us.
Madam President, I yield the floor.
The PRESIDING OFFICER. The Senator from Tennessee.
Mr. CORKER. Madam President, I know the time is slightly before the
hour. I do not know if there are any Democrats who want to speak beyond
the Senator from Michigan during this hour. With that, I think we are
anxious to get going.
Madam President, I ask unanimous consent that the Republican speakers
be permitted to enter into a colloquy during the time controlled by the
minority, which I understand ends at 4 o'clock today. Is that correct?
The PRESIDING OFFICER. That is correct.
Without objection, it is so ordered.
Mr. CORKER. Madam President, just to make sure people who may be
watching the Senate floor understand what is happening, Republican
Senators took all day yesterday and today to read the bill and to
actually go through sections of the bill to discuss it and make sure
all of us are very familiar with the various pieces of it.
I think all of us are united in concern about the way this bill is
paid for. It is hard for me to believe that anybody could suggest that
taking $464 billion out of Medicare, which is insolvent, would be a way
to fund a new entitlement; or that pushing down an unfunded mandate to
States, which we are going to talk about in just one moment, makes any
sense at all--$25 billion worth; or increasing the Medicare tax, which
would not be a tax to make Medicare more solvent, but instead go to a
new entitlement program--we all know Medicare is going to be insolvent
by the year 2017; and to have a bill that pays for itself over 10 years
by having 6 years' worth of costs against 10 years worth of revenue;
and then to have something such as the CLASS Act, which I know the
chairman of the Budget Committee has called a Ponzi scheme, where, in
essence, you create a program that takes in premiums over a 10-year
period on a new entitlement for long-term care--another new
entitlement, I might add, in addition to the one we are talking about
today--it takes in those premiums but bars any money from going out for
5 years. So what you have is, in essence, a collection system that
creates $72 billion. So I think all of us are very concerned about how
this is funded.
But today we want to talk about our tremendous concerns with the
Medicaid expansion that is taking place. I am joined by a number of
Senators who have had vast experience in State government and vast
experience in health care.
I think the American people have now realized this bill insures, per
the CBO, 31 million additional people. But the expansion that causes
that to occur is that 15 million people now will be on Medicaid who are
not on Medicaid. It is the largest expansion of Medicaid in U.S.
history.
What we are doing to make sure this works budgetarily is we are
forcing States to pick up the tab. I got an e-mail last night from my
State--and I know other States are going to be talking about that, or
people from other States. But last night, the State sent me an e-mail
and said this was going to cost our State almost $800 million.
Our State has been well governed for years. The senior Senator from
Tennessee was Governor in the middle-eighties. We have had both
Republicans and Democrats who have governed our State very well. In our
State, we do not expect our revenues to be back to 2008 levels until
2013. So you can imagine that our Governor, who is on the other side of
the aisle, is very concerned about us here in Washington saying he has
to expand his Medicaid Program. We are going to expand it around the
country by 15 million people, and he has to pay for it. He is more than
upset about that particular issue.
I know people here in Washington--the Washington establishment--
generally speaking, are upset about the fact that States actually
balance their budgets. We don't do that here, but in order to show
almost disrespect for the way our States, in most cases, have to
balance their budgets, what we are saying is we are going to make it
more difficult on them by making sure that in order to reach a goal, we
force our States, through an unfunded mandate, to cover an additional
15 million people under their Medicaid programs.

Let me just mention that I thought we were actually going to do
health care reform. I know there is probably a lot of laughter taking
place in the halls of this building today because I thought when we
talked about health care reform, that is what we were going to do.
We know Medicaid is one of the worst programs that ever existed as it
relates to health care. Let me just mention a couple stats. The Cancer
Journal published that Medicaid recipients were two to three times more
likely to die from the disease than people who were not on Medicaid.
The American College of Cardiology in 2005 said Medicaid patients were
almost 50 percent more likely to die after coronary artery bypass
surgery than patients on Medicare or private pay. Forty percent of
physicians in our country don't even take Medicaid. In urban areas, 50
percent of specialists have blocked patients from entering their
program.
So I wish to say just this and then I will stop because I want to
hear from other colleagues who have been around here for awhile. But
when I was back home during August, citizen after citizen said to me: I
know we are going to have health care reform. What I would like is just
to have what you, Senator,

[[Page S11936]]

have. That is what I would like to have. I know Senator Burr worked on
a bill that would do that. It would create the ability for people to
participate, as we do, in choice. I know Senator Alexander worked with
Senator Wyden and others, and I worked with Senator Burr in the first
Congress to create legislation that did that. As a matter of fact,
Senator Wyden, from the other side of the aisle, created a bill that
did away with Medicaid. It gave Medicaid recipients the same kind of
choice that we in the Senate have. But it seems to me, Senator Reid's
bill goes in exactly the opposite direction.
What it does, in order to add 31 million people to the rolls, 15
million people are being forced into Medicaid. So I would think, then,
that in order to make sure we are treated just like our citizens, one
of the first votes we might take is that we agree, as Senators, to be
treated the way the majority of people in this program are being
treated, and I assume that going on Medicaid with those same results
for our families would be something we would embrace. I think all of us
heard from citizens across this country that they want the same choices
we have. But in the name of reform, we are going in the opposite way
and, again, locking them into nonchoices, nonphysicians, bad outcomes,
and going in exactly the wrong way we should be going and, to boot,
making States pay for it.
There is one class of people, though, who are not treated that way in
this bill. I have tremendous respect for those immigrants who have come
into our country in a legal way. Let me make sure people understand
that. Sometimes my southern drawl confuses people. I have tremendous
respect for people who have come into this country in a legal way. The
Reid bill does this. He respects them too. What the Reid bill says is,
if you are born in America and you are from 100 to 133 percent of
poverty, then you are barred from receiving a subsidy and are forced to
be on Medicaid, but if you come into this country as a legal immigrant,
you actually can receive a subsidy to purchase a private insurance
policy. I find that most interesting. I don't know if some of my other
colleagues--I know Senator Burr has spent a lot of time on this.
I find this reform very troubling. I know the Senator has worked hard
to give Medicaid recipients the same choice as we have. I don't know
how you feel about the reform that is before us.
Mr. BURR. I thank my colleague from Tennessee. I think it is
important, throughout this education of the American people of what is
in 2,074 pages, to remind them that for every word in here, it costs
the American taxpayer $6.8 million; for every page, $1.2 billion.
I think one has to look a little further at this reform aspect. Does
this bill truly reform health care? I think as you read through the
bill what you find are the words ``require,'' ``must,'' or ``shall''
4,677 times. You find the words ``tax,'' ``fee,'' or ``revenue'' 899
times. You find the word ``agency,'' ``department,'' ``bureau,''
``commission,'' or ``panel'' 470 times. But we are told this bill does
reform health care. We are told it increases competition, it provides
more choice, it stimulates innovation. Yet we find the word ``choice''
40 times. We find the word ``innovation'' 25 times. We find the word
``competition'' 13 times.
I suspect their intent is to fix what they haven't reformed by
allowing the Secretary of Health and Human Services, in 1,677 spots, to
define or determine what congressional intent was. Think about that.
This bill basically turns over a lot of the decisionmaking to the
current or future Secretaries of Health and Human Services to decide
what we meant in the Congress.
Well, my good friend from Tennessee raised a lot of things on
Medicaid, and I wish to talk about Medicaid, but I also wish to mention
that, once again, we are paying for this by cutting $464 billion from
our Nation's seniors. That is a trust fund. They have paid in premiums.
Similar to the CLASS Act--it shouldn't be a surprise to us that they
are going to steal money out of the CLASS Act that hasn't even been
created yet because in the bill it is taking $464 billion from seniors
who have paid into it for a lifetime, and within that group of seniors,
11 million seniors are going to have their benefits cut because they
chose Medicare Advantage as their preferred insurance product. It is
not a question of whether they can keep what they have; they can't keep
it because their benefits are going to be cut, and that affects
America's low-income seniors the most.
As a matter of fact, in this bill, we fix doctor payments for 1 year.
So, in 2011, doctors' reimbursements are going to be cut 23 percent. I
see Dr. Barrasso on the floor. So we know more doctors are going to
stop covering Medicare beneficiaries. The pool is going to get smaller.
We are going to affect every senior's health.
Mr. CORKER. In essence, Medicare will become more similar to Medicaid
because of this bill. Less physicians will be covering Medicare
recipients because this bill, instead of using the $464 billion to make
sure physicians are paid, will leverage a new entitlement. So my
assumption is, this program, unless something else happens, will become
more similar to Medicaid. Medicare will become similar to Medicaid.
Mr. BURR. The Senator from Tennessee is 100 percent correct. Today,
40 percent of our Nation's physicians under Medicaid will not see
patients because the reimbursements are so low.
Reform in health care means you have to eliminate cost shifting. As
Dr. Barrasso knows, cost shifting means when somebody goes in for a
service, gets health care delivered, and doesn't pay or somebody goes
in who is underinsured, gets delivered a service, and their
reimbursement doesn't sufficiently meet the needs of the cost of that
service delivered. But it doesn't stop there. Medicaid reimburses at 72
cents of every dollar of service provided. Today, for every Medicaid
beneficiary in America, every time they receive a service from a
doctor, a hospital, or wherever, 28 cents is shifted over to the
private side to those who pay out of pocket, to those who have private
insurance.
If you are reforming health care, you can't reform health care
without eliminating cost shifting. Yet in this plan, we increase the
rolls of Medicaid by 15 million individuals. In essence, what that
means is we are going to have cost shifting on steroids now. We are
going to have more cost shifting than we had before, which means a
higher inflation rate on private health care, that which we pay out of
pocket or that which employers, in fact, provide for their employees.
As a matter of fact, incorporated in this bill is a disincentive for
small business success. I am not sure everybody has read to that point
in the bill yet, but for a company that today can't afford, because of
their competition to offer health care--the day they hire their 51st
employee, the Federal Government will send them a tax bill of $38,250.
At a time when we have 10.2 percent unemployment, 11 percent in North
Carolina, small business is going to be the engine of job creation in
this country, and we are saying as soon as you are successful enough
that you hire the 51st person, if you don't offer the health care we
tell you you have to offer, we are going to send you a tax bill of
$38,250.
Unfortunately, it doesn't stop there. For the Medicaid beneficiaries,
for the Medicare beneficiaries, for everybody in America where we have
said drugs are too high, devices are expensive, innovation costs money,
what are we going to do? We are going to tax drug companies. We are
going to tax medical device companies. We are going to actually raise
the cost of our ability to detect something earlier, where our options
are greater and, hopefully, through having those options earlier, in
fact, we are going to be able to treat a disease or cure it much
cheaper.
I might add it is somewhat ironic that we are going to tax vaccines
at a time when the industry is trying to meet the needs for vaccines
for H1N1 across this country. This bill puts a new tax on the vaccine
industry we have tried to revitalize in America.
Let me suggest to my colleagues, this is not a health care bill. This
is a layaway plan. In fact, what we have been presented is a plan where
they are asking Americans to pay for it for a number of years--4, to be
exact--before they get their product. We are going to pay in, in taxes;
we are going to pay in, in Medicare shift; we are going to begin to
increase the rolls in Medicaid, to wait 4 years down the road before we
get the product, before we get any benefit out of it. What we are going
to find

[[Page S11937]]

4 years down the road is that costs change. You see, it sold as a $849
billion plan today, an $849 billion health care reform package. Well,
that is not what it is. If you look at it truly over 10 years, it is a
$1.2 trillion plan. If you wait to start until the benefits are paid
and look at it for a real 10 years of revenue and benefits, it is a
$2.5 trillion plan.
We can't even be honest enough with the American people that we tell
them exactly what it is going to cost. But you would expect that out of
a layaway plan, and, in fact, that is what we have in front of us.
Let me suggest to my colleagues that if you reform health care, you
can have coverage expansion without additional taxpayer investment. You
can't take the things that are broken in our system and actually
increase their use, such as Medicaid, and expect at the end of the day
you are going to be able to save money, provide a better level of care;
more importantly, that you are going to have a population that gets the
benefits everybody else does: a medical home, preventive care, chronic
disease management. It doesn't happen in Medicaid today. It will not
happen when you increase the rolls of Medicaid. It will only happen
when you reform health care, and this bill does not do it.
I thank my colleague from Tennessee.
Mr. CORKER. Our colleague from North Carolina has worked extensively
on this issue. I think we have a couple Senators who have some business
off the floor that is very important. I think Senator Barrasso may be
one of those, and I think Senator Johanns is in the same boat. I know
as a physician, the Senator actually knows something about health care.
Mr. BARRASSO. Twenty-five years taking care of families and the
people of Wyoming. I have taken care of people on Medicaid and
Medicare. We heard from Senator Burr about North Carolina and Medicaid
as well as Medicare and I have concerns about both. I take care of all
patients, regardless of their ability to pay. So what we know right now
is that the Mayo Clinic--and the Mayo Clinic in Rochester, MN, has been
held up in the Senate by our colleagues. It has been held up by the
President of the United States as the model for what we should try to
get to do in America for health care. The Mayo Clinic has now told
Medicare and Medicaid patients they are not welcome. It has put out the
sign: No vacancies for you. It is astonishing. It is hard to believe
the Mayo Clinic would say: No thank you, we don't want you, but they
have done that.
Mr. CORKER. So I guess if you had Medicaid, it is kind of like, in
many cases, you have something that is not usable; is that correct? I
know Senator Alexander has spoken to an analogy in the past in that
regard, but it makes it pretty difficult if you are a Medicaid
recipient.
Mr. BARRASSO. As the senior Senator from Tennessee said, it is like
having a bus ticket when no bus is coming. Others commented in the
paper that it is like putting more people into a sinking ship.
Why would the renowned Mayo Clinic not want to see these patients?
They are sending out letters saying if you are from these surrounding
States--Wyoming and others in the Midwest and the Rocky Mountain West
send many patients there--you cannot do it. The Mayo Clinic is able to
provide the kind of care they do because they take very few Medicaid
patients, they take very few Medicare patients, and they take people
who have insurance. That is why we know premiums go up when more people
are on Medicaid. There are actually two hospitals in Rochester, MN--
Mayo Clinic, where 5 percent of their patients are on Medicaid. At the
neighbor hospital in the same community, it is 29 percent of their
patients.
The hospitals in Tennessee cannot take everybody out of town. We have
to take care of those people. When reimbursement is so low by the
Federal Government, which is the biggest deadbeat payer in the world
when it comes to health care--the deadbeat Federal Government pays so
little, the Mayo Clinic wants nothing to do with them. That is why they
came out against these proposals.
Harvard Medical School gave these proposals a failing grade and said
people who support these are collectively in denial, because they know
we are looking at a health care bill that will raise the cost of care,
to be paid for by raising taxes and cutting Medicare for seniors. Our
seniors on Medicare cannot even get into the Mayo Clinic. It is
fascinating. Mayo set up a branch in Arizona. They say they will no
longer accept Medicare for patients seeking primary care at its
facility in Arizona: We don't want them. No vacancies for you. If you
want to come in, you have to pay additional fees--a $250 annual fee
plus anywhere from $174 to $400 a visit if you are on Medicare.
Mr. CORKER. I assume that by the Reid plan taking $464 billion out of
Medicare savings and not using that money to deal with this huge doc
fix issue--the fact that physicians are going to have a 23-percent cut
in a year, they are not dealing with that. I know it costs about $247
billion to keep them whole. I assume that would keep many physicians,
such as the Senator's former colleagues from--it would cause them to
drop Medicare recipients, is that correct?
(Mr. LEVIN assumed the Chair.)
Mr. BARRASSO. It will absolutely prevent new Medicare and Medicaid
patients from getting in. The Medicare cuts will prevent doctors from
taking new patients and may cause them to drop others. The concerns are
so large, and the concerns aren't just for the doctors. I am concerned
for the people in Wyoming, who depend upon Medicare for health care. I
know the Senator is concerned for them in Tennessee. How will they get
the care they need? More people are coming of Medicare age every day.
This big bill, this monstrosity, will cut close to $500 billion from
people who depend on Medicare for their care. The American people--
those watching--need this care. But this takes it away to start a whole
new government program. It is not fixing the program that is going
broke already.
So the hard reality is--and I think the spokesperson for the Mayo
Clinic said it well. She said that ``it simply is the reality of the
health care business and how we are going to be able to continue our
mission when these payments are so far below what it costs to provide
the care.''
You are not even talking about staying open, keeping the doors open,
breaking even. The reimbursements are so far below what it even costs
the Mayo Clinic--the model being held up by Senators on the other side
of the aisle--so far below what it costs them to provide care. So as we
look at this and say how can we take care of and help the people of
America get health care, quality care, what we need to do is be aimed
at driving down the cost of care. This means an increase of the cost of
care and premiums. They are going to do it by raising taxes, and
everybody will be affected. The Senator from North Carolina, a State
with an incredible background in technology and advances in medical
devices--anything that taxes them will be passed on to everybody,
regardless of income level. Every patient in America will suffer. The
Mayo Clinic--the world-renowned Mayo Clinic, where anybody in America
would like to go for their care--I heard the Senator from Tennessee
say, in addition to what the Senator from North Carolina said, that
people in his State want to have the same level of care you would have.
We would all want that. The Mayo Clinic says if you are on Medicare or
Medicaid, like many of the other States, don't come here, because we
cannot afford to have you, because Washington--the biggest deadbeat
payer of all time--isn't paying enough to keep our doors open.
Mr. CORKER. I know to the people in Tennessee this doesn't pass the
commonsense test--a whole new entitlement when we cannot take care of
the ones we have. I know the people in Wyoming are also that way. The
people in Tennessee know this bill will cause the private insurance
they now have to go up, which is exactly the opposite effect Americans
want. We have a former Governor here, who has important business off
the floor in a minute. He has run their Medicaid Program. He wants to
speak to this issue. I thank the doctor, Senator Barrasso, somebody who
actually knows about health care, for being here to talk about this
issue.
Mr. JOHANNS. I thank Senator Corker on behalf of not only myself

[[Page S11938]]

but the folks back home in Nebraska for giving me a few minutes today,
and I also thank Dr. Barrasso. When he talks, I want to listen. I am so
tempted to yield my time to him because he is so knowledgeable in this
area. I do have a few things I want to say.
It occurs to me that after the vote tonight, what we should do is
declare a recess for 2 weeks. We should take this bill out across our
States and listen to the people. We should listen to the doctors, like
Dr. Barrasso, who are on the front lines every day. We should listen to
the nurses and hospital administrators and say: What do you think? I
think we would get an earful.
I did four townhall meetings during the short recess around Veterans
Day on health care issues. I have been all over the State of Nebraska.
Let me tell you a story--and every single Senator can tell this same
story. I visited a small hospital in our State, the critical access
hospital--and Dr. Barrasso is familiar with these. Under Federal law,
these hospitals are 25 beds or under. They are in our small
communities, not only in Nebraska but all across America. They have no
margin for error, because all they do is hospital services. They don't
have an exercise program or whatever. It is hospital care they provide.
I asked the same questions to those doctors and administrators. I would
say: Let me ask you, first, could you run this hospital and keep it
open on Medicaid reimbursements? It was 100 percent unanimous: We would
go broke.
I asked a second question: Could you keep this hospital open on
Medicaid and Medicare reimbursements? It was 100 percent unanimous.
They say: No, we would go broke.
What does this bill do? It expands Medicaid. Fifteen million people
will be added to Medicaid--the largest single expansion in Medicaid in
the program's history. Nearly half of the reduction of the uninsured in
this bill is due to moving people onto Medicaid, a program that if you
had to live on those reimbursements, and you were a critical access
hospital, you would close your doors. That is shocking to me. Who were
they listening to when they wrote this bill? Why can't we take these
staff people, who have been holed up in the majority leader's office
for 6 weeks, to Nebraska or Wyoming or Oklahoma or Tennessee or Texas?
It makes no sense to me.
I came here saying I was going to work to solve real problems for
real people. We say that a lot out there. Let me give you a real people
perspective about my State. Again, every Senator can tell this story. I
was in a beautiful little community hospital--a critical access
hospital, with 25 beds or less--in Valentine, NE, in a beautiful part
of our State along the northern tier. It is a beautiful area, the
Niobrara River Valley. There are great people there. It is off the
interstate. It is a beautiful part of our country. Pick up a Nebraska
map, because when I say this--if you look at the map, it will bring
home what I am talking about. Between Chadron, NE, in the northwest
part of the State, and O'Neill, NE, closer to the north central part of
the State, lies Valentine. That little hospital in Valentine is the
only hospital in that northern area that is providing deliveries for
babies.
When you pass this bill and you expand Medicaid that they can't live
on, and the reimbursement rates are disastrous for them--if you mess
around with that hospital's ability to deliver babies, you have a
crisis in the northern part of my State. You can tell that story over
and over.
I wanted to talk about this last thing, and I will do it quickly,
because other colleagues want to speak. As a former Governor, I dealt
with Medicaid to try to balance the budget. I was the Governor in
Nebraska post-9/11, when our economy and the Nation's economy tanked.
We had to cut budgets over and over. My State of Nebraska just finished
a special session. They cut about $300 million from the State budget.
Four hundred people, the Associated Press reported, will lose their
jobs because of these very difficult budget decisions.
Here is the point I want to make: When this is fully in effect, we
will drop into the States--my State included--billions of dollars worth
of unfunded mandates for Medicaid--billions of dollars in a program
where already 35 to 40 percent of our doctors cannot afford to take
Medicaid patients, and they are saying: We would go broke if we had to.
We are adding insult to injury by telling our Governors they have to
figure out that in addition to the historic problems they are having
with their budgets, they have to deal with an unfunded mandate. In a
moment of candor, one of my colleagues who worked on this for years
said something when I asked: Why Medicaid? It is so problematic. Why
all these millions on Medicaid? In a moment of candor he said to me:
Because it makes the score look better.
Mr. CORKER. Yes, it is the cheapest route for us and the most
expensive way for the States. This has been mostly about moving money
around. I have not seen a lot in here that has a lot to do with reform.
I appreciate the comments about Medicaid and what it will do to your
State. After having been a Governor, I know that Dr. Coburn, the
Senator from Oklahoma, is here, and we have the Senator from Texas, who
has been highly involved in every health care meeting we have had.
Senator Hatch helped create SCHIP years ago. I think he knows that in
this bill not only is there an unfunded mandate for Medicaid, not only
are there taxes and Ponzi schemes, such as the CLASS Act, that have
been put together, it doesn't fund an existing program such as SCHIP.
That is another huge burden of $40 billion or $50 billion. I don't know
if Senator Alexander wants to speak to that. I thank Senator Johanns
for being here. I know he has a meeting off the floor.
The PRESIDING OFFICER. The Senator from Texas is recognized.
Mr. CORNYN. I express my gratitude to the Senator from Tennessee for
leading this important discussion on Medicaid. If I can pull back for a
moment, I think it is important because this is such a complex subject,
as we can see from this 2,074-page bill. We need to define our terms.
Medicaid, obviously, is a program for low-income people, shared by our
State and Federal Governments. Medicare is for seniors, paid for
entirely by the Federal trust fund, $38 trillion in unfunded federal
liabilities to two entitlement programs, both of which are in terrible
financial shape. Rather than make this better, this bill makes it
worse. I will describe very quickly how in my State of Texas. I have
watched on C-SPAN and on the floor Senators come here and say tonight
we are having merely a procedural vote on whether to proceed to the
debate.
I thought we had been having a debate about health care reform for
the last year or so. I point out that under the Senate rules, we will
not be able to change one period, one comma, one sentence, one part of
this bill unless we can get 60 votes to do so. So the increase in
premiums, the taxes on small businesses and the middle class, the cuts
in Medicare, this expansion of Medicaid--all of these are a fait
accompli unless 60 Senators vote to change it. That is under the rules
of the Senate.
It is not true, in my humble opinion, that people can come in here
and say: We are going to vote yes to proceed tonight at 8 o'clock, but
it doesn't make any difference, the debate is just beginning. Not so.
I again thank the Senator from Tennessee for raising this concern.
Both of our Tennessee colleagues have been in the forefront of
discussing this issue.
I think this is shameful. The expansion of Medicaid in this bill to
cover 60 million Americans is shameful. It consigns people to a health
care gulag which they cannot get out of, where they get bad outcomes in
terms of their health care, where they cannot find doctors who will
treat them at the low rates paid for by Medicaid, and it bankrupts our
States.
The Medicaid officials in Texas have told me, after their preliminary
review of this 2,074-page bill, it will cost Texas taxpayers, in
addition to their Federal liability, $20 billion over the next 10
years.
Our friends who have been Governors have told us, as Governors and as
State legislators, they have to make terribly hard choices. But when
the Federal Government imposes an unfunded mandate on the States to
pick up $20 billion over the next 10 years, what does that do to our
ability to do other things, such as law enforcement, higher education,
and the like? It shoves those to the side because the Federal

[[Page S11939]]

Government is going to jam this down the States' throats--another
unfunded mandate--and it disrupts those States, as the Senator says,
that are operating on balanced budgets. They do not have the luxury of
printing money like the Federal Government.
Mr. CORKER. Mr. President, did the Senator from Texas see this
weekend where college students in California were having public
protests about the huge increase in tuition out there? Yet here we are
getting ready to pass something that is going to drive that up even
more because the State of California will have to cover more Medicaid
recipients without the money being provided. So this is going to
exacerbate that situation. I don't know if the Senator saw it this
weekend.
Mr. CORNYN. The Senator is correct. It is a 32-percent increase in
fees and tuition, and that is in California alone, which is bankrupt
already. This is the direct result of the irresponsibility coming out
of Washington, DC, forcing more costs on them.
I know there are other colleagues who want to talk about this topic,
and I want to have this continued conversation. I think this is a good
format for parsing what is in this bill.
Let me mention one anecdote in Dallas, TX. If you are a Medicaid
recipient, or a low-income child or beneficiary in Dallas, TX, only
38.6 percent of the doctors will see a new Medicaid patient--38.6
percent. In other words, 61 percent will have restricted access to
Medicaid because, as the Senator from Tennessee and the Senator from
Wyoming pointed out, it only pays about 72 percent of what a private
insurance policy would cover.
Mr. President, 85 percent of Americans have private insurance, and
they pretty much like what they have. They think it costs too much, and
we agree. We want to help them bring down that cost. But we have these
safety net programs which, frankly, do a lousy job. They promise
coverage, but they deny access because of low reimbursement rates.
Let me give an anecdote of what this means to 6-year-old Ruth Guerra
in Dallas, TX. I took this article from the Dallas Morning News, dated
June 3. It says:

When Ruth Guerra, 6, tries to write, holding the pencil
puts just enough pressure on her left pinky to make it bleed.
With her condition, if she falls down while playing or a
classmate accidentally brushes against her, she bleeds.
Last week [her mother] Sandra Ramirez . . . took time off
from her hourly job at the Dollar General after another one
of Ruth's bleeding episodes.

Unfortunately, because she qualifies for Medicaid--and while people
in Washington say: Isn't it great; we are going to give 60 million
people Medicaid--what it means for Ruth Guerra is that she has to wait
6 months to get an appointment with a doctor who will actually see her.
That is what I mean when I say this bill consigns 60 million people to
a health care gulag they cannot get out of.
I agree with the Senator from Tennessee. We need to provide the
American people with choices that Members of Congress have, among an
array of choices. What this does with the mandates, with the force-
feeding Medicaid on people such as Ruth Guerra and on the States, along
with the huge budget deficits that are going to come from it is
shameful.
Mr. CORKER. I thank the Senator for his contributions, being down
here on a Saturday on a very important issue. I know Senator Coburn is
here. Senator Alexander is here. I don't know what order they may want
to speak. It looks like it is Dr. Coburn.
Again, each Monday, typically in his State, he is actually seeing
patients. He knows something about Medicaid. He knows something about
health care. Many of the reforms he put forth would give people a
choice, low-income citizens a choice like we have. But, instead, this
bill confines them to Medicaid. I know he is going to talk about that.
I thank the doctor very much for being here.
Mr. COBURN. Mr. President, I thank Senator Corker.
I have had the distinct pleasure of delivering over 2,500 babies for
Medicaid insurance and taking care of their children. These are
wonderful folks. I didn't do any differential between Medicaid and
private insurance in my practice, but most of my colleagues did.
The heartbreaking part about Medicaid is that when you have a sick
child who needs a specialist, you cannot get one. You just cannot get
one. You say: Why can't you? Do they not care? Yes, they care. But you
know what. Because of the Medicaid reimbursement for pediatric
subspecialities--pediatric cardiologists, pediatric oncologists,
pediatric hematologists--there are not any.
We only have two pediatric cardiologists in the city of Tulsa serving
1.9 million people. Try to get an appointment for a Medicaid patient
there. I can hardly get a regular one. How did that happen? The reason
we have a shortage of pediatric subspecialities is directly related to
the Medicaid system in this country because the reimbursement is so low
that you cannot afford to have a high percentage of Medicaid patients
in your practice and still pay your bills.
So what consequently has happened is doctors do not go into
pediatrics, and then they do not go into the subspecialities of
pediatrics. So I end up having 8-month-old children seen by adult
cardiologists or adult hematologists because there is no available
doctor to see them because we have created a system through the
substandard reimbursement of Medicaid that has directed people coming
out of medical school away from that speciality.
As a matter of fact, last year, if you take all the medical students
who graduated from medical college, whether it is osteopaths or
allopaths, M.D.s or D.O.s, 1 in 50 went into primary care. That is
general internal medicine, family practice, or pediatrics, only 1 in
50.

We have 50 million baby boomers going to hit Medicare in the next
7\1/2\ years, and we are not going to have the primary care doctors
there to take care of them. The reason is because through government
programs, we have incentivized doctors not to do primary care.
Consequently, we don't get there.
The other point I will tell you is that if you look at perinatal
mortality rates in our population across the country, it is, No. 1,
directly related more to poverty than it is to anything else. But the
second most important factor is that if you are in Medicaid, you are
twice as likely to have a perinatal mortality event--in other words,
your child dies after childbirth--than if you are in private insurance.
It doesn't matter what your culture is. If you are poor, but you have
private insurance, the likelihood your baby is going to do better is
greater.
Think about that: a promise we are going to give you care, but the
result of the care is going to be less good. We are going to give you
care, but it is not as good care, and it is not available care. We are
going to make you wait in line, but we are going to call it care.
Care delayed is care denied. Let me say that again. Care delayed is
care denied. If, in fact, you have a problem that needs attention, and
you cannot get what you need, it does not matter what Medicaid does if
you cannot get treatment.
If you look at the subspecialities in Medicaid, 65 percent of them do
not see Medicaid patients. We have about 40 percent in primary care who
will not see a Medicaid patient. We have about 65 percent of the
specialities, because there is such a shortage in the specialities,
that what we are saying is we are going to have 60 million people in a
system that says: You get care, but guess what. It is not available;
you are on Medicaid.
Senator Wyden did offer a plan, I say to Senator Corker, that would
put every Medicaid patient in this country, except dual eligibles, into
private insurance. So did we with the Patients' Choice Act, the first
bill introduced on our side of the aisle. We take the stigma off saying
you have a low-paying plan, and we give them the same kind of insurance
we have right here in this body. By doing it, we save the States $1
trillion over the next 10 years. Think about that.
But that isn't nearly as important as we have a major increase in the
positive outcomes for Medicaid patients. You cannot talk about Medicaid
without talking about Indian health care because as you add up Medicaid
to Medicare to TRICARE to VA to Indian health care, when you add all
that up, the government is running 61 percent of our health care right
now. No wonder we are in trouble.
I do not deny there are big problems with the insurance industry. I
do not

[[Page S11940]]

deny we need a Patients' Bill of Rights that protects people's rights
and their interests. I do not deny we need transparency in the
insurance industry both on price and quality. I do not deny anything.
The question we ought to ask is, if we are going to truly reform
health care, are we going to allow everybody, when they say they have
health care, no matter where they get it, to have an equal shot at
getting equal care?
You see, this bill does not do that. This bill puts Medicaid patients
in jail and says: If you happen to be lucky enough, the lucky 60
percent to get into the line, you will be OK. And if you need a
subspecialty, if you happen to be part of the lucky 35 percent, you
will be OK. But everybody else is in jail. You are in monopoly jail. We
are promising--the government--to do that.
A final point--and then I will yield so others can talk--is the idea
that my State--Texas is a big State. It is our southern neighbor. They
sometimes have a better football team than we do. They certainly did
this year. We are about one-eighth the size of Texas in terms of
population. We cannot afford $2.8 billion over the next 10 years, I say
to Senator Cornyn. We are going to say we are going to cover 15 million
people and some of those will be in Oklahoma. We cannot afford it.
What we can afford is to insure them if we make true changes in care,
if we truly change and incentivize preventive care, management of
chronic disease--if we truly reform health care. These bills do not
reform health care. What they do is grow government.
They are not going to change outcomes, other than except they are
going to limit what you can and cannot do through cost-effective
comparativeness.
As we look at this bill, what we need to do is think about those we
are going to promise something we are not going to deliver. We are
going to call it a system, but they are not going to have it available.
I thank Senator Corker for leading this discussion, and I yield.
Mr. CORKER. I thank Dr. Coburn. As I listen to him, I realize we have
a health care reform bill before us where half the money, $460 billion,
is taken from a program that is insolvent. Instead of making it more
solvent--a program that would take $38.6 trillion in the bank today,
earning Treasury rates to make it solvent--it is a pretty big number--
we are taking $\1/2\ trillion out of that program to leverage a new
entitlement. The reform we are getting out of that is we are moving
half the folks into a program that not a person in this body would want
to be a part of; is that correct?
Mr. COBURN. That is correct.
Mr. CORKER. That is not the kind of health care reform I thought we
were going to be doing. I am shocked. As a matter of fact, as I said
many times, I don't think there is a person on the other side of the
aisle who would vote for this bill if you and I offered it; do you
think that?
Mr. COBURN. Probably not. But the Senator sparks one question. Think
about this, and I have experienced this as a physician.
I care for patients and they lose their job, they have a financial
catastrophe, and all of a sudden they become dependent on Medicaid. We
continue to see those patients. But do you know what normally happens?
You lose your insurance, you loss your job, you come on hard times and
go on Medicaid. You can't go back to the doctor you had before because
they are not taking new Medicaid patients. So somebody you have been
with for 15 years, all of a sudden you can't get back in because they
are not going to pay enough for them to care for you. It is a
discriminatory system that says we will send you down the line.
That doesn't mean there are not truly caring physicians in this
country, but it has to be said, outside of pediatrics, if you want to
look at quality parameters, the Medicaid population ends up going to
the less-qualified, the less-experienced, the less-good-outcome
physicians in this country.
Mr. CORKER. I thank the doctor. It is so good to hear from somebody
who has dealt, year after year, with Medicaid recipients with his
compassion.
Senator Hatch from Utah, I don't think there is a person in this body
on this side of the aisle who has spent more time trying to make sure
the poor children of our country have health care. No one has done
that. I know he is here to speak today about this huge Medicaid
expansion. I thank the Senator for the leadership he has shown in this
body for years, ensuring that young children in this country have
appropriate health care.
Mr. HATCH. I thank my colleague for leading out here, talking about
this very important issue. You and your senior colleague from Tennessee
are great Senators and mean a lot to all of us.
It is funny to me that the people in this body don't listen to the
only two doctors in the body, and both of them are excellent
physicians. Both of them are concerned about people. Both of them make
such cogent arguments in the field of health care. I think we have had
a very good argument by Senator Coburn, from Oklahoma--one of our two
doctors in the Senate.
Senator Barrasso is an orthopedist, a specialist. He has come here to
fight for the causes he believes to be right. He knows what is trying
to be put off on America today is not right.
Our States are facing a historic deficit of more than $200 billion
right now. Yes; that is what our States are facing right now without
this bill. One of the biggest drivers behind this is the Medicaid
Program, which takes up an increasing share of our States' budgets
across the country.
The Senate bill, which is nothing more than a 2,074-page takeover by
Washington of our health care system, calls for the biggest Medicaid
expansion ever--133 percent of the Federal poverty level. That is 150
percent in the House bill, if we pass that monstrosity.
My home State of Utah only allows Medicaid coverage of up to 133
percent of the Federal poverty level for infants, children under the
age of 5, and pregnant women. Other categories of citizens are,
however, covered at different levels. For example, nonworking parents
are only covered up to 48 percent of the Federal poverty level.
This bill will now massively expand the level of Medicaid coverage to
133 percent for everyone. Who is going to pay for that? Our colleagues
say the Federal Government will. What are they going to pay for it
with? We are running the Federal Government right into bankruptcy. It
is ultimately going to be the responsibility of the States and the
States can't do it. Think of New York, New Jersey, California, just to
mention three. Let's not forget that the House has already passed a
Medicaid expansion of 150 percent of the Federal poverty level. The
Congressional Budget Office estimates this massive entitlement
expansion will cost States an additional $25 billion over the next 10
years.
You heard me right, $25 billion more. That is over the next 10 years.
However, if history has taught us anything about the way things work
in Washington, I believe this number is actually a huge underestimation
and the real impact on our States will be much higher. I would like to
read the following excerpt from a letter sent to me by Governor
Herbert, our Governor in the great State of Utah, and what this
Medicaid expansion would mean for my State. It is a quote. This is what
my Governor has to say:

As I am sure you know, Utah, like most other states, is
suffering from the negative impacts of nationwide recession.
As we prepare the state's fiscal year 2011 budget, we face
continued cuts to agency budgets and reduced government
services on top of painful reductions made last year. The
unfunded mandate of a forced Medicaid expansion will only
exacerbate an already dire situation. If required to increase
our Medicaid program as envisioned in Washington, Utah, and
most every other state, will be forced to find the money to
do so through other means. This will require states to either
raise taxes or continue to cut budgets in areas currently
suffering from a lack of funding, such as public and higher
education.

We are seeing a real life example of this in California right now.
Faced with a mounting State budget crises, we recently saw that the
State-run University of California system had to hike its tuition rates
by 32 percent--32 percent!
I don't know about anyone else, but I will not allow this to happen
in my home State of Utah just because Washington thinks it is a good
idea to keep expanding government programs on the back of our States.
Here is the reality that our States are facing:

[[Page S11941]]

Unemployment rates rose in 29 States in October. A significant number
of States are facing unemployment rates much, much higher than our
national rate of 10.2 percent--the highest in 26 years: Michigan, 15.2
percent; Nevada, 13 percent; Rhode Island, 12.9 percent; California,
12.5 percent. In fact, California, Florida, Delaware and Washington,
DC, posted their highest unemployment rates since 1976.
The last thing we need right now is for Washington to impose more
liability on the states.
This alone should be a reason enough for every Senator to stop and
rethink their decision about letting this ``tax and spend'' bill move
forward.
But I have to tell you, I know what is behind all this. Ever since I
have been here, there has been a push to have more and more people
moved into Medicaid. Why is that? Because if they can push more and
more people into Medicaid, then ultimately we will have a single-payer
system--in other words, socialized medicine in this country, where the
government will control everything. That is what is behind a lot of
this bill.
I have to tell you, what bothered me an awful lot about this bill is
that even the CBO Director, whom I find to be an honorable, honest man,
Dr. Elmendorf, he said that if we go to a government plan--which is a
hallmark of what our friends on the other side want to do--then you
could have almost 10 million people going into that plan. However, if
you look at the Lewin Group study, they say if you go to a government
plan, we could have 119.1 million people going into the new plan.
What is it going to be, the 10 million or the 119.1 million? I
guarantee it is going to be a lot closer to the 119.1 million than it
will be to the 10 million.
Our friends on the other side started criticizing the Lewin Group
after this report. They have quoted them for years before this report.
Now that they don't agree with our colleagues on the other side, they
think it will only be 10 million. Don't kid yourselves. If you had to
choose between the 10 and the 119 million, you know doggone well it
will be closer to the 119.
If we move millions of more people over from private insurance into
government health care, I can't tell you the pressure that will be on
America, the pressure that will be on the health care professionals.
We heard from one of the great doctors in this body, whom we ought to
listen to, that we can't get the primary care people to take care of
people now on Medicaid, let alone adding millions more under this
expansion.
I thank my colleague from Tennessee for his leadership on this. I am
happy to be here to say a few things about it because I have spent a
lifetime working on health care issues. Before I ever got here, I
actually tried medical liability and defense cases, defending doctors,
nurses, hospitals, health care providers. I know what these costs are.
They are just beginning to explode.
If this bill passes, it is going to be an explosion of health care
costs such as we never dreamed possible.
I am very concerned about this. It is all driven by a desire to get,
right here in Washington, control over all of our health care. If we do
that, we deserve the problems we are going to have.
I thank my colleagues for the great work they are doing.
Mr. CORKER. I thank the Senator very much for coming. No one in this
body knows more about what is happening in public programs than he. We
heard for the last 55 minutes from the Senators from Texas, Oklahoma,
Wyoming, Utah, North Carolina, Nebraska. I can't think of a better
person to close us out this afternoon than the distinguished Senator
from Tennessee. I am fortunate to serve with this Senator. He was a
Governor, an education Secretary. He knows what he is talking about. I
am proud the senior Senator from Tennessee is going to close us out on
what I think has been an outstanding hour on the floor.
Mr. ALEXANDER. Mr. President, for those who are watching, Republican
Senators are reading through the bill, reading the bill in its
entirety. It is kind of like reading the entire New Testament in Greek.
It is better to have somebody help interpret it. We have been talking
about page 396, title II, subtitle A, section 2001, which expands
Medicaid. We have heard eloquent statements about how moving 15 million
low-income Americans into a program called Medicaid, which is a medical
ghetto, is not health care reform. We have also heard Senator after
Senator say what right do we have to expand Medicaid and tell the
States that you are going to pay for it. What kind of arrogance do we
have to say that to States that are in their worst fiscal condition
since the Depression?

The Reid bill requires states to expand Medicaid eligibility to cover
all persons under 133 percent of poverty, which means those earning
about $14,000 per year for an individual and about $29,000 per year for
a family. Individuals who are not otherwise covered by an employer-
sponsored insurance would not be eligible for tax credits. In effect,
every American below 133 percent of poverty would be locked into
Medicaid which is like confining them to a medical ghetto. With this
bill we are on path to expand the largest ``public option'' we already
have, Medicaid, and it could bankrupt the States, because they will be
paying for it. As the former Governor of Tennessee, I do not see how
Tennessee can pay for their part of the Medicaid expansion included in
Senator Reid's health care bill without a new income tax, or seriously
damaging higher education by raising tuition like California just did,
or both.
I am opposed to this expansion of Medicaid, which, according to the
CBO, would cost States an additional $25 billion, and add 15 million
people to the Medicaid Program. This would be the largest single
expansion of Medicaid in the program's history. Why? Because nearly
half of the reduction of the uninsured in the Reid health care bill is
due to people moving into the government-run program that is Medicaid.
Expanding Medicaid to cover uninsured individuals is a terrible
vehicle for health care reform, because dumping this many more people
into that program will increase problems for beneficiaries getting
access to care and for maintaining quality. Plus the program is already
riddled with fraud and abuse; this would just invite more of that. Most
Governors are struggling with Medicaid in its current form, and they
agree that expansion is a bad idea. This includes Democratic Governors.
Tennessee's Medicaid Program is called TennCare. The Tennessean from
Thursday printed an article that reports how ``People covered by
TennCare may face new limits on their coverage and reductions in their
benefits next year, under a plan unveiled Wednesday to help slice state
spending.'' The article continues, ``The limits are meant to help
TennCare, the State's Medicaid program for the poor, pregnant women and
children, meet Govenor Phil Bredesen's goal of reducing spending by
most State agencies by as much as 9 percent as the State deals with a
shortfall in tax receipts that could reach as much as $1.5 billion over
the next two fiscal years.''
If the Reid health care bill is passed, TennCare might introduce a
$10,000 annual cap on hospital coverage for the 1.2 million enrollees.
Additionally, they might also eliminate coverage for occupational,
speech and physical therapy, and limit enrollees to no more than 15
outpatient procedures and 15 lab procedures in a year. This past
Sunday, the Tennessean ran another story titled, ``Bredesen faces
painful choices as TN begins budget triage'' which states ``there is no
quarrel with the general position that Tennessee State Government faces
a grim situation'' and the Governor anticipates that roughly $750
million in cuts will be needed for the next fiscal year. To make
matters worse ``state tax collections are already $101.3 million less
than assumed when this year's budget was enacted.''
Another article from the Tennessean reported that the State ``might
release as many as 4,000 non-violent felons, possibly even including
people convicted of drug dealing or robbery, under a plan outlined
Monday by the Department of Corrections to deal with the state's budget
crisis,'' and Tennessee is not alone in its budget crisis. Even though
many States are going through budget crises much like Tennessee,
Senator Reid has proposed to as even more costs onto these States.
Earlier this month, the National Governors Association released a
fiscal survey of the States and an accompanying release, ``The State
Fiscal Situation: The Lost Decade.''
That report said:

[[Page S11942]]

The recent economic downturn started in December 2007 and
likely ended in August or September 2009, making it one of
the deepest and longest since the Great Depression.

It went on to say:

Medicaid spending, which is about 22 percent of state
budgets, averaged 7.9 percent growth in FY 2009, its highest
rate since the end of the last downturn six years ago.
Medicaid enrollment is also spiking, with projected growth of
6.6 percent in FY 2010 compared with 5.4 percent in 2009.

We don't yet have an estimate from Tennessee of how much Senator
Reid's bill will cost the state, but we expect it to be in the ballpark
of what the Senate Finance bill would have cost, which according to
Governor Bredesen would have cost an additional $735 million over 5
years. Tennessee can't afford to get a $735 million bill from
Washington. Not only is it wrong to ask states to pay for expanding
this program, but I think it is wrong to dump low-income Americans into
a government-run program that is failing.
Medicaid is a program that, if given the choice, none of us would
join. A 2002 Medicare Payment Advisory Committee survey found that
``approximately 40 percent of physicians restricted access for Medicaid
patients,'' meaning they won't take new Medicaid patients, because
reimbursement rates are so low. Only about half of U.S. physicians
accept new Medicaid patients, and yet this is how the majority leader
proposes we cover the uninsured.
Why is there such an access problem for people on Medicaid? It is
because Medicaid reimbursement rates to doctors and hospitals are so
low. Medicare pays 80 percent of what the private insurers pay and
Medicaid pays about 72 percent of what Medicare pays. Which means if
you are a doctor or a clinic, or a hospital, you get paid about 60
percent for serving a Medicaid patient versus one of us who has his or
her private health care. You can see why this spells trouble, and the
Senate bill does nothing to fix this problem. In fact, by dumping 15
million more people into the program it will only make things worse.
Who would want to be one of those 15 million people?
In addition to access problems, the quality of care for Medicaid
patients is significantly lower than those with private insurance, and
even those with no insurance. According to a survey by the National
Hospital Ambulatory Medical Care, Medicaid patients visit the emergency
room at nearly twice the rate of uninsured patients, and a 2007 study
published in the Journal of the American Medical Association found that
patients enrolled in Medicaid were less likely to achieve good blood
pressure control, receive breast cancer screening, or have timely
prenatal care than similar patients enrolled in private plans. Another
study of cancer patient outcomes found that even after adjusting for
patients who became eligible as a result of their cancer diagnosis,
Medicaid patients have significantly lower survival rates than non-
Medicaid patients.
The final example I will give today of why dumping 15 million more
people into Medicaid is such a bad idea comes from the Government
Accountability Office, GAO. The GAO has determined that the program is
plagued by fraud and abuse. In 2009, the GAO labeled Medicaid as a
``high-risk'' program, finding $32.7 billion in improper payments in
2007 alone. That is 10 percent of the program's total spending.
As a former Governor, I am particularly concerned about the impact
and expansion of Medicaid would have on the State budgets and the
resulting squeeze on higher education spending. When a governor looks
at his budget and sees the things he has to pay for like elementary and
secondary education, prisons, roads, and Medicaid. Then a Governor
looks at the things they want to spend money on like higher education
and a Governor, knowing they have to balance their budgets every year,
can't spend money he or she doesn't have, so something has to give, and
it's usually higher education. As I noted earlier, the New York Times
reported Friday that the University of California Board of Regents will
raise undergraduate fees 32 percent by next fall to make up for steep
cuts in state funding. The article goes on to report that ``The
University of California now receives only half as much support from
the state, per student, as it did in 1990. Even with the higher student
fees, the system needs a $913 million increase in state financing next
year to avoid further [budget] cuts.''
From 2000 to 2006, spending by State governments on Medicaid has
risen 62.6 percent, because of that higher Medicaid spending; higher
education has only seen an increase of 17.1 percent over the same time
period. As a result, tuition at a public 4 year university has risen an
average of 63.4 percent. So Congress passes a generous Medicaid
benefit, and the governors have to pay the bills. Then the governor has
to say to our college students: your turn, pay up. Expanding Medicaid
is exactly the opposite of real health care reform.
Senator Corker, you were the chief financial officer of the State of
Tennessee. You were the mayor of Chattanooga. How would you like it if
someone in Washington passes a program and sends you the bill?
Mr. CORKER. I would be losing a lot of sleep right now. I know people
all across the country who have to act responsibly, unlike us, are
losing sleep over what we are getting ready to do to States across the
country.
Is the Senator finished? Is that the point?
Mr. ALEXANDER. I think we are out of time.
The PRESIDING OFFICER. The Senator has 25 seconds remaining.
Mr. ALEXANDER. The Governor of Tennessee, who is a Democratic
Governor, has estimated that the cost to our State of this bill, of
moving 15 million Americans into this medical ghetto, is about $800
million over 5 years. In my view, finding that much money would
seriously damage higher education, raise tuition in Tennessee like
California's, which just went up, or require us to enact a new State
income tax, or all of those things at once.
I yield the floor.
The PRESIDING OFFICER. The Senator from New York.
Mr. SCHUMER. I ask unanimous consent the next hour of Democratic time
be controlled as follows: 10 minutes under the control of Schumer, with
the remaining 50 minutes of time available for various Democratic
Members to engage in colloquies.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. SCHUMER. Mr. President, today we stand at a crossroad. We can
continue to turn a blind eye to the very real, very dangerous threat
burgeoning health care costs pose to our economic future or we can
choose the path to restoring economic opportunity in this country by
tackling what my dear friend, Ted Kennedy, called the ``great
unfinished business of our society.''
As so often is the case at any major crossroads in our history,
embarking on what we all know is the right path is difficult. Indeed,
this is the single most difficult undertaking I have ever seen in my
30-year career as a legislator. But my colleagues and I know what has
to be done. Tonight is only one step down the road. There will be more
procedural hurdles, more disagreements, more pressure from our
opponents, more television ads, and many amendments. But I have no
doubt we will pass this bill.
There have been many attempts over many decades in many Congresses to
reform health care. This time, moral and economic necessity will guide
us over the finish line. It is unacceptable that in this country--the
wealthiest, greatest country in the world--there are Americans who are
forced to choose between their health care and rent, between their
health care and food, between their health care and an education. But
there are. And there are too many of them, and that must change.
Consider these facts: Health care costs are out of control. Premiums
for New York families have doubled in the last decade. Premiums have
risen far in excess of inflation while median income has remained
stagnant. Costs have risen so much that more than 20 million Americans
have skipped a doctor's visit for no reason other than cost and 23
million Americans have premiums so high they consume $1 out of every $8
earned. Health care costs now account for a staggering 16 percent of
our GDP, far more than any other industrialized country in the world.
For every dollar a small business in the United States spends on health
care, its foreign competitors spend a mere 63 cents. Yet the health
care of the U.S. workforce lags behind all other industrialized
countries. Plain and simple,

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our small businesses will no longer be able to compete unless we act to
reform health care.
Even among those Americans fortunate enough to have coverage, nearly
88 million don't have health care they can rely on. That is half of all
Americans age 18 to 64 and their families. And 46 million of these
Americans have a serious preexisting condition that has made it harder
or more expensive for them to get coverage. In addition, 37 million of
these Americans had a gap in their coverage during the last year.
Our health care system is holding our economy hostage. The
entrepreneur in Binghamton who does not take a chance, who does not
leave a job to start his own firm because he is afraid of losing his
family's health care; the college graduate in Oswego, days away from
losing her parents' coverage, takes a job because it provides health
care, even though that health care eats up a quarter of her paycheck--
each of these individuals who limit their potential because they are
concerned about their health care should inspire action among all of
us.
Passing this bill is an economic imperative. The broken system we
have is not only a burden on the present, it is a tax on the future.
Every day we do not act to fix the health care system is a day that
handcuffs our economy. It drains it of productive workers who do not
treat illness. It drains businesses of money they could otherwise use
to innovate and outperform their foreign competitors, and it drains it
of savings and wealth that every American should have in retirement as
a reward for a lifetime of hard work.
Inaction is not an option. The consequences of failure are simply too
high. Premiums will climb higher, benefits will erode further,
businesses will buckle under the cost of insurance, and Medicare will
go bankrupt. Yet our Republican colleagues would rather see us fail. At
every turn, they have obstructed our path with procedural delays, with
calculated misinformation, and sometimes with outright falsehood. I am
amazed they are against a government health care plan, but they want to
protect Medicare. Medicare is a government health care plan. You can't
have it both ways.
Yet when Democrats move to protect consumers from insurance company
abuses, Republicans fight to allow these companies to drop, deny, or
limit coverage for the people who need it most. When Democrats tackle
waste, fraud, and abuse in our health care system, Republicans cry foul
to preserve the status quo. When Democrats fight to protect and
strengthen Medicare for future generations, Republicans try to weaken
it.
Tonight, there is no question what path our Republicans will take.
They will follow the map handed to them by the big insurance
companies--protecting industry profits, defending unfair practices, and
ignoring the threat rising health care costs pose to America's economic
future. They will continue to speak with two tongues against government
health care and for Medicare. You can't have it both ways.
Our Republican colleagues will not stand in our way. The road ahead
is not a smooth one, but the wind is now at our backs. The American
people want reform, and we will have the votes to finally deliver it to
them. Sure, changes will be made to improve the bill as we move
forward, but we will pass this bill. We will finish this great,
unfinished business.
I yield the floor.
The PRESIDING OFFICER. The Senator from Minnesota.
Ms. KLOBUCHAR. I ask unanimous consent to engage in a colloquy with
the Senators from Maryland, Delaware, Massachusetts, and others who
will be joining us later in the hour.
The PRESIDING OFFICER. Without objection, it is so ordered.
Ms. KLOBUCHAR. Mr. President, as the Senator from New York has so
eloquently stated, the time for health care reform is now. We cannot
afford to wait any longer. We can't afford to wait, for the middle
class.
There are a lot of numbers that get thrown out in the debate, but I
think we can say it pretty simply by just using three numbers. Those
numbers are 6, 12, and 24. What do those numbers mean? Ten years ago,
the average family in this country paid $6,000 for their health
insurance. Now they are paying $12,000. That is an average. I know of
one small business in northern Minnesota, a backpack company, paying
$24,000 for a family of four. One guy started a company with five
employees. He now has 15--a growing business. He is paying $24,000. The
average right now is $12,000 for a family of four. Where is it headed
if we don't bend the cost curve for middle-class families--$24,000
average, little towns all over America, $24,000, 10 years from now.
That is not the kind of stability the middle class needs.
The middle class needs to know, people I know all over my State need
to know that if their kid gets sick, they still can have health care
coverage; that if their kid goes to college and they want to keep them
on their policy, they can still do that. That is what we are talking
about when we talk about stability.
The other piece of this reform effort that is so important, coming
from Minnesota, a State with high-quality, highly efficient care, is
the cost issue, that we begin the long journey of reforming our
Medicare cost so that we actually promote the kind of high-quality care
we see in my State at places such as the Mayo Clinic and we promote
the kind of efficient care we need to see.

My favorite example is in Pennsylvania, the Geisinger Clinic. They
had diabetic patients. They decided it was not going that well. The
patients didn't feel that good about their treatment, and the quality
they wanted was costing too much. They tried something else. For
routine cases, they said they will see nurses and see them more often.
The more difficult cases went to endocrinologists, and they reviewed
the routine patients' records. Higher quality care, happier patients,
better care, lower costs--$200 per patient per month--that is what
happened. They got less money for that higher quality care, less money.
That is what we are talking about. We want to use those kinds of models
so we get higher quality care for America at a more efficient rate.
Some of my colleagues across the aisle have been using the name of
the Mayo Clinic in vain. This matters to me because I come from
Minnesota. It is the home of the Mayo Clinic. The minority has
suggested that the Mayo Clinic doesn't want any part of this bill. They
have said the Mayo Clinic wants nothing to do with this bill. They have
said the Mayo Clinic--and this is an exact quote from the Senator from
Wyoming--``is no longer taking Medicare or Medicaid patients.''
Let me set the record straight. Like anyone in this country, the Mayo
Clinic is looking at this bill. They like some provisions, and they
don't like others. They have specifically said they support the
creation of accountable care organizations, bundling of payments, the
creation of an independent commission to evaluate Medicare solvency,
which is in the Senate bill, the MedPAC idea. They are supportive of
these issues because right now it is becoming harder and harder for
them to cope with the current Medicare payment system.
This allegation that they are no longer taking these patients is
completely incorrect. They made a decision not to take about 80
patients a year from the State of Nebraska because they weren't getting
paid. They are still taking all Medicare-Medicaid patients from
Minnesota and the contiguous States. This is not a small amount. Forty
percent of Mayo patients are on Medicare. Six percent--I wrote this on
the back of an envelope driving in with one of their chief doctors, so
you know it is accurate, unlike the ``facts'' we are hearing over
there. Forty percent of their patients are on Medicare, 6 percent on
Medicaid, 46 percent are on Medicare or Medicaid. Sixty percent of
their business is from Medicare or Medicaid.
It is just false. But what is true is that they want to see reform.
They want to see reform of the Medicare and Medicaid system. They want
to have it based on quality, not on quantity. That is why they support
the quality index I sponsored, along with Senator Cantwell of
Washington.
Just putting your head in the sand and hiding behind the stacking of
that bill--by the way, we had a three-page bill with the Bush TARP
plan, that didn't work out that well when there were no accountability
measures in that. That is not going to bring us the

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kind of health care reform the Mayo Clinic wants to see for the rest of
this country.
I heard a lot in Minnesota from small businesses. Small businesses
are paying 20 percent more than big businesses for their health care
right now. Why should employees of little businesses, which are really
the entrepreneurial engine of our States and the Nation, why should
they have to pay 20 percent more than people who work for big
businesses? This reform effort allows them to pool their numbers,
allows them to join together so they can buy private insurance off an
exchange with the same kind of numbers you have at a major corporation.
I know the Senator from Maryland has been very devoted to the idea of
helping small businesses.
I ask Senator Cardin about this specific issue. How does the Senator
see this as helping small businesses in Maryland and helping the middle
class in his State?
Mr. CARDIN. Let me thank Senator Klobuchar for setting the record
straight as it relates to the Mayo Clinic. It is interesting, I have
had conversations with people at Johns Hopkins University, the
University of Maryland Medical Center. I hear the same thing. They
desperately want to see health care reform. The cost issues are beyond
their ability to maintain the excellence of our health care system. We
have to get health care costs under control.
If I might point out, I was listening to my colleagues on the other
side give every reason why we should not move forward with the debate,
saying: Don't worry, things will be OK. Those were the same arguments
they made 15 years ago, which was the last opportunity we had to debate
comprehensive health care reform. They blocked it from being on the
floor of the Senate 15 years ago.
What has happened in the last 15 years, after they said: Don't worry
about it. Everything will be OK. Just keep on with our current system
of protecting the private insurance companies. They will do a great
job.
In the last 15 years, we have seen health care costs go up, $912
billion, almost a three-time increase. We have seen the per capita cost
of health care go from $3,400 to $8,100. We have seen that share of our
economy in the last 15 years go from 13 percent of our economy to over
17 percent of our economy. We need to act.

One more number I want to give because it affects Mayo Clinic and
affects Johns Hopkins because in many cases they are the provider of
last resort, where no one else will give care. Also, the number of the
uninsured has increased since 1993 from 39 million to 46 million.
The legislation that is being brought forward by our vote later today
will reduce the number of uninsured by 31 million. Mr. President, 98
percent of Americans will be covered by health insurance with this
bill. It reduces the growth rate of health care costs in America. It
provides an affordable option for every American. This is a critically
important bill.
The Senator mentioned small companies. I am glad the Senator did
because small companies are the ones that are most discriminated
against today in our health care system. They pay 20 percent more for
the same coverage as a larger company. They do not have options. They
do not have a lot of choices about who they can get to insure them. Not
only is the cost so high, the annual increases are unpredictable. How
do you run a business, if you are a small business owner, not knowing
whether your health care cost is going to go up by 10 percent, 20
percent, or 40 percent in the following year? You cannot.
As the Senator knows, we have had small businesses come before us and
tell us they are going to have to decide to eliminate their health
care. In one case, we had a small business owner who said: Look, I am
going to have to give up my business and start to work for a larger
company because I can't afford the health care.
We are at a crisis. I do not understand my colleagues on the other
side saying they do not even want to have a debate on this issue, they
do not even want to vote so we can take up this issue. Instead, they
want to protect the private insurance companies and let them continue
to make these profits, continue to cause real problems for our
consumers.
I have letter after letter from people who are confronting the
problems of private insurance today, where they are denying coverage
based on preexisting conditions or not covering a specific drug under
their policies. There is no effective way to challenge private
insurance companies today. This bill will give the consumers of America
a chance against our private insurance companies.
Ms. KLOBUCHAR. Mr. President, if the Senator would yield, I see the
Senator from Delaware is in the Chamber. Both the Senator from Maryland
and the Senator from Delaware serve on the Judiciary Committee, and we
have had several hearings in that committee about an issue people do
not always think about that hurts the middle class, and that is the
money that is being sucked down the fraud tube. Medicare fraud is $60
billion a year, I think.
Mr. KAUFMAN. It is up to $220 billion.
Ms. KLOBUCHAR. Mr. President, $220 billion. This bill will give us
the tools. I know I wish to add even more to it on this subject, to go
after that money, so that money can go back to help the middle class
afford health care.
I yield to the Senator from Delaware.
Mr. KAUFMAN. That is absolutely right. What we are going to do is
increase the number of whistleblowers, people who will see health care
fraud and report it. We are going to get more prosecutors. We are going
to get more FBI people. We are going to get more people to make sure we
bring this health care fraud down. That is part of this bill.
But I do not understand--to follow up on what the Senator from
Maryland said--how can you say you do not want to debate the bill, when
you look at the fact that the alternative is our present health care
system, which is totally, completely broke? How can you say you do not
want to do it? You say you are fiscally responsible. How can you say
you are fiscally responsible when you are not going to do anything
about Medicare and Medicaid health costs and the cost of health
benefits in this country?
As we have said many times before on the floor, my State is one of
the worst cases; that is, in 2016, a family of four making $50,000 a
year would be paying $29,000 in health care premiums. They cannot
afford $29,000 in health care premiums. So what is going to happen?
They are going to have the equivalent of half what they have today. If
they can afford $12,000 or $13,000, they are going to have half the
program.
I heard my colleagues on the other side talking about rationing. What
is going to happen to these people when they are getting half as much
health care from these health care companies? And the health care
companies are the ones that decide what procedures you can have, when
you can have them, and those kinds of decisions. When people have their
health care insurance cut by this amount, you have to worry about
whether they are going to be able to get the things they need.
Of course, Medicare and Medicaid prices are going through the roof.
It is going to bankrupt the country. In 6 or 7 years, Medicare and
Medicaid costs will cost more than everything else in the Federal
Government. So how you can talk about----
Mr. CARDIN. Will my colleague yield?
Mr. KAUFMAN. Absolutely.
Mr. CARDIN. On the Medicare issue, during the last hour we heard all
these people, who for a long time have been trying to privatize
Medicare and reduce the program, now saying that Medicare is going to
be in jeopardy if this bill moves forward. It is very interesting. The
AARP gets it right when it says:

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

This bill strengthens our health care system, strengthens Medicare
for the future, and that is what is going to be critically important to
our seniors.
I thank my colleague.
Mr. KAUFMAN. I think that is absolutely right. Right now, medical
bankruptcies are 60 percent of U.S. personal

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bankruptcies--a rate 1\1/2\ times what it was 6 years ago--because of
medical bills. The thing that is striking about this is, 75 percent of
the families entering bankruptcy because of medical bills actually have
health insurance. Two-thirds of all Americans filing for bankruptcy
because of medical bills already have health insurance. We cannot stop
that unless we change the system and give people more insurance and
give them better insurance and make sure you cannot be denied for
preexisting conditions and make sure--the killer--once you get sick--it
is bizarre. You get sick, and then the health insurance company comes
in and cuts off your health insurance. No wonder so many people are
going into bankruptcy.
Ms. KLOBUCHAR. If the Senator would yield, I see the Senator from
Massachusetts is in the Chamber, who I think has firsthand knowledge of
the importance of this bill, having taken the seat once held by our
dear friend Senator Kennedy, who worked so hard to get this bill done,
to get health care to the people of his State.
I say to the Senator, maybe he would want to talk about what this
would mean to the people of Massachusetts.
Mr. KIRK. I thank the Senator.
I thank Senator Klobuchar for her leadership, as we approach the
important moment on voting on a motion to proceed with this debate.
I was appointed by the Governor of the Commonwealth basically in
conformity with Senator Kennedy's wishes. He knew how divided this body
was over the important health care legislation and the importance of 60
votes so we could proceed to debate the merits of this bill. I am
honored and humbled to be standing at his desk, to be one voice and one
vote from Massachusetts.
It is a historic moment, and it is a poignant moment. As I reflect on
my experience on his staff, as Senator Kaufman was on Senator Biden's
staff at that time, my experience began 40 years ago under the
leadership of Senator Kennedy. That was the time he first spoke about
the need for national health insurance that would be affordable and
accessible to every single American--in hearing after hearing, in
speeches on the Senate floor, and in field hearings throughout America,
prodding, listening, leading.

I can only reflect on how proud he would be of his colleagues and the
leadership of Senator Reid and Senator Dodd, Senator Harkin, Senator
Baucus, all his colleagues who are now uniting in this moment of
history to do for the American people what they have waited for for
several decades, even since the first utterance of this important
health insurance coverage by former President Harry Truman.
Having read through this bill and knowing how proud Senator Kennedy
would be of this legislation, I will tell you why he would be. If you
look through the bill, what does it do? It saves money. It controls
costs. It reduces the Nation's deficit. It stimulates competition. It
expands coverage. It strengthens Medicare. It attacks fraud, waste, and
abuse. It increases transparency. It eliminates patient discrimination.
It promotes flexibility and innovation. It rewards quality and value--
not quantity and volume--of health care. It provides affordable,
quality health care choices for individuals, families, and small
businesses across America.
It introduces, through Senator Kennedy's leadership, a provision
which provides long-term services for the elderly and the disabled.
Mr. CARDIN. Mr. President, will the Senator yield for one moment?
Mr. KIRK. Before I do, I say to the Senator from Maryland, there is
one large, major question. If this bill promises to do all these
things, for the life of me, I cannot understand how 1 of the 100 of us
could go home for Thanksgiving and be able to explain to middle-class
families, who are stretched and looking for health security and
financial stability, that he or she would not vote even to debate the
merits of this legislation.
Mr. CARDIN. I was going to comment, listening to the Senator, at the
desk that was Senator Kennedy's desk, how proud he would be of the
statements the Senator is making here this evening. Senator Kennedy was
our champion for middle-income families in America. He understood they
needed a voice in the Senate, and he was their strong, passionate
voice.
This bill speaks to middle-income families. It is what Senator
Kennedy fought his whole career for here in the Senate, to do something
that would help middle-income families.
As the Senator points out, we need to bring down the cost of health
care. Health care costs are rising three times faster than wages.
Senator Kennedy understood better than any of us that Americans are
falling farther and farther behind because of the health care issues,
because of health care costs. Private insurance companies can make lots
of money if health care costs go up. They are not losing. It is the
middle-income families who are getting hurt by the system.
He understood that small businesses could not survive unless we
figured out a way to deal with the health care issues. And as to people
on Medicare--most people on Medicare are from middle-income families.
We need to protect Medicare for the future. That is why, again, I get
very concerned when I hear what we have heard over the last hour in the
discussions, because one of the principal reasons we need to bring this
bill forward on the floor of the Senate tonight is to strengthen
Medicare, to make sure it is there for the future, to make sure it
stays strong, and to make sure we expand benefits, as we do under this
bill.
I thank the Senator because those of us who have heard Senator
Kennedy speak on the floor of the Senate know how sorely missed he is
here, and we are proud you are representing that vote here on the floor
of the Senate tonight.
Mr. KIRK. Mr. President, I thank the Senator from Maryland very much.
Ms. KLOBUCHAR. Mr. President, if the Senator would yield, I also see
the Senator from Rhode Island in the Chamber. Rhode Island is a State
that has one of the highest unemployment rates right now in the
country, and it certainly is a State that would welcome this kind of
reform. And also on the issue we have been talking about, Medicare, the
Senator from Rhode Island has long fought for seniors.
As to Medicare, as has been pointed out, if we do nothing, it is
going to go in the red by 2017. The seniors I know who are 65 want to
live to be 95 and still have Medicare. People who are in their fifties
want to make sure Medicare is there for them when they are 65. That is
why it is so important we make these smart reforms, to raise the
quality of the care, and to make sure we preserve and save Medicare.
And that is what this bill is about.
I yield to the Senator from Rhode Island.
Mr. REED. Mr. President, I thank the Senator from Minnesota. I want
to add my comments to that of the Senator from Maryland and the Senator
from Delaware to commend the new Senator from Massachusetts. He not
only carries on the great work of Ted Kennedy, but he does it with the
same passion and eloquence.
What struck me in this legislation--and reminiscent of Senator
Kennedy--is that this legislation will provide real help to real
people. It is about solutions, not slogans.
Let me illuminate, if I may. Premium relief. What is troubling so
many middle-class families? They are too wealthy to qualify for direct
public assistance in terms of the Medicaid Program, but they are not
wealthy enough to pay for insurance.
This legislation will cap family outlays on medical insurance
premiums. Families making under $88,000 will pay no more than 10
percent of their income on premiums. They will be given direct
assistance through the tax system. There will be a rebate. So people
now, rather than staring at 20 percent, 15 percent, 18 percent
increases, will at least know there is a cap. And perhaps if we do our
work well enough, the whole system will begin to reduce below the 10-
percent mark, and everyone will benefit.
It is also notable that real families worry about many things. They
worry about educating their children. They want them to be educated,
but they also recognize as full-time students in higher education, they
can stay on the family health care plan. It is interesting to note that
decisions made about education are tied into health care, and also, in
fact, as to where you work, if you should keep your job you do not like
because you have health

[[Page S11946]]

care or go on, whether you strike out to start a new business because
you have this brilliant idea or stay in your current position because
there is health care there. But what this bill does, again, is provide
real help for real people and allows families to keep their children on
their health care plan until they are 26 years old.

It also reforms dramatically the insurance system. Again, we listen
to many of the complaints: Oh, we don't want a government-run health
care system; we don't want bureaucrats telling us what to do. The
irony, of course, as you mentioned, and Senator Schumer did, too, is
that one of the most popular health care programs in this country is
Medicare, which is government run. One of the other most popular health
care programs in this country is run through the Veterans'
Administration, which is a government agency. The least popular
programs are private health insurance, where everyone has complaints--
doctors, patients, providers. This legislation will prevent lifetime
limits that insurance companies dictate. It will also do many other
things.
So let me conclude because I appreciate very much--and if the time
allows, I have a question for the Senator from Massachusetts. But this
is a bill that when you move past all of the rhetorical smokescreens--
because, frankly, most of our colleagues on the other side don't want
to do anything. They didn't want to do it in 1993 and 1994; they didn't
want to do it in 1933 and 1935; and they still don't want to do it--
this legislation helps real people with solutions not slogans about
nationalization and bureaucrats.
Ms. KLOBUCHAR. The Senator from Delaware.
Mr. KAUFMAN. I was presiding yesterday for I don't know how many
hours. When you listen to what is said on the Senate floor by the other
side, they are talking about a model where there is no competition. Any
tax on an insurance company is going to be passed on to the consumer.
What kind of a business--I don't know anybody in business who, if they
get an increase in cost, they just pass it on to the consumer. Right? I
mean, we have a law of supply and demand the last time I checked. But
every single one got up and talked about the cost and said this is
going to hurt the consumer. It is not going to hurt the insurance
companies because they are just going to pass it on to us. The reason
they are going to pass it on to us is kind of obvious.
Here is a list, a small list, that lists all the States in America
and how much of their insurance is tied up in two or less companies. Do
you know what you have to do? You have to get down to No. 40, Oregon,
because the first 39 States on this list, two insurance companies make
up over 50 percent of the market in their State. How can you have
competition when you have so much of the business tied up in just one
entity?
The way you can tell there is not competition? You don't have to have
an advanced degree in economics to figure out there is no competition.
How do you know there is no competition? Every January, my premiums go
up. The only other thing I know that I get that goes up every January
is my cable bill, right? There is no competition in cable. You either
take cable or you don't. They say there is competition. So every year,
whether it is January, February, or March my cable bill goes up. And
every year, just like clockwork, my health insurance premiums go up. So
clearly, there is not competition.
That is why a public option is so important. We have to have a public
option so there is competition not only in the top 39 States where one
firm has over 50 percent--two firms have over 50 percent of the
business--but in all 50 States.
That is what this bill does. It is amazing to think on the other
side, the support they have for competition, and I believe they do and
I know them and I respect them and they all are concerned about
competition--except every once in a while they kind of turn a blind eye
to the fact of how powerful competition is. Competition is valuable and
powerful in keeping costs down and increasing benefits and quality of
care--only when there is actually competition. So we are going to have
to have competition. This bill will actually do it.
Ms. KLOBUCHAR. If the Senator will yield, I think we have been joined
by the Senator from North Carolina, who is a member of the HELP
Committee and I know has a background in business and understands a
little bit about competition.
So how does she see this as being a problem? I know in the State of
the Senator from Maryland there is limited competition, and in a number
of our States one or two providers--Minnesota is an exception, but one
or two providers dominate the market, jacking up the prices.
The Senator from North Carolina.
Mrs. HAGAN. I think one of the key points is the fact that this bill
is going to eliminate discrimination based on gender and preexisting
conditions. I have two children right now who are in their midtwenties.
My daughter is paying more per month for health insurance than her
brother. Yet it is the exact same policy. The same with preexisting
conditions. How many people do we know who have a condition such as
diabetes or asthma, or a woman who has had a C-section who is,
therefore, denied from getting health insurance? We have to be sure we
correct this, and that is what this bill does.
Let me give a couple of examples. So many people in North Carolina I
have heard from have some of these situations. Recently, I got an e-
mail from a family in Greensboro. It is a working family. The husband
has Graves disease, which is a treatable condition, but he can't obtain
health insurance because of this condition. Without health insurance,
his life is gravely in danger. He repeatedly uses the emergency room
for care.
To make matters worse, he has a 2-year-old son who has hemophilia and
has to be taken to the emergency room every time he bumps his head,
which sometimes can cost, for a 2-day supply of medicine, $4,600. The
family makes too much money to qualify for Medicaid and, obviously,
with these preexisting conditions, health insurance is way out of reach
for them. It is heartbreaking for this family. What the father has
decided to do is to purchase life insurance instead of trying to get
health insurance, and he is 29 years old.
Ms. KLOBUCHAR. If the Senator will yield, I think what the people
will be shocked to find out is that I think in eight States domestic
abuse is actually a preexisting condition. You talk about gender
discrimination. If a woman is a victim of domestic abuse, she will
basically not be able to get certain insurance policies. Is that right?
Mrs. HAGAN. That is right. In all but 12 States, insurance companies
are currently permitted to charge women more than men for the exact
same policies.
Mr. CARDIN. If the Senator will yield for a moment, as Senator
Klobuchar pointed out, if you don't have competition--and Senator
Kaufman said the same thing--if you don't have competition, what is
your choice? You are going to have to pay the premium.
There was a Washington Post article written about a street in
Gaithersburg. Gaithersburg is a growing suburban community not far from
here, certainly middle-class families. They think they are doing fairly
well. It talked about one street in Gaithersburg, and they gave half a
dozen stories about people--real stories--about people having problems
with our current system. They talk about Patty, who has private
insurance and thought she was in good shape. She talks about having to
search a book in order to find out what doctor she could go to to stay
in the network because it is too expensive to go out of network, and
then she hits her deductible and finds that her fees and copayments
come in fast and strange, making it unaffordable for her with her
current insurance coverage. She has no other choice. That is the only
insurance she can get.
Two doors down the road is Chuck who needs oxygen, needs certain
medicines. He had to fight with his insurance company to get the
prescription drug covered. He got the prescription drug covered, only
to find out the nurse who administered the drug was not covered, and it
cost $400--another problem with a private insurance company.
Across the courtyard, Will and Sarah, they have insurance today. They
are going to lose it because he

[[Page S11947]]

just lost his job, and he has no prospect for being able to afford
insurance.

The last one is Martha. This is a very interesting one. Martha went
to the emergency room for delivery of her child. She needed an
epidural. She made sure she went to a hospital that was in-network
because she wanted to make sure it was covered. Guess what. That
anesthesiologist she had no control over was not in-network and she had
to pay all that extra money. Again, no choice. She had no choice in the
system. There is no competition.
I know we have Senator Kirk here who is our newest Member. Perhaps
the Senator could tell us what he is hearing from Massachusetts. He is
a new Member here. I don't know whether he is getting the same stories
of what is happening in his State.
Mr. KIRK. Well, it is exactly the same story, with one exception, I
would say to the Senator from Maryland, which is that 3 years ago,
Massachusetts adopted its own health reform. Now, 97 percent of the
people in Massachusetts are covered with health insurance.
As you have said and as the Senator from Rhode Island has said, the
best illustrations of the need for health reform are the individuals,
the real people. So I will tell my colleagues a story about a young
lady. She is a waitress, a 24-year-old girl. Her name is Jessica
Wheeler from Somerville, MA. She is a waitress and works part time as
an intern. She had dreams of graduate school, but she was concerned
about health insurance. We have an exchange in Massachusetts not
dissimilar to what is being offered in this legislation where there is
increased competition from private insurers and others. She applied to
the exchange and was found eligible and enrolled and took out an
insurance plan.
Shortly after, she was stricken gravely ill with organ failure and
was hospitalized for an extended period of time. She was made well. She
has to take a pill every day in order to keep up with her condition,
but her coverage was complete. She has applied now to graduate school,
and although she probably has her tuition issues stretching her means
and so forth, she is free of the concern and need of expensive health
care bills; otherwise, she would have been without. So it is just
another illustration.
Just one other point on competition that keeps coming back and back,
I ask myself: Why do middle-class families save their hard-earned money
to buy health insurance? Obviously, the answer is so that they will
have coverage if they get sick. Without competition, I will tell you
what is going on. Insurance companies--now get this--are denying
coverage because people are sick or they say: Well, you reached a
certain limit, and we didn't realize you were going to get that sick,
so we dropped the coverage.
Ms. KLOBUCHAR. If the Senator could yield, I have exactly the same
kind of example where someone wants to buy coverage, they are willing
to pay for some coverage, but they can't. They basically are cut out
because they are sick.
This is one of the saddest letters. We just got this from Cheryl from
Bemidji, MN. She says:

I am writing to you because I just got off the phone with
my daughter Mickey. At first I couldn't understand her
because she was sobbing so hard. Her husband had just been
told by his boss that they wouldn't be carrying health
insurance on their employees any longer. They are a small
company in northern Minnesota and it was costing them $13,000
a month. For her, for my daughter, this is a matter of life
and death. She has cystic fibrosis. Because it is a
preexisting condition, the insurance companies won't touch
her unless it is under a group plan such as the one her
husband just lost.

She says:

You need to stand and be my voice, be Mickey's voice.
Mickey is a fighter, but she can't keep fighting a system
that is so against her. Mickey has already lived longer than
any of the doctors expected. I want her to live to see her 5-
year-old son become President one day.

That is from a mom in Bemidji, MN.
So I will just ask my colleagues, how can we continue to go down this
path where hardworking families--a man who has a job, who is working
for a small business, gets cut off from his insurance, and because his
wife has cystic fibrosis, they aren't going to be able to afford
insurance.
The Senator from Delaware.
Mr. KAUFMAN. I think the reason we use these examples so much is
because certain words kind of roll off your lips; words such as
``preexisting condition.''
Here is an example involving Angela in Dover, and she is a bartender,
not a waitress. Her income is from tips. She has no health insurance
through her employer. She became pregnant. She tried to find private
health insurance, but she was declined coverage because pregnancy was
considered a preexisting condition.
Now, just do a visual for a minute. This woman has been living off of
tips. She is about to have a baby, and there is nowhere she can go to
get health insurance. She applied for Medicaid to find prenatal care
for herself and her baby, was denied coverage because she earned $200
more than the monthly income limit. I mean, just picture this now, if
you were in this situation. She called organizations and clinics and
was unable to find a payment plan she could afford.
Midway through her pregnancy, Angela decided to cut back her work
hours so she could qualify for Medicaid. She worked all 9 months of her
pregnancy and delivered the baby on May 27. The Medicaid coverage she
got was especially crucial because she had complications with
hyperthyroidism and was able to get the necessary prescriptions to
control her condition.
OK. Do we have the picture? How would we like to see ourselves with
our spouses or our kids with this kind of a decision? The sad part of
the story, as if it is not sad enough, is that Angela was so anxious to
ensure that everything possible was done for a healthy baby and the
system threw up roadblocks. Pregnancy should not be considered a
preexisting condition.
People in this country who are pregnant should not have to worry, in
addition to going through the trauma of being pregnant for 9 months and
the baby being healthy and all the fears you have and on top of that
fear they may go into bankruptcy because they cannot afford to pay for
the doctor bills for their baby. This is real stark to me.
We are going to vote tonight on cloture so we can move to a bill that
will, once and for all, make sure Angela Austin and all the women
similar to her who have the ``preexisting condition'' of pregnancy will
only have to worry about their baby and what is going to happen to her
and not worry about what she is going to do when the child is 2 and she
is in bankruptcy, because so many people are going into bankruptcy.
Ms. KLOBUCHAR. Maybe the Senators can answer this. In these thousands
of letters and calls we get from these people, they are asking us to be
their voice. They don't want to say we are not going to debate this
bill at all, that we are going to put it in a drawer and pretend it
didn't exist.
Mr. CARDIN. That is the interesting point. These are all real
stories, people who are being denied health care today because of
arbitrary practices from private insurance companies or the way our
system is currently organized.
The vote tonight is a pretty simple vote. If you think the current
system is what you want, OK, I understand why you are voting against
cloture. I understand that you say the status quo is fine; we don't
even want to debate the issue; we don't care about the people who have
been affected by the arbitrary actions of private insurance companies
and saying that pregnancy and childbirth is a ``preexisting condition''
or when you are using over-the-counter drugs to keep your cholesterol
under control and the insurance company says that was a preexisting
condition.
All we are saying tonight is: Is this worthy of debate on the floor
of the Senate--a clear vote? Those who vote for cloture say this is
worthy. The people who have written us these letters are entitled to
have the Senate take up this issue. That is why we point out that there
are numerous groups, including the American Medical Association, that
say vote for cloture, let's have this debate before the American
people.
Ms. KLOBUCHAR. Along those lines, before I yield to the Senator from
Massachusetts, I started out talking about the cost issue. I wanted to
put in the Record the statement of November 5, 2009, from the Mayo
Clinic. There have been things said about their position.

[[Page S11948]]

My friends on the other side have said they ``don't want any part of
this bill'' and they ``want nothing to do with it.'' Those are exact
quotes. They said they ``are not taking Medicare and Medicaid patients
anymore.''
Those are exact quotes. They are all incorrect. I will put this in
the Record. It is dated November 5, 2009. ``Points of Agreement and
Divergence.'' They say:

We are encouraged by much--including provisions to pay for
value in health care, an insurance exchange, individual
mandate, subsidies for people to achieve coverage, and pilot
projects on accountable care organizations and bundling of
payments.

To be fair, they also say they are ``concerned about other areas
including a public option that is based on Medicare rates. . . .''
As you know, the options in the House and Senate bills are not based
on Medicare rates but negotiated rates. They are concerned about the
long timeline for implementation of value provisions, as I am. They are
concerned about across-the-board cuts for providers. They neither
endorse nor support the bill. To say they don't want any part of the
bill is false.
I ask unanimous consent that this material be printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:

A Perspective on Current Health Reform Issues From Mayo Clinic

Reform Bills: Points of Agreement and Divergence

As the House and Senate prepare to bring their final bills
to their respective floors, Mayo Clinic would like to
highlight the areas of agreement and divergence in the bills
and our positions on health care reform. We are encouraged by
much--including provisions to pay for value in health care,
an insurance exchange, individual mandate, subsidies for
people to achieve coverage, and pilot projects on accountable
care organizations and bundling of payments.
At this juncture, Mayo Clinic will neither endorse nor
oppose entire bills in the House or Senate, but will continue
to point out provisions that we think move the country toward
patient-centered health care and areas where we have
concerns.
While many provisions in the bill are aligned with our
recommendations, Mayo Clinic remains concerned about other
areas including a public option that is based on Medicare
rates, the long timeline for implementation of pay for value
provisions and across the board cuts to providers.
It is critically important that we accelerate the timeline
to adjust the Medicare payment system to pay for value in
order to truly bend the cost curve--especially in light of
the growing number of baby boomers reaching retirement age.
These payment reform provisions should not lag behind
expanding coverage to more Americans. In any event, we must
focus on ensuring the financial viability of health care for
the long term to ensure that patients have access to quality
care across the country.

Support House IOM Study of High Value Care and Geographic Variation

Mayo Clinic supports the provision that was added to the
House bill that will charge the Institute of Medicine to
study and design new payment methodologies to build value and
address geographic variation into the Medicare payment
system. The proposal is consistent with Mayo Clinic's focus
on creating a mechanism to better define value, measure it,
and create new payment methodologies that reward it.
Most of us, as patients or family members, don't stop to
think that our doctors and hospitals are generally paid more
for doing more tests and procedures--whether or not we need
it. Take for example, the story of a patient eventually seen
here at Mayo Clinic:
An older gentleman went to an emergency room because he
fainted. A CT scan of the heart was done and showed
calcification. Urgent heart catheterization was recommended
and then bypass surgery was performed. Later, when a stress
test was done, an abnormality was found and a second heart
catheterization showed a complication--one bypass was
blocked. Stents were placed in the heart artery where
the bypass was blocked. However, the fainting spells
continued. With his issue unresolved, the patient came to
Mayo Clinic, where we conducted a lengthy assessment by a
team of physicians. It was determined that all he needed
was an adjustment of his medications. In the end, the
tests, stents, and surgery performed at the other facility
were not needed, did nothing to help the patient, but were
paid for by Medicare. On the other side, the additional
office time spent at Mayo to fully assess patient's
situation and ensure proper diagnosis and treatment was
not covered by Medicare.
Doctors and hospitals are usually paid more for doing more
tests, visits, hospital admissions, and surgeries rather than
spending time with the patient and assessing their individual
needs. What if instead, the system rewarded doctors and
hospitals for spending time with patients, for doing a
procedure successfully, for the fact that you leave the
hospital without a fall or infection, and for providing
excellent service to you while you were under their care.

Support Cantwell Amendment to Incentivize Value in Medicare

We support a similar provision in the Senate Finance
Committee bill introduced by Sen. Cantwell that will help
move Medicare in the direction of paying for value by
creating a value modifier for physician payments that will
create incentives around value in the Medicare physician
payment formula.

Insurance Reform that Gives Access to All

We believe coverage can be achieved without creating or
expanding a government-run, price-controlled, Medicare-like
insurance model. A public option that employs a true
negotiated rate process is better than a system based on
Medicare rates. However, we are concerned that the exchange
could be opened to large employers, which could result in a
large shift from private to public insurance plans.
We support reforms to the current insurance system that
eliminate pre-existing condition exclusions, and create an
individual mandate where individuals can purchase private
insurance in various ways:
Through employers,
On the individual market,
Through co-operatives, or
Through an exchange model like the Federal Employees Health
Benefit Plan (FEHBP).
We also believe that the government should help people
afford the insurance through sliding scale subsidies as
needed.

Encouraged by Accountable Care Organization Pilot Project

Mayo Clinic is encouraged by provisions in the House and
Senate bills that allow groups of providers who voluntarily
meet certain statutory criteria, including quality
measurements, to be recognized as Accountable Care
Organizations (ACOs) and to be eligible to share in the cost-
savings they achieve for the Medicare program. Both houses
propose to start an ACO pilot program January 1, 2012.
Mayo Clinic believes that under this approach, a group of
physicians would be responsible for quality and overall
annual Medicare spending for their patients.
Different payment models could be tested. For example,
physicians would be paid FFS rates, less a withhold, and
then receive bonuses for meeting resources use and quality
targets over the course of a year. Options should include
creating virtual accountable care organizations based on
physician-hospital referral relationships. Such an
approach would create incentives for physicians and
hospitals to work together to provide better value care.

Bundling Payments Can Help Contain Costs

Both the House and Senate bills have provisions to test a
system of bundling payments for Medicare Parts A and B. We
are pleased with the pilot projects on Medicare payment
bundling. However, we would like to see a more aggressive
implementation timetable--not one that starts in 2014 or
later, but finishes by 2014--so that we can see more
immediate financial results for the Medicare system.
To realize cost savings quickly, Mayo Clinic believes
Medicare should start bundled payments for high-cost hospital
episodes such as total knee replacement, heart attack, and
lumbar disc herniation. Over time, bundled payments could be
considered for some chronic conditions as well. The bundled
payment should include hospitalization (Part A), physician
(Part B) and post-acute care (nursing home, home health care,
etc.) services. The outcome would be defined as reasonably
attainable improvement in health status in the safest, most
cost-effective way and would cover the entire episode of care
through the patient's return to function.
The goal is to reduce practice variation and focus on an
outcome-based goal. Such a reformed payment model would
encourage improved coordination of care among physicians,
hospitals and nursing homes, and it would encourage
utilization of nursing and other non-physician caregivers.

CMS Innovation Center to Enhance Quality, Improve Patient Safety

Mayo Clinic also supports the proposal in the Senate
Finance Committee bill that calls for the HHS Secretary to
create an Innovation Center within the CMS. The Innovation
Center will be authorized to test, evaluate, and expand
different payment structures and methodologies which aim to
foster patient-centered care, improve quality, and slow the
rate of Medicare cost growth. The provision calls for
promoting improved quality and reduced cost by developing a
collaborative of high-quality, low-cost health care
institutions. The collaborative would develop best practices
and proven care methods in improved quality and efficiency,
as well as assist other health care institutions on how best
to employ such best practices and proven care methods.

Independent Commission to Extend Medicare Solvency

The Senate Finance Committee proposal includes a provision
to establish a 15-member Independent Medicare Commission to
develop and submit proposals to Congress aimed at extending
the Medicare program's solvency and improving its quality.
Each year, beginning in 2013, the Medicare Actuary's Office
would make projections about

[[Page S11949]]

whether Medicare's per-capita spending growth rate in two
years will exceed a targeted rate. In years when Medicare
costs are projected to be unsustainable, the Commission's
proposals will take effect unless Congress passes an
alternative measure.
Mayo Clinic believes that this commission can insulate many
health care decisions from direct political influence in
Congress while still being accountable to Congress. We also
believe that the commission should have the authority to
change the health care payment system with the goal to move
away from fee-for-service medicine and toward paying for
team-based, coordinated care.
In addition to payment reform, the commission could serve
as a trusted national data aggregator, making performance and
pricing information publically available so that stakeholders
can identify best practices and high performers.
This perspective is written by Jeffrey O. Korsmo, Executive
Director, Mayo Clinic Health Policy Center; and Bruce Kelly,
Director of Government Relations, Mayo Clinic.

Mr. KIRK. I know time is running short. I want to say one thing about
this. We have heard talk about the status quo. Make no mistake, this is
a situation with respect to--we assume when we hear the words ``status
quo'' that things will remain as they are.
In the area of health care and health insurance, things are not going
to remain where they are. The status quo is not the status quo. We
either move forward or we fall back. If we don't address or at least
debate the merits of the bill and don't move it forward, we all know
what is going to happen. The figures are there. The average family
premium, which is now over $13,000, in 2016 will double to $24,000.
That is not the status quo. That is falling back. Similarly, the number
of uninsured will rise from 47 million today to 54 million in 2014.
That is not the status quo. That is falling back. Fourteen-thousand
people will continue to be dropped from coverage each day. That is not
the status quo. That is falling back. I could go on.
There is a reason this bill needs to be debated. It is because the
average middle-class working family deserves and needs health care
security and financial stability. This bill will bring them that. At
least I hope that the Members of the Senate--all 100--would say that,
on the merits, this bill and this need should be debated.
Ms. KLOBUCHAR. I thank the Senator from Massachusetts. The Senator
from North Carolina is here. I know the people of North Carolina and
the people in the South have concerns about the current state of
affairs in health care as well.
Mrs. HAGAN. Yes. A lot of what we have been talking about are people
who don't have health insurance and who want it enhanced because of
preexisting conditions. We have people who are sick and stuck with
health insurance.
I received an e-mail from a young North Carolinian who works for
AmeriCorps. She was the valedictorian of her high school class. She
suffers from a brain abscess. Her illness has put her into debt for the
rest of her life. She has health insurance, but it ran out when she hit
a $50,000 cap. Her bills far exceed the cap. It is sinking her entire
family into debt. She is sick and stuck.
How many people do we know who have a spouse or themselves who have
health insurance, and they are working, but they cannot switch jobs
because they would lose their health insurance? I have a good friend
whose husband has cancer. She wants to change jobs, but she cannot do
it because of the condition of her husband. Once again, people are sick
and they are stuck. We have to be sure we can have a debate, that we
can move forward on health care reform so we can help people.
Mr. KAUFMAN. We are all concerned about the economy. Even with health
care reform, I think for every Senator I talk to on both sides of the
aisle, their biggest problem is getting people back to work again and
getting the economy moving. It is truly tragic when you think so many
people are losing their jobs. Under our present system, the way it is
structured, when you lose your job, you not only lose the money coming
in to you, you lose your health insurance. You lose your self-respect
because we are all judged on where we work. That is how people judge
us.
As has been said, the longest walk is the walk home to tell your
spouse and your kids that you lost your job. The irony of ironies and
the thing that makes this so incredible is that you don't just lose
your job and self-respect, you lose your health care insurance.
We have a system, and we have to change the system so these people
out their right now can maintain their health care insurance and care
for their children and their families, as they and everybody in their
families go through this very traumatic experience.
Mr. CARDIN. We are running out of time, with only a few more minutes
left. I want the people in Maryland and of the Nation to understand
what this vote means. We are going to bring an amendment to the floor
of the Senate for debate. Any Senator will be able to offer an
amendment to how we should advance health care. The Senator from
Massachusetts is absolutely correct. We are either going to continue to
see our health care system with more people being denied coverage, with
the costs escalating much faster than our economic growth, with
businesses having to decide to terminate plans--that is what is going
to happen--or we can take up health care reform and try to rein in the
practices of private insurance companies and provide a way where every
American can get access to affordable health care. That is why the
American Cancer Society Cancer Action Network says:

The American Cancer Society Cancer Action Network urges all
Senators to vote in favor of allowing critical health care
legislation introduced by Senator Harry Reid this week to be
debated on the Senate floor. With thousands of cancer
patients being denied coverage, charged excessive premiums,
and facing exorbitant out-of-pocket costs, it is urgent that
the Senate take action now, not later, to protect and extend
health coverage to millions of Americans in need.

Last week, Cynthia and Eric Cathcart were here in the Senate. They
are two people who are self-employed. They cannot even get an insurance
policy to cover their family. They have to have two separate policies,
with two deductibles and two premiums, and they cannot afford it. We
must take up this issue for the Cathcarts and the millions of Americans
who cannot make it under this current system. Middle-income families
are depending upon us tonight.
Ms. KLOBUCHAR. There is a lot of talk about Medicare and our seniors
and what this bill does. Think of the woman I talked about who is a
fighter, as her mom says, but she cannot keep fighting a system that is
so against her. As you pointed out, the advantage of this bill is, it
gives our seniors a better playing field with the drug companies paying
for their drugs in the doughnut hole. Also, it is my understanding that
AARP wants to advance the bill. Certainly, AARP has stood up for
seniors for years and years and years. They know we need to preserve
Medicare and keep it safe.
Can the Senator comment on AARP?
Mr. CARDIN. AARP not only wants us to advance the bill; they support
the bill. They believe this bill will improve the Medicare system, make
it stronger, and provide additional benefits, particularly in reducing
the dread Medicare doughnut hole. They want the Members of the Senate
to vote to allow this bill to come to the floor.
Ms. KLOBUCHAR. Maybe we should end with the Senator from
Massachusetts, the home State of Ted Kennedy, having the last word of
this very interesting colloquy, in which we heard from the Senators
from North Carolina, Rhode Island, and Maryland.
Mr. KIRK. I thank the Senator. I am honored to be a Senator in this
body. Back home, they think I am the 60th vote. I would like to believe
we would have a more enlightened full body and that 60 would be a
number we would pass through.
The American people are looking forward to debate on this issue. I
think they believe they deserve many of the aspects that are contained
in the bill. On behalf of my constituents in Massachusetts and those
who, for so many years, revered and loved and elected and reelected
Senator Kennedy--I think they all, as we do, have him in our minds and
hearts tonight, and we hope we can advance this bill to the American
people, knowing his spirit and years of work are a reminder of our
obligation.
I hope we will have a successful vote this evening. That will provide
an opportunity for the American people to

[[Page S11950]]

hear a debate and perhaps allow corrections by whatever amendments may
be needed, so we proceed, keeping in mind, as is true in all
legislation, we cannot let the perfect be the enemy of the good. The
good is something our people have been waiting for, for decades. The
time is now. Let the debate begin.
I thank the Chair and yield the floor.
Ms. KLOBUCHAR. I thank the Senator. I believe our hour has ended. We
yield the floor.
The PRESIDING OFFICER. The Senator from Utah is recognized.
Mr. BENNETT. I ask unanimous consent that during the next hour, those
Senators who come to the floor may be allowed to proceed in a colloquy.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BENNETT. I came to the floor early so I could listen to what my
Democratic friends have had to say. I found it quite enlightening, and
I have a few comments with respect to it.
They have been debating vigorously against the status quo. They have
been giving us examples, heart-tugging, real-life examples of people
who are finding difficult problems in the situation as it now exists--
as if the debate were between the status quo and doing something.
The debate is between the solution that has been offered by the
majority leader and other solutions, which people on this side of the
aisle have been trying to bring forward through the entire time and
have not been allowed to come forward.
We recognize that things need to be done to fix problems with respect
to the health care situation. We realize the legislation we have been
living with for all these years needs to be amended. We have been
unable to get any of our ideas to come forward. Now we are told there
is such urgency to deal with the status quo that we must pass this
bill, and we must pass it virtually without amendment.
I would like to point out, as I have done before, if there is such
urgency with respect to the challenges we have in health care, why do
we wait until 2014 to have those changes come? We have heard all these
examples coming on the Democratic side of the aisle of people who have
terrible problems under their health care plan. We must act, we must
act immediately, and the act will be to say to all of these people: We
will solve your problem in 2014. We will delay all of these reforms we
are talking about until 2014.
I made that point the other day, and the Senator from Maryland said,
no, some parts of this bill will begin immediately. And he is exactly
right. The parts of the bill that would begin immediately are the
taxes. We will start taking in money in 2010 if this bill passes. The
annual pharmaceutical manufacturers fee would drive up the price of
everybody's drugs, an annual nondeductible $2.3 billion fee. That will
begin in 2010. The medical device manufacturers fee, another $2
billion, will begin in 2010. The medical insurance provider fee, that
will begin in 2010. The cosmetic surgery fee, that will begin in 2010.
In 2011, there will be a limit on contributions and in 2013 a high-cost
insurance excise tax. All the taxes are front-loaded, but all of the
reforms they promise this bill will bring to all of the people whose
stories they told us will not take place until 2014. The status for
them will remain quo. For all of these attacks on the status quo, the
one change we will get is they will start charging the taxes but they
will not start delivering any kind of health care reform until 2014.
Why are we delaying until 2014? Not because they do not think people
need it but because they realize that if they start spending at the
same time they start taxing, the score they will get out of the
Congressional Budget Office will point out the true cost of this bill.
And it is the true cost of this bill that is the kind of thing we need
to be debating and talking about rather than listing story after story.
My State is full of them, and I am just as sympathetic as anybody of
people who have problems with the present health care system. That is a
false debate.
We all realize, all 100 of us realize that something has to be done
to make the health care system better. This is not, should we do
nothing; this is a debate about what should be done. The proposal we
have from the majority leader is not the answer to the problems we
face.
Mr. KYL. Mr. President, I wonder if I may interrupt to ask, when the
Senator said this is not the approach, the approach taken by the
Democratic leader, among other things, because of the cost of it--my
colleague from Arizona is here, and I think no one takes second place
in this body to him in carefully looking at the cost of every bill we
have on this floor. He frequently proposes amendments to reduce the
cost of the bills.
I wonder if my colleague from Arizona agrees with my colleague from
Utah and is aware of the respected columnist David Broder who wrote in
today's Washington Post--actually, it is for publication tomorrow--a
column, the title of which is ``A Budget Buster in the Making.''
Mr. McCAIN. Mr. President, I say to my colleague, not only is David
Broder's column this morning important, but he is probably the most
respected columnist in America. He talks about it in far more eloquent
terms than I can.
I ask my friend from Arizona--a very unusual event happened today.
The majority leader, I guess proceeding on the concept, the age-old
tried tactic of ``shoot the messenger,'' came to the floor of the
Senate and excoriated David Broder, of all people, probably the most
respected columnist. I might say, Mr. Broder from time to time has
written an article or two or more that has been critical of me, but he
always had my respect. For the majority leader, who cannot rebut the
facts in David Broder's column, to come to the floor and excoriate one
of the most respected columnists in America is remarkable.
One of the things, I say to my friend from Utah, is that I do not
think Americans really understand the scam that is going on here of
beginning to collect taxes. Tax increases and Medicare cuts of
approximately $1 trillion begin 40 days from now. In other words, on
the first of January, according to this plan, Americans will begin
experiencing cuts in Medicare and increases in taxes, 40 days from now.
But then it will be 208 weeks and 1,460 days before any benefits from
the legislation come about.
Tell me, isn't that like a couple goes to buy a house and they say:
OK, you can have the house for X amount. And by the way, you have to
start making the payments now and for the next 4 years before you can
move into the house. Is there anybody who would agree that is nothing
but a scam on the American people? I do not think the American people
truly understand the reason why--and why would they do that? To
disguise the real cost of this $2.5 trillion bill. That is why they do
it. I think Bernie Madoff went to jail for this kind of behavior.
Mr. BENNETT. I say to my friend from Arizona, he reminds me of a
real-life experience of a husband who at Christmastime came back to his
wife and presented her with a brilliant Christmas present that she had
not been expecting. She said to her husband: How could we afford this
because the only amount we had in our Christmas budget was--pick a
number--$200, and this is obviously worth more than $200.
He said: Oh, don't worry about it. I paid $200 for it.
She said: How in the world did you get $200?
He said: The department store agreed to take the other $1,000 in
payments later on.
That is exactly what is happening here. We are making a downpayment
and telling ourselves that the total cost is covered as outlined by the
Congressional Budget Office.
Mr. McCAIN. Again, it is so important that we read this hernia-
inducing bill, that we understand the details of it. Specifically in
these cuts, which are going to take place in 40 days--40 days from now;
Happy New Year, America--in 40 days, it will cut $135 billion from
hospitals, it will cut $120 billion from 11 million seniors on Medicare
Advantage.
I would like to pause there for a moment. Senator Kyl and I represent
the State of Arizona. We have thousands and thousands--and I am going
to get the number before this debate is over--of seniors who are on
Medicare Advantage. They are going to cut out the Medicare Advantage
Program and tell the American people that if you like your insurance
policy you have, you can keep it? How does that work? Then

[[Page S11951]]

there is $15 billion going to be cut from nursing homes, $40 billion
from home health agencies, and $8 billion is going to be cut from
hospice care--my God, hospice care, $8 billion.
Here we are telling the American people that we are going to fix
health care in America, and the way we are going to pay for the massive
government takeover of health care is through cuts. It is terrible on
its face, but does anybody really believe these cuts are going to take
place? Does anybody really believe the doctors are going to be cut $247
billion in the next 10 years? Does anybody believe we are going to cut
$247 billion--or whatever it is--from Medicare? We are not. Why are we
not? Because we are a loving, caring nation. We are not going to tell
our seniors that they are not going to receive a high quality of
Medicare.
Of course, this latest mammogram incident where a board, not unlike
the one that is envisioned in this bill, said that women over 40 should
not have mammograms--by the way, I have a close friend, Carly Fiorina,
who has just recovered from chemotherapy. What would her situation be
today if she had not had a mammogram? Women all over America are rising
up about it. If you think that is bad, wait until you get this
legislation.
By the way, while my friends are standing, I would like to say please
sit down, I have shocking news. The three Senators we were worried
about--the Senator from Louisiana, the Senator from Arkansas, and the
Senator from Nebraska--shocking news. They are going to vote for this
bill to move forward. That was an issue of tremendous speculation with
the media. I certainly did not know that with all the protestations we
had from those three Senators that, by golly, they were thinking long
and hard. Guess what. So, OK.
Mr. BENNETT. I say to my friend from Arizona, and then I will yield
to my friend from Tennessee, Senator McCain just asked a question: Does
anybody really believe these cuts will take place?

I share with him an experience I had driving home from the Senate
just this week. I was listening to the radio, and the first story on
the radio was this vote coming up. The Senate is going to vote at 8
o'clock on Saturday. The second story was that the House of
Representatives just passed a doc fix of $200 billion. So we already
have action by the House of Representatives proving that the comment by
Senator McCain is exactly right. Before this bill even gets passed,
they are reversing the cuts over in the House of Representatives.
Senator Reid tried to do it here before we got to this bill, and we
voted him down. So the House is going to take care of it, and they will
ping-pong the bill over here.
There is no question that these cuts will not take place.
My friend from Tennessee wishes to comment.
Mr. ALEXANDER. Mr. President, I see the Republican leadership in the
Chamber. It seems as if every other word we hear coming from the other
side is that this vote tonight is historic. I agree, it is historic.
But I think my view of why it is historic is a little different from
their view.
I wonder if my colleagues would not agree with me that this bill is
historic in its arrogance? It is historic in its arrogance to think
that we in Congress are wise enough to take this entire complex health
care system, that serves 300 million Americans and is 16 percent of our
economy, and think we can write a 2,074-page bill and be wise enough to
change it all at once. It is historic in its arrogance by dumping 15
million low-income Americans into a medical ghetto called Medicaid,
which none of us or any of our families would ever want to be a part of
for our health care. It is historic in its arrogance by sending the
States, that are going broke, a big chunk of the bill for what we have
just done. It is historic in its arrogance because it tells Americans
that the bill costs $849 billion and then thinks we are not smart
enough to read the print and figure out that the real cost is $2.5
trillion when it actually is implemented. It is historic in its
arrogance by telling us that paying for reimbursement for physicians is
not an important part of a health care bill. It is historic in its
arrogance because it cuts and taxes grandma's Medicare, which according
to the trustees will be broke by 2015 to 2017, and then spends it on
somebody else other than grandma. The bill is arrogant because its
telling us it will reduce premiums for most Americans, when, in fact,
it increases premiums for most Americans.
So People say: Where is the Republican health care bill? My answer to
that is, don't expect Senator McConnell to come rolling in here with a
wheelbarrow with a 2,074-page budget-busting, debt-ridden, arrogant
piece of legislation because that is not what we believe in.
What we need to do as a Congress is re-earn the trust of the American
people by setting a clear goal of reducing health care costs, showing
some humility, and starting to move step by step in that direction. I
hope during this hour that we have a chance to talk about the specific
steps to reduce health care costs that we Republicans have offered day
after day to no avail.
Mr. KYL. Mr. President, if I can interrupt my colleague and
compliment him on the phrase ``arrogance.'' Maybe ``hubris'' is another
word. To think we are smart enough in Washington to figure out what is
best for 300 million Americans is truly arrogant.
A question posed by my colleague from Arizona a moment ago: Do they
really think they can whiz this by the American people with regard to
it not adding to the deficit, for example? Good question.
I want to get back to that Broder piece my colleague from Arizona
quoted. There is actually a survey that answers that question. It turns
out the American people are pretty smart about this. The question in
this Quinnipiac poll read:

President Obama has pledged that health insurance reform
will not add to our Federal budget deficit over the next
decade. Do you think that President Obama will be able to
keep his promise? Or do you think that any health care plan
that Congress passes and President Obama signs will add to
the Federal budget deficit?
Answer: Less than one-fifth of the voters, 19 percent to be
exact, think he will keep his word. Nine out of 10
Republicans, 8 out of 10 independents said that whatever
passes will add to the torrent of red ink and by a margin of
4 to 3 even Democrats agreed that this is likely.

That is why, Broder says at the end:

By a 16 point margin the majority of this poll said that
they oppose the legislation moving through Congress.

So while it is true they are rather arrogantly trying to contend
there will not be any big budget deficit from this, the reality is the
American people have broken the code they will. One of two things will
happen. My colleague from Arizona put his finger right on it. Either we
will make cuts in Medicare, for example, that we have never had the
political ability to make in the past, in which case our seniors will
be hurt, or else, as David Broder said, this bill will truly be a
budget buster.
Neither of those results are very sanguine outcomes to an attempt to
transform or reform our health care.
Mr. McCONNELL. Will the Senator from Arizona yield for an
observation?
Mr. KYL. Absolutely.
Mr. McCONNELL. I certainly share the views of Senator McCain that
letting these cuts stand is not likely. On the other hand, the
President of the United States said he would veto any measure seeking
to reverse these cuts. So we have a Hobson's choice: Either the cuts
will occur in which case seniors will be devastated or they will not
occur, as the Senator from Arizona has pointed out, and the deficit
will balloon further.
Mr. McCAIN. Did the majority leader happen to notice that the AARP
has now endorsed this bill? It has endorsed a bill that will cut
people, 300,000 of them in my State, from their Medicare Advantage
Program, that would cut $15 billion from nursing homes, that would cut
$8 billion from hospices, and that AARP, which, by the way, I
understand gets some $60-some million out of this deal--I say to the
senior citizens in my State: Take your AARP membership card, cut it in
half, and send it back to AARP because they have betrayed you.
Mr. BENNETT. If I could make the comment, Mr. President, among the
people who do not believe these changes would not occur is CBO itself.
CBO itself agrees this is smoke and mirrors. They do it in very polite
language, but let me share with you the language. They say:

These longer-term calculations assume that the provisions
are enacted and remain unchanged throughout the next 2
decades, which is often not the case for major legislation.

[[Page S11952]]

That is about as gentle a way as CBO can put it. They don't believe
this thing is going to stand without these kinds of changes. Yes, they
have come forward because their computers say: You put the numbers in
this way, this is the result you get. But human beings are saying that
is not what is going to happen over the next two decades.
Mr. KYL. If my colleague will yield, Broder, in his column as to this
estimate of budget deficit, he says it depends upon two big gambles.

Will future Congresses actually impose the assumed $420
billion cuts to Medicare, Medicaid and other Federal health
care programs? They never have.

Mr. McCAIN. Also, I would like to follow up on what the Senator from
Tennessee has said because, particularly from some quarters on the
other side of the aisle, we have been attacked: Where is the Republican
plan?
A very important article was written by Robert Samuelson in the
Washington Post on November 16--again, one of the most respected
economists in America.
I don't lay off these opinions of my own on them, but the fact is,
when you have highly respected people like Robert Samuelson, one of the
most respected economists in America, I quote from his column--the
title is ``Obama Care, Buy Now, Pay Later.'' That is the title of it.
He says--which I think is directly in consonance with what the Senator
from Tennessee said:

[A] prudent society would embark on long-term policies to
control health costs, reduce government spending and curb
massive future deficits.

Then he goes on to say:

So what do they do? Just the opposite. Their far-reaching
overhaul of the health care system--which Congress is halfway
toward enacting--would almost certainly make matters worse.
It would create new, open-ended medical entitlements that
threaten higher deficits and do little to suppress surging
health costs. The disconnect between what President Obama
says and what he's doing is so glaring that most people could
not abide it.

That is strong language from an economist. I think what the Senator
from Tennessee is saying, and what we are trying to say is, let's go
forward. Let's have malpractice reform. That is nowhere in this
monstrosity. Why don't we encourage health savings accounts and expand
them? Why don't we let people go across State lines to get health
insurance policies of their choice? Why don't we reward wellness and
fitness? There is a long list of amendments, of fixes to the long-term
costs of health care that we could control, that we could enact
tomorrow on a bipartisan basis. They do not add to the deficit. In
fact, what they do is control health care costs, which is what is wrong
with health care in America.
The quality of health care in America is outstanding. It is the cost.
We could be working together step by step, as the Senator from
Tennessee says, with a long list. I am sure he will add to them the
ones I just gave out to control health care costs in America. We stand
willing to do it.
After this bill fails, because the American people overwhelmingly are
beginning--it may pass the Senate. It may pass the House. It will not
pass.
Then why don't we sit down together for a change, Republicans and
Democrats, and move step by step to fix the health care problems in
America?
Mr. ALEXANDER. The Senator from Arizona is exactly right.
There is no Senator in the Chamber who has a better record of working
across party lines on bipartisan steps in the right direction than the
Senator from Arizona. But going to Mr. Samuelson's comment--I was
talking to a businessman this morning.
I said: If you had a problem in your company, would the first thing
you would do is to tear the whole company down and start over again? Or
if the football team had lost two or three games, would you blow up the
stadium and run everybody off? No, that is not the way you do it.
The person I was talking to said: What I would do, I would identify
the problem, I would test the solution, I would phase it in, and I
would make sure we can afford it.
The American people know that. I think they are sitting up there
looking at us saying: What are these guys doing? Two-hundred-fifty
million of us have health care policies, 85 percent. We would like for
the rest of America to have that opportunity too. But we know we can't
afford that until we get the costs down.
Why don't we do as the Senator from Arizona suggested, let's move
step by step in the right direction to re-earn the trust of the
American people by reducing costs?
He said: Why haven't we done that? One of those steps is to allow
small businesses to pool their resources and purchase a health plan,
which the Congressional Budget Office has said would allow nearly 1
million more employees of small businesses to be covered. Their rates
would be lower than they are paying today. It would save $1.4 million
of Medicaid. This is what the Congressional Budget Office said. So it
would reduce costs, increase insurance coverage, and lower premiums.
The reason we are not considering it is because when we brought it up,
the Democrats said no. They filibustered it. They didn't come across
the aisle and say that is a pretty good idea; let's put that together
with two or three of ours, and we will reduce costs.
I say to Senator Bennett of Utah, you have founded a company. You
have run a company. If you were having a problem with the cost of a
product or some other fundamental problem, is the first thing you would
do, is to think you were wise enough to tear the whole thing down and
start over again? Or if you called in a consultant and he recommended
that to you, what would you say to him?
Mr. BENNETT. Obviously, I would not respond in the way the folks
across the aisle have responded to this health care crisis. The example
the Senator has given is a valid one. That is not how you deal with it.
The other point I would make is that if I had a serious problem that
was causing difficulty for the survival of the company, I would not put
the solution off for 4 years while I raised prices on the existing
products to try to pay for it. I would try to do what I could to get
the fix upfront as soon as possible.

As both Senators have pointed out, we Republicans have fixes that
could start now and don't have to wait until 2014 in order to get a
good CBO score.
Mr. McCAIN. Along those lines, again, about this Madoff-type
budgetary procedure, I am not that good at math. I am sure the Senator
from Tennessee is. Help me out.
We have $1 trillion that they want to make in offsets, right, in this
10-year plan. If you started the program at the same time that you
enacted the savings, that would be $1 trillion, right? That would be
$2.5 trillion. So the deficit, if you used correct accounting
procedures--in other words, you bring in the benefits at the same time
you start paying for it--you would end up with a $1.5 trillion deficit
to the budget? Does that make sense?
Mr. ALEXANDER. It sounds right to me. It is another part of the
arrogance of this bill, which is to say we are not smart enough to
figure it out. The majority is saying the 10-year cost of the bill is
$849 billion, but it doesn't start counting until the fifth year, and
Senator Reid thinks the American people are not smart enough to figure
that out. That is part of the arrogance of the bill.
Mr. McCAIN. If the benefits kicked in at the same time the taxes did,
you would be talking about a $2.5 trillion cost.
Mr. ALEXANDER. That is $2.5 trillion, right?
Mr. BENNETT. I point out the CBO makes the same point at these 10
years. Again, quoting the CBO letter, talking about the 10 years
following, when you have the full 10 years of expenditures instead of
just 5 or 6 years of expenditure, it says:

Under the legislation federal outlays for health care would
increase during the 2010-2019 period, as would the federal
budgetary commitment to health care.

So those who are saying this is going to be a saving to the
government and you are going to turn the cost of health care--turn the
cost curve with respect to health care down, the CBO has said: No, that
is not the case. The Federal commitment would go up in those years.
Again, by delaying the implementation of the expenditure while
implementing immediately the implementation of the revenue, they are
creating the kind of financial chicanery that, as Senator McCain has
said, put Bernie Madoff in jail.

[[Page S11953]]

Mr. McCAIN. Could I bring up another issue to the Senator from
Tennessee and the Senator from Arizona and Utah. A New York Times
article this week stated: ``Drug Makers Raise Prices in Face of Health
Care Reform.''

Even as drugmakers promise to support Washington's health
care overhaul by shaving $8 billion a year off the Nation's
drug costs after the legislation takes effect, the industry
has been raising its prices at the fastest rate in years.
In the last year, the industry has raised the wholesale
price of brand-name prescription drugs by about 9 percent,
according to industry analysts. That would add more than $10
billion to the nation's drug bill, which is on track to
exceed $300 billion this year. By at least one analysis, it
is the highest annual rate of inflation for drug prices since
1992.

So the moral of the story is, you lie down with dogs and you get
fleas. So they cut a deal with the administration to cut drug costs,
and guess what. With inflation zero, no inflation, they have decided to
raise costs by more than 8 percent. Oh, the Consumer Price Index has
fallen by 1.3 percent. The Consumer Price Index has fallen by 1.3
percent, and the prescription drugs have increased in cost by 9
percent.
What does this do to seniors? Seniors are not going to get a COLA in
Social Security this year because the consumer price index has fallen--
which is the indicator as to whether cost of living adjustments are
given to Social Security recipients. So what does the drug industry do?
Without inflation, they raise the cost of prescription drugs by some 9
percent at a time when Americans are hurting more than ever. Shame on
the drug industry. Shame on those people, and shame on the
administration for cutting a deal with them.
Mr. KYL. Mr. President, I see our other colleague from Utah here. I
know that during Finance Committee deliberations, he was directly
involved in one of the conversations about the drug costs and also has
been working on his own ideas for alternative approaches to some of
these problems. I will ask a question and then if my colleague from
Utah, Senator Hatch, may like to comment further, we would invite that.
Is it the case that the Joint Committee on Taxation, which reported
to the Finance Committee, and the Congressional Budget Office both said
that not only would the increased taxes on the pharmaceutical industry,
the medical device industry, and the insurance industry be passed on to
consumers in the form of higher premiums but that overall under the
legislation that is before us, for the average family as compared to
what prices are today, insurance premiums would actually go up and this
was one of the two major reasons, the other being mandated benefits?
Mr. HATCH. The Senator is absolutely right. They even said the
premiums of the so-called government plan would be higher than private
sector insurance premiums. It is incredible.
I have enjoyed the comments by the distinguished Senators from
Arizona, Utah, and Tennessee. If you look at what they are trying to
do, they are going to throw out a system that 85 percent of the
American people feel is basically OK, because they have not taken care
of the 15 percent who don't have insurance. But when you deduct the 6
million people who work for companies that provide insurance but they
don't take it--they would rather have the money--and you take out the
11 million people who basically qualify for Medicaid or SCHIP but are
not enrolled, and you deduct those who earn over $75,000 a year and can
afford their own insurance, and then you take the illegal aliens, the
documented workers and undocumented workers, you basically come down to
17 million people who need and deserve our help. We are going to throw
the whole system out for 85 percent of the people when we could,
through subsidization, help those who deserve help.
It doesn't make sense. What are they thinking over there? I hope it
is not that they want to take us to socialism or to Europeanize us,
when Europe is trying to get away from Europeanization.
We are rapidly approaching one of the most important votes for all of
us in the Senate. This is bigger than any of us, our parties or our
ideologies. This is about the future of the greatest Nation in the
history of the world. It is about your children and my children. It is
about your grandchildren, my grandchildren. Elaine and I have three
great-grandchildren and two more on the way. It is about giving the
future generation the same opportunities and same sense of pride. It is
about every American's way of life.
Every American business will be subject to this. Look at that thing,
a 2,074-page edict from Washington. I am going to spend my time before
this historic vote to highlight some very important numbers. Every
Member of this Chamber should understand what they are voting to
advance. Make no mistake, our actions today will not be without
consequences. History and future generations will judge us by what we
do here today.
Zero is the number of provisions prohibiting the rationing of health
care, not one word prohibiting the rationing of health care. All you
have to do is look at some of the things that happened this week and
you start to worry about it. How about this? Zero is the number of
government-run entitlement programs that are financially sound over the
long term. Consider these important numbers: 10.2 percent national
unemployment rate, the highest in 26 years; 70, the total number of
government programs authorized by this bill, 70 new programs at a time
when we are going into fiscal insolvency; 1,697 times the Secretary of
Health and Human Services is given authority to determine or define
provisions in this bill. We are turning the whole thing over to the
bureaucrats here in Washington. More numbers: 2,074 total pages of this
bill--look at that--2010, the year Americans start paying higher taxes
to support this bill. My colleague from Utah and my colleagues from
Arizona and Tennessee have brought that out in no uncertain terms. The
year when this bill actually starts is 2014, most of the major
provisions of this bill. Some of them don't even begin until 2015. The
number $6.8 million is the cost to taxpayers per word in this bill; $8
billion is the total amount of new taxes on Americans who do not buy
Washington-defined health care; $465 billion in cuts in Medicare at a
time when Medicare faces a $38 trillion unfunded liability to finance
more government spending; $494 billion is the total amount of new taxes
in this bill.
If you think that is all, I think you have something coming here.
According to the Budget Committee, using CBO figures, $2.5 trillion is
the real cost of this bill over a 10-year period. Our total national
debt will be $12 trillion. These numbers are facts and they are
indisputable.
Let me finish by reading an excerpt from a fellow Utahn from Provo
who is worried about what this bill will do to our country.

I am writing out of deep concern over the increasing
expansion of government. I moved here from Germany 20 years
ago. I love America because it is free--free-er than Germany
in that I have the freedom to choose among other things how I
want to insure my family (we have six children). I'm all for
affordable health insurance which requires affordable health
care. I am self employed and have been hit hard by the
economy. There is a good chance that we would actually
benefit from [this bill]. Business has been so bad that we
would qualify for free school lunches if we asked for it. But
I don't want more government handouts. I don't want the
government telling me what kind of insurance I need to have.
I don't want the government telling me what services I can
receive when I need them. I don't want them taking an ever
greater part of my income to help finance government programs
such as the ``public option'' and the army of government
employees it will take to administer such a program. I do not
want more government. I want less. A lot less.

These people from Germany have been living in our country as citizens
for 20 years. They know what it was like to have their type of a
system. I think we ought to pay attention to that humble person who, in
spite of the travails they have, don't want this big, massive
government program to become law.
Mr. McCAIN. Mr. President, I thank both Senators from Utah for their
thoughtful comments and significant involvement. I wish to return to
the issue of what we need to do. I say that because criticism has been
leveled at this side of the aisle that we have no plan; therefore,
since we have no plan, we should embrace this. The fact is, we have had
plans. We have had proposals. We have tried to get them listened to.
They range from medical malpractice reform to other free market cost
reduction measures that add competition

[[Page S11954]]

and quality to the health care system. Our objective is affordability
and availability.
I want to talk with the Senator from Tennessee about the issue of
medical malpractice reform. Here is a huge piece of legislation. Yet I
ask my friend from Tennessee, is there any measure in this bill we have
been able to detect so far--we have been able to detect $100 million in
additional Medicaid benefits for the State of Louisiana, but we haven't
been able to determine all of the aspects of this bill. On the issue of
medical malpractice reform, physician after physician in America says
they have to practice defensive medicine for fear of finding themselves
in court. Why is it that we have literally no addressing of an issue
that could significantly reduce cost?
As I recall, the CBO said that medical malpractice reform could
reduce direct medical costs by some $54 billion over 10 years. There
are other estimates that say if we added in the cost of the practice of
defensive medicine over prescription medicines and drugs because of
fear of finding themselves in court, this could be as much as $200
billion. Yet there is not one significant addressing of the issue of
medical malpractice in this legislation. I think that is a testimony to
the influence of the American trial lawyers association.
Mr. ALEXANDER. Mr. President, I would say to the Senator from
Arizona, that is a part of the problem. But I think of it a little
different way. There has been a lot of talk this week about medical
care availability for women in America. In Tennessee, in 45 of our 95
counties, there are no OB/GYN doctors. So pregnant women in Tennessee
in those counties have to drive 50, 60, 70 or 80 miles for prenatal
health care. They might have to check into a hotel for a few days in a
big city in order to have their baby.
Mr. McCAIN. Could I add, the mirror opposite of that is the State of
Texas which was hemorrhaging medical doctors and care providers and
then, after they enacted a very modest malpractice reform, there was a
flood of physicians returning to the State of Texas. Isn't that the
case?
Mr. ALEXANDER. That is exactly right. In fact, a number of us have
offered to the Senate, as a part of the way we would go about reducing
health care costs, basically adopting the same kind of provisions they
did in Texas which still leaves anyone who is hurt, a complete right to
recover from that injury, but makes a major change in the availability
of doctors to that patient. And in the case of Tennessee, we were
talking about OB/GYN doctors to women who are about to have babies. The
Senator from Arizona said that would save at least $54 billion over 10
years. No one doubts that reform of medical malpractice, junk lawsuits
against doctors, would reduce costs. The point we are trying to make
here is, instead of that historically arrogant 2,074-page bill that
presumes we know enough to change every aspect of health care in
America, why don't we re-earn the trust of the American people, who
have lost a lot of confidence in those of us in Washington, and start
taking steps in the right direction to reduce cost? We could do it by
adopting our legislation to reduce unwarranted medical malpractice
suits. That would be one step.
Mr. McCAIN. Could I revisit with the Senator an issue we talked about
a little earlier and with my friend from Utah as well. This is the
recent spate of publicity concerning a recommendation that women wait
until 50 years of age before--I see our physician Dr. Barrasso is here
also--getting routine mammograms. That ignited a firestorm throughout
America and story after story of women who have experienced breast
cancer who state categorically that if they hadn't gotten the mammogram
when they did, it is possible they would not be alive today.
Now that is a nice academic discussion. But I would ask--maybe Dr.
Barrasso would answer it--isn't that the kind of advisory board this
legislation could put into law; that those kinds of mandates could come
down, which could literally jeopardize the health and lives of
Americans?
Mr. BARRASSO. Mr. President, I would say to my colleague and friend
from Arizona, this type of legislation would have cost my wife her
life. She is a breast cancer survivor, diagnosed by a routine screening
mammogram. She was in her forties when that mammogram was performed.
She went through the testing and had the operation. In that age, in her
forties, she already had the breast cancer spread from her breast to
one of the lymph nodes. It was a screening mammogram that saved her
life. She has had three operations, two bouts of chemotherapy. As a
result, she is a survivor--6 years later.
But this piece of legislation says: No, no, do not worry about it.
There is not going to be any denial of care. There is not going to be
anything like that. But if you turn to page 1,150, it talks
specifically about this preventative task force, specifically saying
when they make their recommendations there is going to be money that
taxpayers are going to pay to tell people what those recommendations
are. Then, if you go to page 1,190, it says that if it is not approved,
they will deny payment for that service--deny payment. It does not say
they might.
Mr. McCAIN. I say to the Senator, you would not describe that as a
``penal panel''?
Mr. BARRASSO. Some people might.
Mr. KYL. Mr. President, I went back to my office and got the exact
pages our doctor colleague has just been talking about--page 1,189 and
page 1,190 of the actual bill. My colleague from Arizona asked the
question--this entity, this U.S. Preventive Services Task Force; the
entity that made the recommendations with regard to mammograms is it
possible their recommendations could be used to deny coverage or reduce
payments or deny payments?
Well, here is the exact language, if my colleagues would like to hear
it. The Secretary of HHS is, of course, the person who implements this.
It is not the task force. The task force makes the recommendations, and
then the Secretary of HHS issues the regulations. Quoting:

Notwithstanding any other provision of this title,
effective beginning on January 1, 2010,--

That is just a couple months from now--

if the Secretary determines appropriate, the Secretary
may--
(1) modify--
(A) the coverage of any preventive service described . . .
to the extent that such modification is consistent with the
recommendations of the United States Preventive Services Task
Force. . . .

So there you have modifying the coverage. Then, secondly, as my
colleague was just reading:

(2) provide that no payment shall be made under this title
for a preventive service described in subparagraph (A) of
such section that has not received a grade of A, B, C, or I
by such Task Force.

In other words, they make the recommendation, and they say this does
not meet our standards, so she can say, therefore, we are not going to
pay for it.
That is taking the recommendations of this task force and translating
it into the rationing of health care. This is how rationing begins.
Mr. BENNETT. Mr. President, if I could share with Senators this
statistic. We hear a lot of talk about everybody has to be covered. We
talk about the United Kingdom, where they have a plan where everybody
is covered. The cancer survivor rate for women with breast cancer in
the United Kingdom, after diagnosis, is 57 percent. The cancer survivor
rate in the United States, where we have people who are not covered, is
67 percent. I do not think we want to move in the direction of bringing
that rate down.
Mr. BARRASSO. The reasons for that are they are not doing early
enough screening, and even once they are able to find the cancer in
Great Britain, how long do they have to wait in line until they
actually receive the surgery? The delay of care is the denial of care,
and that is what is going to happen under this bill.
I see my colleague from Idaho standing as well because he is familiar
with this situation. But I look at this and see the numbers. They said:
Well, we don't want to cover this service because it would only save 1
life out of 1,900 women in their forties. Well, in my case, that 1 life
out of 1,900 was my wife Bobbi.
I know the Senator from Idaho wants to get involved in this
discussion.
Senator Risch.
Mr. RISCH. Mr. President, as you read these pages, most of it is
incomprehensible. But, interestingly enough,

[[Page S11955]]

the point made by the good Senator from Arizona about the ability of
the U.S. Government to cut off health care to people is stated so
clearly on page 1,189 of the bill. The title of the provision is
``Authority to Modify or Eliminate Coverage of Certain Preventive
Services.'' How much clearer can it be? This bill gives authority to
the group that was identified to modify or eliminate coverage of
certain preventive services.
Had this bill been in effect in the last week when the
recommendations came out on mammograms, American women would be denied
coverage for mammograms in the time period that was identified by this
group. This is absolutely clear on this. This is just the beginning of
the kind of health care rationing you are going to see under this bill.
Americans are frightened, and they should be. Health care rationing is
coming to America if this bill is passed.
Mr. BENNETT. Mr. President, I would like to share another statistic
in this whole circumstance that I think we need to focus on because,
back to the Broder column Senator McCain talked about, we are talking
about the amount of expenditures and the creation of a new entitlement.
Let's go back to the debate on the budget. We got the numbers that
said the projected revenue for fiscal year 2009 was $2.2 trillion. The
entitlement spending for 2009 was $2.2 trillion. That means everything
we have done in government--our embassies overseas, our military, the
national parks, education, whatever it is--absolutely everything in
2009, other than entitlement spending, had to be borrowed money.
What are we doing with this bill? We are going to increase
entitlement spending. We are going to increase the role of government
that this Congress or future Congresses have no direct control over
through the appropriations process. I have been chairman of an
appropriations subcommittee. The amount we have control over in the Ag
Subcommittee is about $17 billion. The total bill was $80 billion. The
rest of that $80 billion was off-limits to the Appropriations
Subcommittee because it was on autopilot as entitlement spending.
The entitlement spending for farm subsidies is small potatoes, to use
a farm subsidy word, compared to the entitlement spending for health
care. So facing the kinds of deficits we are facing, facing the runaway
entitlement spending we have, the largest portion of which is
entitlement spending for health care, what are we being told to do?
Increase the entitlement spending for health care and put future
Congresses in an even deeper financial bind by taking even more of the
total portion of the Federal budget that is outside the appropriations
process and putting it on autopilot. That is the issue we must keep in
mind as we look at this whole circumstance.
Mr. McCAIN. Mr. President, I thank the Senator.
Could I go back, again, and reemphasize with my colleagues and the
American people what is very odious about the bill that is before us;
that is, the Madoff-style budget gimmickry associated with this
legislation. In 40 days--in 40 days--tax increases and Medicare cuts of
approximately $1 trillion will begin--in 40 days. That is 6 weeks from
now. But any benefits that would accrue from this legislation would
begin in 208 weeks--1,460 days.
So why in the world would we approve--and, obviously, we know why it
is done. It is to make the budget look better, when it is deception
being perpetrated on the American people because we are not telling
them the true cost. We are not telling the truth because, if the
benefits started at the same time the taxes started, it would be a $2.5
trillion deficit over 10 years.

It is unfair to the American people, who are going to have to foot
the bill for this massive piece of legislation--it is unfair to them to
tell them they are going to have to start paying the taxes and footing
the bill for it and only 4 years later would any benefits come to them.
I think that is a really wrong thing to do to the American people.
Do you know what. The American people are beginning to figure it out.
Mr. President, 51 to 35, the American people do not want this. The
American people do not want an increase in the deficit. They want the
spending stopped, and they are figuring it out. I am afraid my friends
on the other side of the aisle may have underestimated the intelligence
of the American people.
Mr. ALEXANDER. Mr. President, I would like to thank the Senators from
Arizona, Utah, and Idaho. Reading that big bill is very hard to do. So
for those who are watching, what we have been trying to do--as Senator
McCain and Senator Kyl just did--is take specific provisions and
discuss them and interpret them.
We have done that with the higher premiums. We have done that with
the higher taxes that the bill will require. We have done that with the
Medicare cuts. Earlier today we had an hour discussion, led by Senator
Corker, that discussed how the bill would send the costs for Medicaid
expansion to States.
We have talked now about what we would do if this bill were to fail,
which we hope it does. We think this bill is historic in its
arrogance--arrogance that we could turn over this whole system, that we
think the American people cannot figure out that the bill costs $2.5
trillion, instead of the $849 billion, as advertised.
What we propose is, we move step by step in the direction of cutting
health care costs for individuals and for our government. We have
proposed legislation that would reduce junk lawsuits, combat waste,
fraud, and abuse, allow small businesses to pool resources to purchase
insurance, allow Americans to purchase health insurance across State
lines, expand health savings accounts, and promote wellness and
prevention.
Mr. BENNETT. Mr. President, I wish to make the point, again,
following up on what the Senator from Tennessee has had to say, that
the argument we are hearing from the other side is a false argument
when they say it is either this bill or the status quo and the
Republicans have nothing to offer.
We have been offering proposals all along. I have been immersed in
this for 3\1/2\ years, cosponsoring, with my Democratic friends, ideas
on the way to go forward. Those proposals were not even allowed to be
considered in committee. The 2,000 pages we see before us were written
without a single Republican knowing where the room was, let alone being
in the room. Then we are told: But you stand for the status quo, and
the status quo is unacceptable.
I repeat what I said earlier: The way this bill is constructed, the
status will remain quo until 2014, as far as benefits are concerned,
but the taxes will start immediately. But we all know the revenue that
comes from those taxes will not be held in trust to pay for the
benefits in 2014. They will go for other things, to pay for the $1.4
trillion deficit we have this year. Then, in 2014, when the expenses
start, the money will all have been spent that had been brought in, in
the 4 years previously, and, as the CBO says, there will be change.
I yield the floor.
The PRESIDING OFFICER. The time reserved for the Republicans is
expired.
Under the previous order, the time until 6:30 p.m. will be controlled
by the majority.
The Senator from Michigan.
Ms. STABENOW. Mr. President, it is my pleasure and honor this evening
to be here to strongly support this motion, this historic motion to
proceed to a historic debate about whether we, as America, the greatest
country in the world, are going to make sure all Americans have access
to affordable health care insurance. This is something that has been
debated for 100 years. Now we have the opportunity, with the House
having passed their version, to move forward to this debate where we
will have lots of opportunity to offer amendments and to debate honest
differences in policy. But in the end, I believe confidently that we
will come together to move forward to pass legislation that will save
lives, that will save money for the American people, that will protect
Medicare, and that will stop insurance abuses happening for families
every single day.

I have come to the floor so many times to talk about health insurance
reform, as has the distinguished Presiding Officer from Rhode Island. I
wish to take just a moment to say thank you to a few people because, as
the Presiding Officer knows, we would literally not have this
opportunity today if it were not for Senator Harry Reid,

[[Page S11956]]

our distinguished majority leader. He is a quiet, smart, determined,
focused leader who has listened to everyone, who has looked at the work
products from the Finance Committee and the HELP Committee and brought
together a combined bill that is the best of both. He is going to give
us the opportunity to continue to debate and improve it on the floor
before final passage. So I thank Senator Reid. I know he is passionate
about his State of Nevada, and that is his No. 1 love after family, but
I think No. 2 is the Senate and the ability to lead and get things
done, and I thank him.
I thank Senator Baucus for his incredible leadership on the Finance
Committee; Senator Dodd for his leadership and stewardship in bringing
the HELP Committee through with their legislation; Senator Harkin,
Senator Wyden, and Senator Bennett, who is on the floor. We are not
agreeing on the movement forward on this bill, but there have been 2
years of working on health care that I appreciate, and their efforts
together to work on health care.
I thank Senator Snowe. I don't know if she is going to be with us
this evening, but her courageous vote on the Finance Committee is
something we desperately appreciate. I know she is going to continue to
provide input, and I am hopeful she will be with us on the final vote
because her input and her knowledge have been extremely important in
this process.
I also thank the memory of a very important Senator named Ted
Kennedy, who I know is here in spirit, for 40 years of dedication to
this cause.
Finally, I thank President Obama. If not for his vision, we would not
be here today. For 8 years under a former President, we did not have
the opportunity to get here to this place. We did not have the
opportunity to be able to end insurance abuses and truly protect
Medicare for the future, to put forward health care reform, to save
lives, and to save money. I also thank President Obama for
understanding that health care is also about jobs and that we have too
many people in this country today who are losing their job, and with
that they are losing their health insurance. So it is impossible to
talk about health care reform without also talking about jobs because
for most families they are connected and one and the same.
I have spoken on the floor so many times on health care cost and
access. Frankly, health care is something that brought me to public
service 30 years ago; when I was 5, I just want to say that for the
record. I led an effort in our community to keep a nursing home open in
Okemos, MI, and ever since then have been fighting to get to this
debate, to get to this point in terms of affordable health insurance
for all Americans.
So tonight, after this vote, we start the real debate. This bill
provides a framework for every American to find affordable insurance.
Is it everything I would do if I was writing it by myself? Of course
not. Every Member can say the same thing. But the Democratic process is
coming together with the best ideas and negotiating and doing the best
we can to be able to solve as much as we can in the best way possible.
I am going to continue to work to make health care truly affordable and
will be sponsoring and cosponsoring amendments as we move forward to
improve on what I believe is a very good bill. I am confident that at
the end, again, we will pass legislation that saves lives, that saves
money, that protects Medicare, and that stops insurance abuses.
When we first started this effort, I set up the Health Care People's
Lobby on my Web site so that people could share their stories, how they
felt about what we should be doing. Should we move forward and act?
What should happen? What were their experiences with their health
insurance and the companies that cover them now? I have heard so many
stories. I wish to thank everyone--thousands of people--who has shared
their story. I want to put a face on this debate and vote tonight by
sharing just a couple with you.
When we say saving lives, this is not just a slogan. We are talking
about saving lives. Forty-five thousand people have the ultimate
rationing every year because they can't find affordable insurance. As a
consequence, they lose their lives--45,000 people in the greatest
country in the world. We can do better than that, and that is what this
bill is about.
I wish to share just one story of a young man, Joe, from Okemos, MI.
He is a recent graduate of dental school. He worked very hard, was very
bright. He was just between jobs after completing his residency, and we
know how long and hard that is, to get to that point. He suddenly fell
ill. This was only a few months ago. He called his mom. She urged him
to go to the doctor, but because Joe didn't have insurance, he was
worried about going to the doctor, so he didn't. He continued to feel
worse. His family finally got him to agree to go to the hospital, but
by then it was too late. Joe died at age 27 of an aneurism--27 years
old--because in America, he didn't have insurance and was afraid he
couldn't afford it if he went to a doctor.
This is about saving lives. This is about saving money for businesses
that are trying to keep the doors open, that may provide insurance now
but are at a point where either the jobs go or they have to stop
providing insurance. So people come in, and the owner says: I want to
keep you working, but we are not going to be able to have health care
for you anymore.
This is about the fact that our country is spending twice as much as
any other country on health care and yet sometimes having outcomes that
are far worse than we would like to see as it relates to other
countries. We are 29th in the world in the number of babies who make it
through the first year of life. Of all of the insurance companies a
woman can choose from if she goes into the private individual insurance
market--59 percent don't provide maternity care, basic care, prenatal
care, care for mom and baby during the first year. So that is going to
change because of the values we bring to this.
We are going to protect Medicare. Folks don't have to believe us.
There is a lot of debate about what is happening in Medicare. I am very
proud to say we have received a very strong letter from the AARP
supporting a ``yes'' vote this evening to move forward on this debate,
and that is critically important for us.
Let me share from the Web site of AARP what they say--the champions
for seniors in this country; what they say, not what we say--about what
is being done in health care reform.
On their Web site:

Myth: Health care reform will hurt Medicare.
Fact: None of the health care reform proposals being
considered by Congress would cut Medicare benefits or
increase your out-of-pocket costs for Medicare services.
Fact: Health care reform will lower prescription drug costs
for people in the Medicare Part D coverage gap or doughnut
hole so they can better afford the drugs they need.
Fact: Rather than weaken Medicare, health care reform will
strengthen the financial status of the Medicare program.

That is why AARP has written a letter urging us all to vote yes on
the motion this evening we will be voting on, because we are
strengthening Medicare for the future.
Then let me speak to the question of insurance reforms because the
reality is that the majority of people have insurance. The majority of
us so far have insurance through our employer, and we hope that as we
bring down the costs and save money, that, in fact, we will be able to
make sure people are going to be able to continue to have the coverage
they are paying for today. So we are talking about insurance abuses and
stopping those insurance abuses.
I wish to share a couple of stories from individuals who have found
themselves in a very difficult situation. I realize my time has come to
an end, so I will be brief, but I do want to share just a couple of
stories in conclusion.
From the newspaper recently: Benjamin French, a young boy in
Michigan, was born with his right arm missing below the elbow. In his
12 years, he has been fitted with seven prostheses. His most recent
replacement will cost nearly $30,000, and his doctor says he will soon
grow out of it. He is a 12-year-old who is growing up, so as he gets an
artificial arm, it has to be replaced periodically to be able to grow
with him. But according to his insurance company, the boy is ineligible
for future coverage of prosthetic devices because he has already spent
his lifetime maximum benefit. That is going

[[Page S11957]]

to stop. We are going to eliminate those lifetime caps that get in the
way of a 12-year-old being able to have the artificial arm he needs as
he grows up so he can lead a normal life.
I wish to share one other story, and that is from Glen from Sterling
Heights. He is 62 years old. He got laid off in December. It doesn't
look as if he will be called back. He writes:

I am too young for Medicare. I have preexisting conditions,
so nobody wants to insure me. If I get sick before I can get
Medicare, my savings and everything else will be wiped out.
This is not the way I pictured retirement was going to be. I
raised four children, got them through school, and married;
paid taxes and did what I thought was the right and moral
thing to do. I didn't create this mess, but I am sure paying
for it.

He did the right and moral thing, and that is what we are being asked
to do on behalf of the American people.
Vote to move forward tonight. Vote for the debate. Doing nothing is
not an option when we are losing jobs, people are losing lives; when we
are losing the capacity of the country to be able to provide the health
care for our families that we need to provide. It is our turn tonight
to vote yes on proceeding to a debate that I believe, working together,
will result in legislation on health care that will save lives, save
money, protect Medicare, and stop insurance abuses.
Thank you, Mr. President. I yield the floor.
The PRESIDING OFFICER. The Senator from New Jersey is recognized.
Mr. MENENDEZ. Mr. President, for many months the voices of opposition
to any health care reform have been loud and clear. They have been
shouting at townhall meetings and heard in debates in this Chamber. All
too often, we have heard shrill voices raised in anger from those who
are either misinformed or who would choose the status quo that benefits
insurers at the expense of families. For too long those voices have
gone unanswered.
The Patient Protection and Affordable Care Act we are about to
consider is our answer. It is loud and it is clear. It is thoughtful
and historic. Once again, like so many other pieces of landmark
legislation in the last century, it is a product of this side of the
aisle.
Those who have chosen to block any attempt at health care reform this
year are on the wrong side of history, just as those who came before
them had one response to every landmark piece of legislation for the
last 80 years. Their response has been a resounding ``no.'' They told
us that it is not good for business, that it is socialism, that it
stifles free market forces, and that it is too much and it goes too
far.
We have heard the same fear mongering and innuendo since the New
Deal. There are those who raised the specter of socialism then and said
no to Social Security. They said no to unemployment insurance when
President Roosevelt proposed it as part of the Social Security Act.
They said no when John Kennedy and Lyndon Johnson fought for Medicare.
They said no to the Civil Rights Act. They said no to the Voting Rights
Act. They said no to the Clean Air and Clean Water Acts. They said no
to jobs programs. They said no to increasing unemployment insurance,
when people needed it the most. They said no to government oversight of
polluters who poison our land with toxic waste, and then they said no
to cleaning it up. They have been on the wrong side of history for
almost a century on every major piece of legislation that has leveled
the playing field for average Americans. They are on the wrong side of
history once again.
All we hear from the other side of the aisle is the dim echo of the
past, with no plan for the future. Americans are tired of the
naysayers, tired of the shrill voices of no, when so much is at stake.
It is time to say yes, time to say yes to stopping greedy insurance
companies from standing between doctor and patients, time to say yes to
ending medical decisions based on risk management and the bottom line
rather than on saving people's lives.
This historic legislation, like so many other pieces of legislation
debated on this floor, is about people--their lives, their hopes, their
health, and their dreams for a better life for themselves and their
families. We can be proud of this legislation. I know that when the
dust settles and the provisions of this bill become clear, America will
be proud of it as well.
This landmark reform legislation includes State-based exchanges
creating a fair, open, and competitive marketplace for affordable
health care coverage. It includes an amendment I proposed for long-
overdue consumer protections for emergency services without having to
call your health care provider and get a prior authorization. It
requires insurance plans to provide behavioral health treatments, such
as those for children who face the challenges of autism, as part of the
minimum benefit standards. It encourages investments in youth therapies
to prevent, diagnose, and treat acute and chronic disease. There is a
tax credit for innovative biotechnology research. It ensures that minor
children qualify as exchange-eligible and provides for the availability
of child-only health insurance coverage in the exchanges. It stops
insurance companies from denying coverage for some preexisting
condition, some preexisting health status, or gender. It ends the
medical benefits shell game that insurers have played with people's
lives.
As soon as this bill passes and the President signs it into law, 1.3
million seniors in New Jersey will receive free preventive care, such
as colonoscopies or any other recommended preventive service; 227,000
New Jersey seniors will have their brand-name drug costs in Medicare
Part D cut in half; 854,000 New Jerseyans will qualify for tax credits
to help them buy health insurance and ease the burden of premiums,
deductibles, and copayments; 107,000 small businesses in New Jersey
could get a small business tax credit--up to 50 percent of premium.
Health care reform will end the hidden tax that gets passed along with
the $1.1 billion spent on uncompensated care in New Jersey. It will
provide portability, security, and choice through the health insurance
exchange for 1.5 million New Jersey residents who don't have health
insurance at all.
The bottom line is that Senator Reid's merged bill helps New Jersey
and America. It is fair, balanced, and fixes a badly broken system. It
is truly a historic piece of legislation and will be remembered as
such. Yet there are all those who will stand against all of it, those
who will stand firmly on the wrong side of history once again, those
who will use every legislative tactic to stop this legislation as they
tried to stop Social Security and Medicare. I am afraid history is
about to repeat itself.
We have seen that the truth has been a victim on the Senate floor
today. We listened to some of the most dire predictions, some of the
most incredible statements, with figures thrown out there that are
astronomical, simply not true, and in defiance of what the nonpartisan
CBO said, which we all depend on--Democrats and Republicans. They said
this bill actually cuts the deficit by $130 billion in the first 10
years and $650 billion in the second 10 years.
In the face of a health care system that seems to work only for
health insurers--certainly not for average Americans--one must ask
what, if any, health care reform are my friends on the other side for.
What were their predecessors for when Americans were standing in bread
lines and needed unemployment insurance? What were they for when they
voted against Medicare? What are our Republican colleagues for now?
They seem to be for one thing only: protecting the status quo, leaving
health care just the way it is, letting insurers make medical
decisions, letting insurers collect premiums and then find creative
ways to deny coverage.
On the other hand, this bill represents the change America voted for.
But as we have seen, change does not come easily. You have to work for
it. You have to fight for it. Sometimes, in the face of the naysayers
and fear mongers, you need more than the truth, common sense, and even
a good plan; you need to fight for what you know is the right thing to
do for every American, not the few, not the powerful and the well-
connected but everyone.
At the heart of it, this vote we will cast tonight is about change.
We can see how hard real, honest, commonsense change is. We must ask
ourselves: Do we continue to be the agents of change or do we stand
with the status quo that discriminates against

[[Page S11958]]

hard-working Americans who are denied health coverage because of
preexisting conditions? Do we continue to be agents of change or do we
stand with the status quo and deny coverage to women when they are
pregnant? Do we continue to be agents of change, however hard it may
be, or do we continue to deny millions of Americans access to quality,
affordable care?
History calls on us to stand on rare occasions for what is fair and
just and right for the American people. This is one of those occasions.
It requires more than parliamentary maneuvers to slow the process. It
requires more than voices raised under the banner of free market values
at the expense of fundamental human values. It requires doing what is
right for the American people. Only then will we find ourselves on the
right side of history. That is what this vote is about.
Mr. President, I yield the floor.
The PRESIDING OFFICER. The Senator from Iowa is recognized.
Mr. HARKIN. Mr. President, I thank the Senator from New Jersey for
his very strong and poignant statement. I listened to it all. I think
he really summed it all up.
Let me add to that by saying we are at a momentous crossroads right
now in the history of our country. We are at a time that likens itself
to 1935, when this Congress passed the Social Security Act. It is like
the time in 1965 when Congress passed Medicare. Both of them were giant
steps forward in the health and economic security of the American
people. But as much as they are part and parcel of our American life
today, both Social Security and Medicare were bitterly opposed in this
Senate by conservatives who did not want to change. In fact, one
conservative Republican Senator said that passing Social Security would
put an ``end to the progress of our great country.'' They attacked
Medicare as socialized medicine. As Senator Robert Taft said at that
time, ``It is going to Sovietize America if we have Medicare. It is
going to be a government takeover.'' Well, here they go again. They are
unduly frightening people in this country. We saw it earlier with the
death panels--all bogus. It was to instill fear in people.
It is hard to change, but the people of America voted last November
overwhelmingly for Barack Obama and for Democrats in the House and
Senate because they wanted to change the system. They knew we had to
change.
People don't fear change. They know it is tough, but they don't fear
it. They don't fear change in our health care system either. What
people fear is keeping the present system. That is what I hear. They
fear being denied coverage because they have a preexisting condition or
one of their children has a preexisting condition and they will not be
able to get health care coverage. That is what people fear. They fear
they will be dropped from their policy because they have come down with
cancer or heart disease or some other chronic illness. They fear that
if they have a serious illness, they will have to go into bankruptcy to
pay the bills. Sixty-two percent of all the bankruptcies in this
country are because of medical causes. Eighty percent of those are
people who already had coverage. That is what people really fear.
Another reason I think conservative forces will fail this time is
because they believe people who have good health insurance really lack
compassion and they don't care about the 46 million other Americans who
don't have it. I disagree. People care deeply about those 46 million
Americans who don't have insurance. It is a national shame when
children don't have access to a doctor.
It is unfortunate that our Republican friends are determined to
prevent us from even debating and amending the bill. That is what the
vote tonight is about. Republicans and the health insurance industry
are joined at the hip, using the same talking points, same distortions,
same cooked-up scare tactics.
All I can say is, since the Republicans' goal is to obstruct,
obstruct, and obstruct, the people of this country are looking to us,
to the Democrats, as they did in Social Security and as they did in
Medicare, they are looking to us to move this country forward. So this
is a call to arms for our caucus. I hate to put it in those kinds of
partisan terms, but what can I do when every single Republican says
they want to obstruct and stop this bill? It is now on us, the
Democratic caucus, all 60 Members, to come here and stand strong for
the American people. Now is not the time to go wobbly in the knees, I
say to my friends in the Democratic caucus. Now is the time to stand
strong, the time to come to the well at 8 o'clock tonight and move this
country forward. It is time to say yes to the American people and no to
these fears and unfounded allegations you will hear from the other
side. Now is the time to take the next step forward in the real
progress of this country.

The PRESIDING OFFICER. Under the previous order, the time until 7:15
p.m. will now be controlled by the Republicans.
The Senator from Iowa.
Mr. GRASSLEY. Mr. President, I wish to be notified when I have spoken
20 minutes, please.
The PRESIDING OFFICER. The Chair will gladly do that.
Mr. GRASSLEY. Mr. President, on November 10, former President Clinton
visited the Democratic Senate caucus. It has been widely reported that
his message to Senate Democrats was that on health care reform, the
worst thing to do is to do nothing.
With all due respect to the former President, that is simply wrong.
Mr. Clinton, the worst thing we can do is pass this bill. This is not
something I say lightly because there are serious problems with our
health care system. There are important steps we need to take to fix
the problems in our system. But the excesses of this bill appear
willfully ignorant of what is going on outside health care. Those
things deal with our economy. Those excesses make this bill far worse
than doing nothing.
We are a nation facing challenging economic times. We have seen the
auto industry go into bankruptcy. We have seen banks shutter their
doors.
I want to refer to a chart of our national debt. The Federal debt has
increased by $1.4 trillion since inauguration. This chart shows the
growing amount of debt the Federal Government is taking on. The amount
of increased debt added since the inauguration is $11,535 per
household. The national debt now exceeds $12 trillion for the first
time in history.
I wish to show a chart on Federal health spending. As this chart
illustrates, this bill bends the Federal spending curve further upward
by $160 billion over the next decade. The red area of this chart is
that net additional Federal health spending, not according to this
Senator but according to the nonpartisan Congressional Budget Office.
Americans have rightly lost faith when in the face of the current
economic crisis Congress thinks this $2.5 trillion restructuring of the
health care system happens to be a good idea.
Perhaps one of the biggest warning signs that this bill will saddle
taxpayers with more spending and debt is the fact that the budget fail-
safe mechanism was dropped from the bill behind closed doors in the
Capitol where this bill was written--and I emphasize ``closed doors.''
The Grassley budget fail-safe mechanism was cut from the bill and lots
of budget gimmicks were added.
Former Congressional Budget Office Director Douglas Holtz-Eakin wrote
in yesterday's Wall Street Journal that this bill is ``fiscally
dishonest'' and that it uses ``every budget gimmick and trick in the
book . . . leave out inconvenient spending, back-load spending to
disguise the true scale, front-load tax revenue, let inflation push up
tax revenues, promise spending cuts to doctors and hospitals that have
no record of materializing,'' and so on.
This bill is simply irresponsible. It is worse than doing nothing.
Let's talk about some of the excesses in the bill. It increases the
size of government by a staggering $2.5 trillion when fully
implemented. It imposes $\1/2\ trillion in new fees and taxes. Imposing
these new fees and taxes as the economy is struggling to recover is
worse than doing nothing. This $\1/2\ trillion in new taxes will hurt
small businesses and destroy job creation. It breaks President Obama's
campaign promise by increasing taxes on individuals and families making
less than $250,000 per year. Adding insult to injury, these fees and
taxes will also cause health care premiums to go up beginning next
year.

[[Page S11959]]

But I don't want you to take my word for it. Both the nonpartisan
Committee on Taxation and the Congressional Budget Office have
confirmed these taxes and fees will be passed through to the consumers
in the form of higher health insurance premiums, and these taxes and
fees will start increasing premiums 4 years before most of the reforms
in this bill take effect in 2014.
Let's take a look at what happens to Medicare and Medicaid in this
bill. Both of these health care entitlement programs are already on
perilous financial footing. Both are facing a financial meltdown. This
bill adds to that burden.
First of all, the Medicare trust fund started going broke last year.
In the year 2008, the Medicare Program began spending more out of the
trust fund than was coming in. The Medicare trustees have been warning
all of us for years that the trust fund is going broke. They now
predict it will go broke right around the corner, about 2017. But
rather than work to bridge Medicare's $37 trillion in unfunded
liabilities, this bill cuts $\1/2\ trillion from that Medicare Program
to fund yet another unsustainable health care entitlement program.
Medicare has a major problem with physician payments that will cost
more than $250 billion to fix. But this bill ignores that problem by
pretending the problem does not exist. This bill would leave future
Congresses virtually no way to restructure Medicare to do the doctors
fix.
By diverting Medicare resources elsewhere and ignoring major problems
such as that one, this bill does worse than nothing.
Then there is Medicaid. The Medicaid Program serves 59 million low-
income children and families. It is our health care safety net and it,
too, is on very shaky financial ground. The Government Accountability
Office has reported to Congress that States are reaching a financial
and budgetary crisis with Medicaid. Like Medicare, Medicaid is
essentially going broke. The Government Accountability Office models
predict that State spending on Medicaid will grow faster than State
revenues for at least the next 10 years.
Here is what the Government Accountability Office has said about this
situation:

Since most State and local governments are required to
balance their operating budgets, the declining fiscal
conditions shown in our simulation suggest that, without
intervention, these governments would need to make
substantial policy changes to avoid growing fiscal
imbalances.

But this bill does not fix this problem either. Here again, this bill
makes the problem worse. This bill adds another $374 billion in
spending to the Medicaid Program. It adds 15 million people to the
rolls of the worst delivery system in health care. It increases State
spending by $25 billion, and that happens to be a hidden tax increase
because States will be forced to raise taxes to pay for this increased
cost--another unfunded mandate. By dropping the equivalent of a 10,000-
pound weight through to our frayed Medicaid safety net, this bill does
worse than nothing. This bill also compounds these long-term
entitlement spending problems by creating yet another new entitlement
program called the CLASS Act. This one is a voluntary Federal program
for long-term care insurance.
I devoted several years of effort to improving long-term care
support, particularly for the disabled and the elderly.
I understand the issues that supporters of the CLASS Act want to
address. But the CLASS Act is simply not viable in its current form.
The CLASS Act is almost certain to attract people who are most likely
to need it. This is known as adverse selection. That will cause
premiums to increase and healthier people to drop out of the program.
It is a classic insurance death spiral.
On November 13, the administration's own chief actuary confirmed
this. The chief actuary issued a dire warning in a report on the CLASS
Act in the House bill, which is virtually identical to the Senate
version. Quoting the chief actuary:

There is a significant risk the problem of adverse
selection would make the CLASS program unsustainable.

For the first 10 years, the CLASS Act saves money. It saves money at
the beginning because it collects premiums before benefits start
getting paid out. But some time afterwards, it starts to lose money. We
all know what happens from there. It will become the taxpayers'
responsibility to rescue the program as it fails. Look at financial
struggles of Social Security. Look at Medicare. Look at Medicaid. Now
go home and look at your children and grandchildren.
Creating an unsustainable CLASS Act is not a responsible thing to do
for our children and grandchildren. By adding the ticking time bomb of
yet another unfunded liability to our children and grandchildren
through the CLASS Act, this bill, again, does worse than nothing.
Health care is one-sixth of the economy. The American people do not
want a bill that makes the economy worse. The nonpartisan Congressional
Budget Office, the Committee on Taxation, and even the Office of the
Actuary of the U.S. Department of Health and Human Services have told
us what the American people already knew: These massive partisan health
care reform bills are going to make the problem worse when it comes to
the cost of health insurance.
According to a September 22 letter from the Congressional Budget
Office to Chairman Baucus about the Finance Committee bill, CBO wrote:

Premiums in new insurance exchanges would tend to be higher
than the average premiums in the current law individual
market.

So according to CBO, after these bills spend $1 trillion, many of the
people struggling to afford their premiums today will actually end up
paying more if this bill moves forward and is enacted. By increasing
costs when people desperately need Congress to lower costs, this bill
does worse than nothing.
It does not have to be this way. When the debate began last year,
interested legislators of both parties set forth benchmarks that were
no-brainers. Health care reform should lower the cost of premiums. It
should make health care more affordable. It should do so without
Medicare cuts that jeopardize access to care for seniors. It should do
so without overloading the Medicaid safety net until it rips. It should
do so without adding to the already unsustainable, unfunded liabilities
by creating yet another unsustainable entitlement program. It should
have done all those things. That is what we intended to do when we
started out.
Instead, this bill threatens the economic recovery. It is $\1/2\
trillion of new taxes hurting small business and destroying job
creation. It calls for an even bigger and more unsustainable Federal
budget. It adds to that burden with a massive new government-run health
plan. It makes health care more unaffordable and lowers quality.
I know some people believe we should get on to the bill and try to
fix it by amendment. But this 2,000-page bill has many more problems
than can be fixed by amendment on the Senate floor.
If you want to improve it, it should be stopped right now and get
back together where we were at one time. Democratic leaders and the
White House have put together one extreme health care plan after
another. After the bailouts for Wall Street and Detroit, a stimulus
bill that led to the highest unemployment in 26 years, and the Fed
shoveling money out the door without any accountability, this health
care reform bill is the straw that broke the camel's back.
What Senate Republicans are trying to say tonight, with tonight's
vote, is we don't support reform just for the sake of reform. Changes
to the health care system must be responsible and not break the backs
of the taxpayers and the job-creating engine in America, small
business.
It doesn't make any sense to make major new unsustainable commitments
to entitlement spending. Already, Medicare's solvency is in jeopardy
and the Reid bill would make things worse for Medicare. Seniors are in
a tough situation today with the way the economy has hit their
retirement savings. We have to step back and remember it is not our
money, it is their money. It is the taxpayers' money we are talking
about--$2\1/2\ trillion of taxpayers' dollars over the decade when this
bill is fully implemented.
Generations of hard-working Americans will be forced to pay the
costly

[[Page S11960]]

price for this bill if it moves forward. It is irresponsible for
Democratic leaders to use their filibuster-proof majority in the Senate
and their control of the House and the White House to push through such
massive legislation, reshaping one-sixth of the American economy. The
unintended consequences of this legislation could have a destabilizing
effect at just the wrong time as America's economy struggles to recover
and working families are doing everything in their power just to hold
on.
The late Senator Moynihan often warned about the perils of a majority
party pushing through major bills and changes in a partisan way. It is
a well-founded warning that Democratic leadership has not heeded--this
time, at least. If a bill like this one cannot get support more
broadly, then something is wrong with it.
Moreover, grassroots America has spoken out against this legislation.
It is alarming how those voices have been disregarded by congressional
leaders. President Andrew Jackson made it clear that our duty is to
tune in to the common sense of the American people who sent us here. I
quote President Jackson:

Our Government is founded upon the intelligence of the
people. I, for one, do not despair of the republic. I have
great confidence in the virtue of the great majority of the
people, and I cannot fear the result.

Listen to what President Jackson said. Listen to the concerns of the
people. They are telling us to reconsider this massive, complicated
legislation and take a path that leads to less spending, less taxes,
and less debt. Instead of continuing to mortgage the future of our
children and grandchildren, we need to get back to basics. Congress
should pass commonsense medical malpractice reform to stop wasting so
much money on defensive medicine. Congress should empower consumers to
shop around for health care and lower costs with competition just like
with other services the consumers buy. Congress should make market
reforms that help small businesses and the self-employed have greater
access to health insurance at an affordable rate.
These issues can be addressed without upending the entire health care
system with the result of higher taxes, higher insurance premiums, and
deficits and debts that will get in the way of the opportunity that
results from the ingenuity and industry of the American people.
If we were sitting around a coffee shop in Springfield, IL, or Little
Rock, AR, and we were discussing health care reform and I told them we
are talking about a bill that is going to raise taxes, cut Medicare,
raise premiums, and not do anything about costs, they would say that is
not health care reform.
I encourage my colleagues to listen to the American people and to
send this bill back to the drawing board.
I yield the floor.
The PRESIDING OFFICER (Mr. Kohl). The Senator from Wyoming is
recognized.
Mr. ENZI. Mr. President, as morning broke over our Nation today,
millions of Americans woke to a typical, crisp fall day. It seemed
ordinary as shop-owners opened their local grocery stores; children
filled soccer fields and families made preparations for Thanksgiving
holiday. It seemed ordinary. But today is anything but ordinary in the
life of our Nation.
We have all heard the phrase and repeated it so many times, that we
have almost grown numb to it--America is facing the worst economic
crisis since the Great Depression. Think about that for a minute. What
that really means is that for every single legislator in this Senate,
we are in unchartered territory.
We have never been here before and recent signs of a slow, unsteady
and jobless recovery are troubling. And, the American people know it.
In a survey from this past week, 82 percent of Americans said that our
Nation's economic conditions are poor.
Consider the news reports from just yesterday that 14 percent of all
mortgage loans--meaning 7.4 million households--were delinquent or in
foreclosure in the last quarter. That is the highest number since the
mortgage bankers industry began this survey in 1972.
Consider the unemployment rate--it reached a 26-year high of 10.2
percent in October. We lost 190,000 jobs in just the month of October
alone. And, according to the Department of Labor's broadest measure,
some 17.5 percent of Americans are without a job entirely or
underemployed. We have shed 3.5 million jobs since January of this year
and the average work-week is now down to 33 hours for the American
worker.
It is against this backdrop that the Senate majority leader has
chosen to bring up this health care bill. Health reform is a huge
undertaking.
Every one of the 2,074 pages in this bill will have a dramatic impact
on the health care of every American. I have to tell you, that is a
bridge. This is a bigger problem than anyone can imagine because it
will affect every single American. This bill represents a massive
government intrusion into the medical care of every American.
Under this bill, the government will review every employer health
insurance plan in the Nation to determine if it satisfies all of the
government mandated benefit requirements. If it does not, the
government will then tax many of those employers.
The government will also now determine whether it believes your
health insurance costs too much. It will decide what benefits should be
covered and what preventive services you should receive.
Earlier this week, the U.S. Preventive Services Task Force
recommended that women under age 50 should not receive annual
mammograms. Anyone who was concerned about this decision needs to
understand that this bill empowers a task force just like that to
determine which preventive services should be covered by every health
plan in America.
As one of the only Members of the Senate to sit on both committees of
health care jurisdiction, I understand the complexities at work in
comprehensive health care legislation. And I understand that this bill
gets it wrong.
Instead of taking a step-by-step approach to health reform,
identifying consensus reforms where we can fix what is broken and leave
what works, the majority leader has chosen a different approach.
Without Republican support and without the approval of a growing
majority of the American people, Senator Reid has chosen to shake
nearly 20 percent of our economy in its foundation in attempting to jam
through a strictly partisan bill.
This bill will increase our health care costs, do nothing to improve
the quality of our care, it will increase our Nation's debt and deficit
and it will harm our Nation's tenuous job market.
There is no credible study and there will be no serious, unbiased
economist who will say that this bill will create jobs or strengthen
our economy. And that is what the people in the most recent election
said was mot important.
Recently, in an op-ed in the Wall Street Journal, the dean of Harvard
Medical School Dr. Jeffrey Flier gave the current health reforms a
``failing grade.'' Dean Flier wrote about the reform bills being
debated in Congress, that ``there are no provisions to substantively
control the growth of costs or raise the quality of care. So the
overall effort will fail to qualify as reform.''
Dean Flier went on to write:

In discussions with dozens of health care leaders and
economists, I find near unanimity of opinion that, whatever
its shape, the final legislation that will emerge from
Congress will markedly accelerate national health-care
spending rather than restrain it. Likewise, nearly all agree
that the legislation would do little or nothing to improve
quality or change health-care's dysfunctional delivery
system.

I ask unanimous consent that this editorial be printed in its
entirety in the Record at the conclusion of my statement.
The PRESIDING OFFICER. Without objection, it is so ordered.
[See exhibit 1.]
Mr. ENZI. With ratings of failed reform like the dean of the Harvard
Medical School, why are we talking about taking the time to tweak a
failure of ideas so we can say we did something. We are not fooling the
American people. The voices of August are still echoing and coming from
a vast majority.
Other experts have weighed in on the provisions in the Reid bill and
their potential impact on jobs. One such provision is the job-killing
tax of $28 billion that will disproportionately fall on the backs of
small business employers in the form of a mandate on employers to

[[Page S11961]]

provide Washington government-approved insurance.

This job-killing tax has been studied by the non-partisan score
keepers at the Congressional Budget Office as well as nationally
recognized economists and health experts. These experts have said that
the costs of this new tax will ultimately be paid by the American
working men and women.
Businesses that cannot afford to provide health insurance will pass
the costs of these new penalties on to their workers in the form of
lower wages, reduced hours and jobs cut. Yes, this so-called health
reform bill will threaten your jobs and if this vote is successful we
will spend weeks debating this bill. And just like committee work so
far, the majority will reject real solutions just like they have
through the two amendment processes that have been merged to make this
flawed bill.
According to one recent study by the Heritage Foundation, this new
job-killing tax in the Reid bill will place more than 5 million low-
income workers at risk of losing their jobs or having their hours
reduced and an additional 10 million workers could see lower wages and
reduced benefits. At a time of unprecedented economic peril, the
majority has chosen to bring a bill to the Senate that will threaten
our Nation's jobs and our economic growth.
This bill will also increase our Nation's growing debt and deficit.
Currently, our Nation's debt is greater than $112 trillion and our
deficit for fiscal year 2009 was greater than $1.4 trillion. As a
percentage of the economy, our deficit is 10 percent of GDP--the
highest it has been since the Second World War. Once again, we are not
debating this bill in a vacuum. Rather, we are debating this bill at a
time when our credit card is maxed out.
I worry about the country that I am leaving for my children and
grandchildren. Our Nation is being buried under a mountain of debt,
which poses a deadly threat to the future of our Nation.
The Federal Government will spend $1.4 trillion more than it receives
in revenue this year. The government will make up that deficit by
borrowing more money, mostly from China and other foreign governments.
These levels of debt are not sustainable and, our foreign creditors
are beginning to recognize this fact. As our creditors grow more
concerned about our ability to pay our debt obligations, the interest
rates we pay will grow. That means that it will soon cost us
considerably more to allow Washington to continue to borrow the money
it needs to fund its current spending binge.
With our current and growing debt, Congress should be concerned.
Think about it--our most fundamental duty as Members of Congress is to
wisely manage the power of the purse for our Nation. The Framers wisely
put in place a process of appropriations that would be annually checked
by the representatives of the American people here in Washington.
In this bill we create yet another stream of mandatory spending in
perpetuity--or until it runs out--that is not reviewed by Congress on
an annual basis.
I remind my colleagues that our Federal deficit is nearly nine times
the size of the deficit just 2 years ago. During the same 2-year
period, our Nation lost 8 million private sector jobs. Our total
Federal debt is now around 85 percent of GDP. According to David
Walker, the former head of the Government Accountability Office, at the
end of the fiscal year 2000, the Federal Government had about $20.4
trillion in total liabilities and commitments and unfunded promises for
just Social Security and Medicare. That number rose to $56.4 trillion
at the end of fiscal year 2008. That is a 176-percent increase in only
8 years. By the end of this year, that number is expected to rise to
$63 trillion. With these staggering statistics, it is astonishing we
are even debating the creation of a new entitlement obligation forever.
A couple days ago, Majority Leader Reid stated that this bill will be
deficit neutral, but you have to understand what that means. First, the
true cost of this bill is hidden by implementing the massive middle-
class tax increases and Medicare cuts in the first year and pushing the
massive costs in health care subsidies out to the fifth year.
Republican Leader McConnell referred to this gimmick as being akin to
paying a mortgage for 4 years before actually moving into the house. I
wish to emphasize that a little bit. It is a gimmick. You collect the
money to begin with, but you don't provide the benefits until further
down the road. Then you say: We covered all those costs. But when you
extend it on out, it will not continue to cover those costs. So
disaster.
As the only accountant in the Senate, I am shocked to see that what
would constitute as fraud in the accounting world seems to be reason to
hold a press conference to do a hollow boast. The gimmicks in this bill
are stunning, whether it comes to implementation of the tax on so-
called Cadillac health plans or the increased taxes or the $464 billion
in Medicare cuts--Medicare cuts. We are already having a problem with
Medicare solvency. It is going to go broke. We are going to take $464
billion from Medicare. Then we are going to form a special commission
and this commission will be able to tell us, on an annual basis, where
we can make cuts in Medicare so it doesn't go broke. But let's see,
there is a deal with the hospitals that they are not going to be
touched. There is a deal with the doctors that they will not be
touched; in fact, theirs is going to be increased. There is a deal with
PhRMA where they will not be touched. Who does that leave? That means
cutting benefits for seniors. They and home health care and nursing
homes are the only places you can cut it, if you let those other people
off the hook. That is what the bill does.
When it comes to the long-term care provisions in this bill that
Budget Committee Chairman Conrad has referred to as a Ponzi scheme, you
have to be a little bit worried. If Washington accounting had to come
under the same laws as private business, the administration and
Congress would be in jail. To attempt to claim the mantle of fiscal
responsibility, the majority leader has jammed 10 pounds of entitlement
spending into a 5-pound sack. Again, entitlement means the payments
automatically go on forever with no further review or constraint. That
is not fiscal responsibility and the American people are not buying it.
They know, evidently better than we do, what we are talking about.
A large majority of Americans believe their prescription drug costs
will go up under this bill and that the cost of their premiums will go
up. They are right. What the CBO score doesn't provide us with and
can't provide us with is the cost of this bill to each and every one of
us. But we know that cost will be great. The CBO evaluation says it is
going to be paid for. Paid for? That is an evaluation of whether it is
going to cost the government anything. It is not an evaluation of
whether it is going to cost the people anything. The only place to get
that money is from the people or, in this case, also stealing it from
Medicare. In order for this bill to reduce the deficit, the majority
leader has to assume that the Medicare payments to physicians will be
cut by 21 percent next year. He also has to assume these payments will
be annually cut another 5 percent for the next 9 years.
In order for this bill to reduce the deficit, the majority leader
also has to assume that more and more middle-class Americans will pay
this new tax on high-cost health insurance plans. According to the
Congressional Budget Office, 84 percent of the revenue collected by
this new tax will come from Americans earning less than $200,000 in
2019. This reminds me of another tax which was originally intended to
target just 155 individuals who made more than $200,000 and did not pay
any income tax. Today the alternative minimum tax now hits millions of
middle-class Americans, and every year Congress has to enact
legislation to prevent it from hitting millions more. This bill is
drafted that same way. It will creep up there and catch everybody in
increased taxes.
In order to believe that this bill will reduce the deficit, its
sponsors must believe that future Congresses will allow millions of
middle-class Americans to be subject to these new taxes. While the
majority leader claims all these things will happen, the American
public isn't fooled.
In this morning's Washington Post, the dean of Washington
journalists, David Broder, not a politically conservative columnist and
someone often

[[Page S11962]]

cited by the other side, pointed out that a recent survey found that
less than one-fifth of the American people believe that health care
reform will be deficit neutral over the next 10 years. By a 16-point
margin, the majority in this poll said they opposed the legislation
moving through Congress. Mr. Broder called this legislation a ``budget-
buster in the making.''
It is difficult to quantify the scope of this bill. I have heard some
of my colleagues talk about how many years would elapse in 2\1/2\
trillion seconds. I heard some of my colleagues talk about how many
cars $2.5 trillion would buy or how many school districts it would fund
or how many decades it would fund State budgets across America. I don't
think people are understanding how comprehensive this bill is that
entails 100 percent of the people. That is the difficulty we in the
Gang of 6 had coming to any conclusion because it is so big that as we
get into one area and scratch the surface and find out what we don't
know, it takes a lot of research time to get there to be able to make
basic decisions. But it was easy to cram into a bill and say: This
solves it, solves it for $1 trillion. We should never say $1 trillion
because that sounds like one, and one is not a very big number.
It is $1,000 billion. We don't know what 1 billion is either, but 1
billion is 1,000 million. So we are talking about a lot of money here.
Perhaps the best way to quantify this bill is, it keeps me up nights
and, more importantly, these issues we are debating keep our
constituents up at night. I am sure everybody has been hearing from
their constituents. We worry immensely about the cost and the
obligations we are passing on to our children and grandchildren. Where
is this bill taking our country, and will we have the courage in our
time to preserve and protect our Nation's great strengths for future
generations? These are the questions that keep me up at night, and I
know these concerns are shared on the other side of the aisle. I sense
it in conversations I have had with the senior Senator from Delaware
and the senior Senator from Nebraska. I sensed it in my work over the
summer with the chairman of the Budget Committee. I know they share
these concerns on the other side. That is why I believe passionately
that we must defeat the motion to proceed on this bill.
I am sometimes an optimist, and I still hope we can start over and
get to work on a bipartisan bill that has the trust and support of the
American people. Any major piece of legislation that has gone through
this body has done so in a bipartisan way. It has been necessary to get
the confidence of the American people. They don't have confidence in
Congress right now. This bill is not helping.
We say we are spending our children and grandchildren's money.
Actually, we are doing that plus spending seniors' money. When you take
that Medicare money, that is what you are doing. The seniors have
figured it out. That is why it was so raucous in August and ever since.
They have been concerned about their future and the promises made to
them. We have a system that is going broke, and then we are going to
take money from it. We ought to back up and make sure Medicare money
goes to Medicare. I know part of that is listed as fraud and abuse. I
am always fascinated when government talks about fraud and abuse
because we talk about it, but if we have known that these billions of
dollars of fraud and abuse were out there, why haven't we been
collecting that money? Once we turn it over to the government to do
that, it is no longer needed. Well, it is needed to pay the bills, but
it is no longer that much of a care because the paid-for has already
been taken care of.
There ought to at least be a separate account set up that you have to
actually collect the fraud and abuse money before you can spend it, but
we are not going to do that.
Every senior can tell you some instances of fraud and abuse that they
think are happening, and we have passed those on. I see some effort to
collect that but not a lot.
As many of my colleagues know, before I came to the Senate, I was a
small business owner. My wife and I owned three small shoestores in
Wyoming and Montana. When I was showing someone a shoe and he or she
said they didn't like it or couldn't afford it, I didn't try to give
them a sales pitch. I knew it was time to try to find another shoe, one
they liked and could afford. There is a lesson from this in this health
care bill. The people of America are complaining, and we are showing
them the shoe we want to show them. They don't want to see that shoe.
They said: We thought you were going to lower my costs. Every person
out there thought they were going to have the benefit of reduced costs,
and they are not seeing it in this bill. They wanted to help out other
people, and some of that is in here, to a limited extent. But that
isn't the main thing that they expected to have happen from this. Small
businesses out there are particularly hurting, and this will react on
small businesses, those shoestores all over the United States, the
grocery stores, the dry cleaners. This is even going to affect doctors.
They are small businesses, for the most part.
So there is a lesson in this story when it comes to reforming health
care. It is time to listen to the customers and find the alternative
they expected, that they wanted, and they can afford.
Probably the biggest help to me in legislating has been the
experience of working in a shoestore. The people tell you what they
want, and they have told us what they want. We haven't listened. If you
want to make the sale, you better listen. You better see how your
inventory matches what they want. We haven't checked the inventory or
we have said: We don't have anything in here that you need, but we have
some things to take care of other people. That is not going to sell.
We have a big decision to make tonight. It will have a lasting effect
on our country, a lasting effect in that if the motion to proceed
passes, we are going to debate it for a long time. A bill this size
deserves a lot of time. It is necessary. And it is more comprehensive
than we are going to be able to get into, no matter how long we debate
it.

So the American people are going to be surprised at the time we waste
when we could be solving jobs and the economy, which is their biggest
concern at the present time.
Mr. President, I yield the floor.

Exhibit 1

Health ``Reform'' Gets a Failing Grade

(By Jeffrey S. Flier)

As the dean of Harvard Medical School I am frequently asked
to comment on the health-reform debate. I'd give it a failing
grade.
Instead of forthrightly dealing with the fundamental
problems, discussion is dominated by rival factions
struggling to enact or defeat President Barack Obama's
agenda. The rhetoric on both sides is exaggerated and often
deceptive. Those of us for whom the central issue is health--
not politics--have been left in the lurch. And as controversy
heads toward a conclusion in Washington, it appears that the
people who favor the legislation are engaged in collective
denial.
Our health-care system suffers from problems of cost,
access and quality, and needs major reform. Tax policy drives
employment-based insurance; this begets overinsurance and
drives costs upward while creating inequities for the
unemployed and self-employed. A regulatory morass limits
innovation. And deep flaws in Medicare and Medicaid drive
spending without optimizing care.
Speeches and news reports can lead you to believe that
proposed congressional legislation would tackle the problems
of cost, access and quality. But that's not true. The various
bills do deal with access by expanding Medicaid and mandating
subsidized insurance at substantial cost--and thus addresses
an important social goal. However, there are no provisions to
substantively control the growth of costs or raise the
quality of care. So the overall effort will fail to qualify
as reform.
In discussions with dozens of health-care leaders and
economists, I find near unanimity of opinion that, whatever
its shape, the final legislation that will emerge from
Congress will markedly accelerate national health-care
spending rather than restrain it. Likewise, nearly all agree
that the legislation would do little or nothing to improve
quality or change health-care's dysfunctional delivery
system. The system we have now promotes fragmented care and
makes it more difficult than it should be to assess outcomes
and patient satisfaction. The true costs of health care are
disguised, competition based on price and quality are almost
impossible, and patients lose their ability to be the
ultimate judges of value.
Worse, currently proposed federal legislation would
undermine any potential for real innovation in insurance and
the provision of care. It would do so by overregulating the
health-care system in the service of special

[[Page S11963]]

interests such as insurance companies, hospitals,
professional organizations and pharmaceutical companies,
rather than the patients who should be our primary concern.
In effect, while the legislation would enhance access to
insurance, the trade-off would be an accelerated crisis of
health-care costs and perpetuation of the current
dysfunctional system--now with many more participants. This
will make an eventual solution even more difficult.
Ultimately, our capacity to innovate and develop new
therapies would suffer most of all.
There are important lessons to be learned from recent
experience with reform in Massachusetts. Here, insurance
mandates similar to those proposed in the federal legislation
succeeded in expanding coverage but--despite initial
predictions--increased total spending.
A ``Special Commission on the Health Care Payment System''
recently declared that the Massachusetts healthcare payment
system must be changed over the next five years, most likely
to one involving ``capitated'' payments instead of the
traditional fee-for-service system. Capitation means that
newly created organizations of physicians and other health-
care providers will be given limited dollars per patient for
all of their care, allowing for shared savings if spending is
below the targets. Unfortunately, the details of this massive
change--necessitated by skyrocketing costs and a desire to
improve quality--are completely unspecified by the
commission, although a new Massachusetts state bureaucracy
clearly will be required.
Yet it's entirely unclear how such unspecified changes
would impact physician practices and compensation, hospital
organizations and their capacity to invest, and the ability
of patients to receive the kind and quality of care they
desire. Similar challenges would eventually confront the
entire country on a more explosive scale if the current
legislation becomes law.
Selling an uncertain and potentially unwelcome outcome such
as this to the public would be a challenging task. It is
easier to assert, confidently but disingenuously, that
decreased costs and enhanced quality would result from the
current legislation.
So the majority of our representatives may congratulate
themselves on reducing the number of uninsured, while quietly
understanding this can only be the first step of a multiyear
process to more drastically change the organization and
funding of health care in America. I have met many people for
whom this strategy is conscious and explicit.
We should not be making public policy in such a crucial
area by keeping the electorate ignorant of the actual road
ahead.

Mr. GRAHAM. Mr. President, the bill we have before us today is a
2,074-page, multi-trillion-dollar bill written in the dark of night.
This process brings back the worst of Washington. The substance of the
bill raises taxes during a recession, compromises individual health
care choices, cuts Medicare to pay for the uninsured and will
eventually explode the deficit--the combination of which will
jeopardize the finest health care system in the world without lowering
costs. Today we are voting on the motion to proceed to the bill and I
will vote no because this bill is broken beyond repair. Instead of
proceeding to a flawed bill, we should stop and start over.
Despite President Obama's repeated statements that Democrats would
legislate in an open and transparent manner, this bill was drafted in
secret and Republicans were excluded. As a candidate and now as
President Obama, he even went so far as to tell the American people
that the negotiations would be broadcast live on C-SPAN. Instead of the
change Americans thought they voted for, we have gotten more of the
same.
The bill we are moving to consider will cost $2.5 trillion once fully
implemented; nearly three times the official CBO score of $848 billion.
The Democrats are playing a shell game to hide the true cost of this
legislation. With this bill we get 10 years of taxes and only 6 years
of programs. While some may claim that the bill is deficit neutral, the
Federal Government's financial commitment to health care under this
bill actually grows. Health care costs are not contained or reduced,
they are simply offset by reductions and tax increases elsewhere in the
Federal ledger.
A central premise of this legislation is that Congress will allow
nearly half a trillion dollars in Medicare cuts to go into effect.
Congress has not had the political will to allow these types of cuts to
stand in the past, so why should we believe that future Congresses will
not follow suit. Case in point, the ``doc fix.'' When we passed the
Balanced Budget Act in 1997, we included a formula to limit the cost
growth in physician spending in Medicare. Congress allowed that formula
to reduce payments to physicians only once and has not done so again.
We leave the flawed formula in place and each year we act to block the
scheduled cuts to physician payments instead of fixing the problem.
This bill increases doctor payments by half a percent in 2010 and then
assumes a 23-percent cut in 2011, budget gimmickry at its finest.
Medicare is currently $36 trillion in the hole, but as we have seen,
Congress doesn't have the will to cut Medicare by fifty cents, much
less $500 billion. When we tried to rein in Medicare costs in the
budget in 2007, we proposed $33 billion in savings and only got two
dozen votes.
In a nod to Congress' traditional actions, or lack thereof, Democrats
even included an Independent Medicare Advisory Board that can cut
Medicare provider payments if Congress fails to act. Cutting an already
cash-strapped program is not the way to finance health care for the
uninsured.
In addition to the nearly half trillion dollars in cuts contained in
this bill, we get a half trillion dollars in new and increased taxes.
The bill would tax Americans who choose higher cost insurance plans, it
would tax employers for not providing health coverage, it would tax
Americans for not buying health coverage, and it would increase the
Medicare payroll tax on some Americans to fund a new health care
entitlement program. In the midst of the worst recession this country
has seen in decades, how can these job-killing tax increases be
justified?
I believe the provisions contained in this bill are bad for America.
We must work to enact policies that preserve patient access to care,
rein in ever increasing costs in the health system while ensuring the
viability of current programs, and promote choice. This bill is a
budget buster that does none of those things.
Mr. President, I cannot support this bill.
The PRESIDING OFFICER. The Chair recognizes the Senator from Montana.
Mr. BAUCUS. Mr. President, a noted psychologist once said:

To be mature means to face, and not evade, [a] crisis. . .
.

Our health care system is in a crisis. This crisis has been decades
in the making, and history has made clear that this crisis will not
solve itself. It is time for us to face the crisis. It is time for
Congress to show mature leadership. It is time for us to reform health
care, once and for all.
For years now, we have prepared for this moment. The Finance
Committee and the HELP Committee studied the issues thoroughly. We have
held nearly 70 hearings, roundtables, and walk-throughs. We have
studied this issue very thoroughly and exhaustively. We each produced a
blueprint for reform--each committee--and we worked together with
Leader Reid and President Obama to combine those blueprints into one
solid plan. This week, tonight, we have brought that plan to the Senate
floor. Tonight, we seek to begin that momentous debate. Tonight, we
seek, at last, to face the crisis.
We have a bill that will put Americans, patients, and their doctors
back in control. We have a bill that will end harmful insurance
industry practices. Under our bill, no longer will insurance companies
be allowed to deny you health insurance. No longer will insurance
companies be allowed to hike up rates for Americans with preexisting
conditions, such as heart disease, cancer, or diabetes. No longer will
health insurance companies be able to take away your health insurance
or reduce benefits when people get sick. Under our bill, no longer will
insurance companies be able to limit the amount of health care you can
use in a lifetime. No longer will insurance companies be able to put
unreasonable limits on the amount of health care you can use in 1 year.
If you pay your bill, the insurance company must renew your coverage
and provide your benefits. No longer will insurance companies be able
to discriminate based on gender or health status. No longer will
insurance companies be able to charge more for women or for people who
are sick.
Our bill will also require insurance companies to disclose the share
of premiums that goes to medical benefits. That is new and very
important. No longer will insurance companies receive tax credits when
they use their profits to provide excessive executive paychecks.

[[Page S11964]]

Our bill is fully paid for. It is fiscally responsible. It will lower
health care costs, and it will reduce the Federal budget deficit.
According to the Congressional Budget Office, our bill will reduce
the deficit by $130 billion in the first 10 years. Over the next
decade, it will further reduce the deficit by about one-quarter of 1
percent of gross domestic product. That is hundreds of billions of
dollars in deficit reduction.
As well, our bill will provide billions in tax cuts for American
families and small businesses. Our bill will create new marketplaces
called insurance exchanges. Individuals and small businesses will be
able, quickly and easily, to view, compare, and buy health insurance
plans.
Today, many Americans already receive quality health care coverage
through their employers. Many are happy with their current insurance
plans. This bill will not change that. We keep the best of our current
health care system. People who are satisfied with their current health
insurance coverage will be able to keep it. But too many others do not
have access to insurance, to quality insurance. For too many, this
system is broken.
Under our bill, new exchanges will provide one-stop shops where plans
are presented in a simple, consistent format. Americans will be able to
know exactly what they are buying. Insurance companies will have to
compete on price and on quality, not on their ability to select the
healthiest people or hide restrictions. Americans will be able to count
on the health care coverage they buy. And tax credits will help to
ensure all Americans can afford quality health insurance.
Small businesses will also have access to exchanges and tax credits.
Through small business exchanges, these companies will be able to pool
together to spread their risk, increase their leverage, and enhance
their choice, just as big companies do.
Members of Congress will be required to buy their health insurance
through the same exchanges that people in their own States use--exactly
the same. No longer will there be a separate congressional health plan.
Our bill will strengthen Medicare. It will improve benefits for
seniors. And it will help to ensure Medicare is sustainable for future
generations. Our bill will cut costs, but it will not cut benefits. Our
bill will increase Medicare benefits. Our bill will provide seniors
with free preventive care and wellness checkups. It will improve care
for seniors with chronic conditions. And it will provide a 50-percent
discount on brand-name prescription drugs to help close the doughnut
hole, the gap in benefits in the Medicare prescription drug program.
Our plan is a good, commonsense answer to the crisis facing American
families and businesses.
On this floor, here in the Senate, tonight, we have a historic
opportunity to consider this plan. We have the chance to make it even
better. We hope to have a full debate. But more important than the
process or rhetoric, we have the opportunity, at last, to face the
crisis. We have the opportunity to show mature leadership. At long
last, we have the opportunity, the historic opportunity, to reform
health care, once and for all. History is knocking on the door. Let's
open it. Let's begin the debate to improve this bill before us today
and provide the service all Americans expect us to perform when they
elect us to this office.
I yield the floor.
The PRESIDING OFFICER. The Senator from Connecticut.
Mr. DODD. Mr. President, I rise in very strong support of this melded
bill, drafted and put together by our distinguished leader, the Patient
Protection and Affordable Care Act.
Before I begin with some brief remarks, let me extend my heartfelt
thanks to our majority leader for his tireless work and thank Max
Baucus of Montana for his tireless work and the members of the
committees who have worked over the past many months to bring us to
this moment.
Others this evening have spoken with great eloquence, in my view,
about the provisions of this bill, what we hope to achieve for our
fellow citizens with the adoption of this legislation.
I commend the Senate HELP Committee, which did such heroic work
during the writing of our portion of the bill--my colleagues, Tom
Harkin of Iowa, Barbara Mikulski of Maryland, Jeff Bingaman of New
Mexico, Patty Murray of the State of Washington, and so many others.
I thank my Republican colleagues on that committee as well. While we
did not end up with a bipartisan vote at the end of that very long
process, we did end up adopting more than 160 amendments offered by my
Republican colleagues to that bill, which I think strengthened the
legislation, made it a better piece of legislation, and many of which
are a part of this legislation this evening.
I also want to pause for a moment, if I can, to recognize a colleague
who is here tonight only in spirit, Ted Kennedy. So much has been said
and written about his lifelong quest to ensure that every American--
every American--has decent health care. Tonight and in the days to
come, we will pay him the highest compliment, as our colleague, by
fulfilling that quest of achieving the goal all Americans aspire for;
that is, a national health care plan that serves every one of our
citizens.
I would like to speak briefly, if I could, to the American people who
are at home this evening and I suspect are just tuning in to this
debate.
This important vote will occur momentarily. Why does this issue and
this debate matter? Why are we here on a Saturday evening? But then
again, for that matter, why are you watching C-SPAN on a Saturday
evening, I might add?
Well, for one thing, health care represents one-sixth of our economy
and affects 100 percent, as we all know, of the population of this
country. And it is true that skyrocketing health care costs are the
single biggest threat to the financial future of our fellow citizens.
But the reason tonight's vote is so historic, beyond those last two
points, is that never, ever before--never before--has this body,
elected to serve the American people, confronted directly this simple
truth: Nothing, absolutely nothing, matters more to you and to your
family than the ability to get the health care you need, when you need
it, from the doctor you choose, at the price you can afford.
Health care is our most basic need. Health care is the most basic
commitment we should be willing to make to each other. No matter what
your family finances, no matter what your hopes and dreams are, no
matter who you are or where you live or what your job is in America, in
our 21st century America, you should be able to get the care you need.
But for too many American families--perhaps your family, as you watch
this tonight from your homes--health care has become your most basic
fear. If you do not have health insurance, you go to bed every single
night knowing that if you wake up sick or your child does, you might
not be able to see that doctor or afford one if you can even find one.
Even if you have health insurance, you are paying more and more in
premiums and getting less and less coverage for your money.
Millions of you are seeing your premiums skyrocket. Yet you lie awake
at night--millions do--wondering: What if I lose my job? What if I get
sick and find out my policy does not cover the costs and the care I
need--or, even worse, your insurance company cancels your policy
altogether? What if you run out of benefits and have to pay out of your
pocket? I wish I could say these fears are irrational fears, but they
are not. There is nothing irrational about those fears. Insurance does
not allow you to be sure of anything these days.
Our system, all 100 of us here know, is broken. People are losing
their homes because they get sick. People are dying because they cannot
afford the cure. This is just not acceptable in our America. That is
why we are here on a Saturday night.
If you have watched the news over the past few months, you have
probably noticed there is a wide range of opinions on how we should fix
things. And that is as it should be. We need all the good ideas we can
get, and hopefully this debate will produce that. But if you have also
watched the debate in the Senate over the last 2 days, you have
probably noticed something else as well. I don't believe a single
person in this body has stood up at any point and said we are OK doing
nothing at all. Therefore, in the weeks ahead we will have a full and
open debate about every provision of this bill.

[[Page S11965]]

But tonight's vote is nothing more than a choice--a choice between
doing something or doing nothing. I urge my colleagues this evening to
join us, hopefully unanimously, to say we should do something. We
should do something about this most basic right that all Americans
deserve.
I yield the floor.
The PRESIDING OFFICER. The Republican leader is recognized.
Mr. McCONNELL. Mr. President, the Nation is watching the Senate
tonight. The American people know how important this vote is. They have
seen the bill the Democratic leaders want to impose upon them, and they
want to know where the rest of us will stand.
This bill itself is a massive monument to bureaucracy and spending.
But at its core it is quite simple. At a moment when more than 1 of 10
working Americans is looking for a job, at the time when the Chinese
are lecturing us about our debt, this bill--this bill right here--costs
$2\1/2\ trillion the government doesn't have and cannot afford. It
imposes punishing taxes on almost everyone. It raises health insurance
premiums on the 85 percent of Americans who already have health
insurance. And if that were not bad enough, it slashes Medicare by $\1/
2\ trillion. Anyone who votes aye tonight is voting for all of these
things.
It is a fact: A vote in favor of proceeding to this bill is a vote in
favor of adding to the tax burden of the American people in the midst
of double-digit unemployment. A vote in favor of proceeding to this
bill is a vote to raise health insurance premiums on people who were
told--they were told--that they could expect their health insurance
costs to go down. A vote in favor of proceeding to this bill is a vote
in favor of deep cuts to Medicare for tens of millions of seniors who
depend on it totally. A vote to proceed to this bill is a vote to
continue the completely out-of-control spending binge this Congress has
been on all year. A vote in favor of this bill tells every American
family sitting in a waiting room tonight, wondering when they will get
to see a doctor or how much it is going to cost: It is not our concern.
Worst of all, a vote in favor of this bill is a vote in favor of the
spending binge that is leading to a massive and unsustainable, long-
term debt that will shackle our children to a future they can't afford.
That is what tonight's vote is all about. If it weren't, none of us
would be here on a Saturday night with the Nation watching and waiting
to see what we do. They are watching because they know that none of
this--none of this--is inevitable.
All it takes is one vote--just one. The simple math is this: If there
were one Democrat, just one of our friends on the other side of the
aisle, just one who would say no tonight, none of this would happen.
The voices of the American people would be heard. We have seen all the
surveys. We know how they feel. If one Democrat were to say no tonight,
he would be saying no to the premium increases, no to the tax cuts, no
to the Medicare cuts--just one on the other side of the aisle. Then we
could start over with a commonsense, step-by-step approach to fix the
problem that got us here in the first place, and that is that health
care costs too much.
That is the sad irony of this whole debate. The problem that got us
here is that health care costs are out of control. Yet the neutral,
nonpartisan Congressional Budget Office, the scorekeeper around here,
says under this bill--this massive bill--health care costs are actually
going to go up, not down, and the American people thought that is what
this whole debate was about in the first place. So 2,074 pages and
trillions of dollars later--2,074 pages and trillions of dollars
later--this bill doesn't even meet the basic goal the American people
had in mind in what they thought this debate was all about--to lower
costs. This bill will actually make the situation worse, and now we are
about to vote on it.
We have heard some Senators come to the floor today and say that they
oppose this bill, but they don't want to stop the debate. They oppose
the bill, but they don't want to stop the debate. Nobody is suggesting
we stop the debate. No one. Not a single Senator on this side of the
aisle have I heard suggest that we stop the debate. But if we don't
stop this bill tonight, the only debate we will be having--the only
debate we will be having--is about higher premiums, not savings for the
American people; higher taxes instead of lower costs, and cuts to
Medicare rather than improving seniors' care. That is what the debate
will be about.
The American people and 40 of us in this room sitting on this side of
the aisle are not asking to end the debate. That is not what we have in
mind, to end the debate. What we want to do is change the debate--not
end it, change it--because once we get on this bill, ladies and
gentlemen, the basic dimensions will not change. The basic dimensions
will not change.
So I ask: Why should we consider a bill we already know the American
people oppose? This is not anything anybody is in doubt about. The
American people think if you don't like this bill, you have an
obligation to try to stop it, and that opportunity will come at 8
o'clock.
I am sure this won't come as a surprise to any Member of the Senate,
but it is going to take 60 votes to change this bill. That means the
bill as introduced--this bill we are looking at right here--will
fundamentally be the bill we will be asked to pass sometime in the
future. That is a fact.
After tonight's vote we will all go home and face our constituents.
We will have to tell them how we voted on raising their premiums,
raising their taxes, and cutting their Medicare. For some of us, that
is not going to be a very easy conversation, but it doesn't have to be
that way. If you want to lower costs and premiums, then we can work
together step by step and pass the commonsense reforms the American
people have been asking for all along.
We can end junk lawsuits against doctors and hospitals which drive up
costs. We can encourage healthy choices such as prevention and wellness
programs which hold down costs. We can lower costs by letting consumers
buy coverage across State lines. We can allow small businesses to band
together to get lower insurance rates. And certainly we can address the
rampant--absolutely rampant--waste, fraud, and abuse that drives up
costs. All of those, my colleagues, are changes worth making.
The American people are looking at the Senate tonight. They are
hoping we say no to this bill so we can start on a better plan that
fixes the problem the American people care about most, and that is
cost. They want us to start over. There is nothing about this massive
bill they like. They want us to start over. They want us to address
their real concerns. All it would take, Mr. President and my
colleagues, is one Member of the other side of the aisle--just one--to
give us an opportunity not to end the debate but to change the debate
in the direction the American people would like us to go.
I yield the floor.
The PRESIDING OFFICER. The majority leader.
Mr. REID. Mr. President, my dear friend, the Republican leader, has
had since Wednesday to read this bill. Obviously he hasn't done so
because the facts he is talking about do not exist except in the minds
of a few people who don't understand this legislation.
For 200 years we have styled ourselves the world's greatest
deliberative body. Deliberation necessarily implies discussion and
great issues, necessarily requires great debate. Today we vote on
whether to even discuss one of the greatest issues of our generation;
indeed, one of the greatest issues this body has ever faced: whether
this Nation will finally guarantee its people the right to live free
from fear of illness and death which can be prevented by decent health
care for all. In the coming weeks, we will finally put people, not
insurance companies, in charge of their lives.
The road to this point has been started many times. It has never been
completed. Merging two such large and consequential bills has never
been done before. It has been an enormous undertaking and we would not
be in this position without the unflagging dedication of many Senators
and extremely loyal staff members. At the top of the list are Chairmen
Baucus and Dodd who have shown dedication and determination in recent
weeks and months that has rarely been seen.
I am proud of every single Senator's input, and I am especially proud
of the two most recent classes of Senators. Elected with strong
mandates for

[[Page S11966]]

progress, they have demonstrated a studious approach to our historic
endeavor and an unwavering belief that all Americans should be able to
afford to live a healthy life.
I wish to explain why we are holding this important vote at this
hour. As a matter of principle that I respect, the senior Senator from
Arkansas insisted we vote only after Senators had time to read and
understand this bill. Senators all have now had ample time to do so.
That is because of the chairman of the Agriculture Committee, Senator
Blanche Lincoln, of Arkansas.
As I have done many times this year privately, personally, as well as
publicly, I again invite my Republican colleagues to join on the right
side of history. I, again, invite them to join us, at the very least,
in a debate about our future.
Around dining room tables in Nevada and across the Nation, families
are agonizing over what to sacrifice next to buy health insurance. They
are questioning whether to fill a prescription or go without it and
hope for the best. Employers are wondering whether they can afford to
provide health care to their employees. They are asking how their
businesses can survive while health care costs grow faster than ever.
Americans need health insurance reform.
Debate is constant between television commentators and the editorial
pages of great newspapers and magazines. The only place where silence
is even considered is in the Senate of the United States.
Tonight--finally--we have the opportunity to bring this debate where
it belongs. We finally have the opportunity to bring this great
deliberation to this great deliberative body. That--and nothing more--
is what tonight's vote does. A ``yes'' vote says to America: I know
this issue is important to your family and to our country, and the
Senate should, at the very least, talk about it.
Let's be real transparent. Beyond all the hype, the hyperbole, and
the hyperventilation, that--and nothing more--is what tonight's vote
does. A ``yes'' vote says to America: I know this issue is important to
your family and to our country, and the Senate should at least talk
about it.
Some of my Republican friends would like the American people to think
that voting to debate the bill is voting to pass the bill. Any high
school civics textbook will tell you that suggestion is absolutely
false. Tonight's vote is not the end of the debate, it is only the
beginning of the debate.
It is clear by now that my Republican colleagues have no problem
talking about health care in press conferences, radio interviews,
television interviews, and townhall meetings. My distinguished
counterpart, the Republican leader, has given many speeches in this
Chamber on the issue of health care reform.
Yet now that we have the actual legislation to debate, to amend, and
build on--now that we have a plan on paper and not just wild rumors--
will they refuse to debate?
After all, if we are not debating, if we refuse to let the Senate do
its job, what are we doing here? If Senators refuse to debate about a
profound crisis affecting every single citizen, the Nation must ask,
what do you fear? In whose voice do you speak? In whose interest do you
vote?
Surely, deliberating health reform cannot be more difficult than
deciding, as Americans have to do, whether to pay your mortgage or your
medical bills. It can't be more painful than not taking your child to
the doctor because it costs too much. It cannot be more humbling than
facing your own employees and telling them: I am sorry, you can't count
on me for your health insurance next year. You are on your own.
It can't be more upsetting than having an insurance company take away
your coverage at the exact moment you need it the most.
My Republican friends, there is nothing to fear in debate. President
Kennedy once said:

Let us not be afraid of debate or discussion. Let us
encourage it.

Be not afraid of debate. It is our job, and it is exactly what the
legislative process is all about--discussing, amending, improving. We
Democrats stand ready to do what needs to be done. We welcome debate,
encourage debate.
Does any Senator seriously think the Founders conceived the Senate
rules in the hopes that legislation would never be deliberated? Of
course not.
Did the Framers of the Constitution explicitly enumerate the powers
of the Senate but in truth hope this body would avoid the hardest and
most urgent questions of the day? Of course not.
Did our Nation's visionaries build this Capitol Building and design
this great Chamber we stand in tonight only so it would remain dark and
silent? Quite to the contrary.
Imagine if, instead of debating either of the historic GI bills--
legislation that has given so many brave Americans the chance to attend
college--this body stood silent. Imagine if, instead of debating the
bills that created Social Security or Medicare, the Senate voices had
been stilled.
Imagine if, instead of debating whether to abolish slavery, instead
of debating whether giving women and minorities a right to vote, those
who disagreed had muted discussion and killed any vote.
I say to my Republican Senators, don't try to silence a great debate
over a great crisis. Don't let history show that when given the chance
to debate and defend your position and work with us for the good of our
constituents, you ran and hid. You cannot wish away a great emergency
by closing your eyes and pretending it doesn't exist.
There is an emergency that exists, and it exists now. The right
response to disagreement is not dismissal, it is discussion. Democracy
is discussion. Democracy needs deliberation. Let us debate our
differences. On some, we will find common ground; on others, we may
not. But let's at least tell America their legislators in the Senate
are willing to find where we can come together.
Nobel Prize awardee Andre Sakharov, one of the great thinkers of the
past century, knew that when opposing sides come together, some of
their ideas can outweigh its parts. Sakharov said:

Profound thoughts arise only in debate, with a possibility
of counter-argument. . . .

So come on, my friends, let us share our ideas in the Senate. Let us
legislate. Let us negotiate. Let us deliberate. Let us debate. Our
country cries for this debate. Our country deserves this debate. Our
country needs this debate.
I extend my great appreciation to the truly tireless men and women at
the Senate Finance Committee, Senate HELP Committee, Congressional
Budget Office, Senate Office of the Legislative Counsel, Joint
Committee on Taxation, the Department of Health and Human Services, the
Center for Medicare and Medicaid Services and the White House:

Congressional Budget Office

Doug Elmendorf, Director; Holly Harvey, Deputy Assistant
Director for Budget Analysis; Kate Massey, Unit Chief, Low-
Income Health Programs and Prescription Drugs Cost Estimates;
Tom Bradley, Unit Chief, Health Systems and Medicare Cost
Estimates; Phil Ellis, Unit Chief, Health Policy Analysis;
Jean Hearne, Lara Robillard, Lori Housman, Mindy Cohen,
Stephanie Cameron, and the rest of their staffs.

Senate Office of the Legislative Counsel

Jim Fransen, Bill Baird, Ruth Ernst, John Goetcheus, Kelly
Malone, Mark Mathieson, Mark McGunagle, Stacy Kern-Scheerer,
Allison Otto, and the rest of their staffs.

Joint Committee on Taxation

Thomas Barthold, Adam Block, John Bloyer, Tanya Butler, Jim
Cilke, Tom Dowd, Robert Harvey, Marjorie Hoffman, Melanie
Houser, Deirdre James, Rachel Levy, Julie Marshall, Pam
Moomau, John Navratil, Ned Newland, Mary Risler, Cecily Rock,
Bernard Schmitt, Chris Simmons, Carrie Simons, Lori Stuntz,
Kristeen Witt.

Department of Health and Human Services

Jeanne Lambrew, Meena Seshamani, Caya Lewis.

Center for Medicare and Medicaid Services

Erin Clapton, Ira Burney, Amy Hall, Maria Martino, Isabella
Leung, Anne Scott, Nancy DeLew, Sharon Arnold, Allison Orris,
Jennifer Snow, Jill Gotts, Chantelle Britton, Molly Long,
Adam Aten, Lisa Joldersma, Sylvia Yu, Laura McWright, Greg
Jones, Dan Miller, Ariel Novick, Rick Foster.
Program Experts in the following offices/centers (in
alphabetical order): Center for Drug and Health Plan Choices
(Tim Hill); Center for Medicare Management (Jon Blum, Liz
Richter); Center for Medicaid & State Operations (Cindy Mann,
Penny Thompson); Office of Clinical Standards & Quality
(Barry Straube); Office of E-Standards and Services

[[Page S11967]]

(Tony Trenkle); Office of Financial Management (Deborah
Taylor); Office of General Counsel (Janice Hoffman); Office
of Legislation; Office of Research, Development and
Information (Tim Love).

The White House

Nancy-Ann DeParle, Mike Hash.

I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The assistant legislative clerk proceeded to call the roll.
Mr. REID. Mr. President, I ask unanimous consent that the order for
the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. REID. Mr. President, I ask unanimous consent that Senators vote
tonight from their desks.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. REID. Mr. President, I ask consent that we start the vote 5
minutes early.
The PRESIDING OFFICER. Without objection, it is so ordered.
The PRESIDING OFFICER (Mr. Dodd). Under the previous order, the clerk
will report the motion to invoke cloture.
The assistant legislative clerk read as follows:

Cloture Motion

We, the undersigned Senators, in accordance with the
provisions of rule XXII of the Standing Rules of the Senate,
hereby move to bring to a close debate on the motion to
proceed to Calendar No. 175, H.R. 3590.
Harry Reid, Tom Harkin, Jack Reed, Edward E. Kaufman,
Jeff Merkley, Roland W. Burris, Daniel K. Akaka, Patty
Murray, Richard J. Durbin, Sherrod Brown, Michael F.
Bennet, Jeanne Shaheen, Sheldon Whitehouse, Bill
Nelson, Mark Udall, Benjamin L. Cardin, Christopher J.
Dodd, Patty Murray.

The PRESIDING OFFICER. By unanimous consent, the mandatory quorum
call is waived.
The question is, Is it the sense of the Senate that debate on the
motion to proceed to H.R. 3590, the Service Members Home Ownership Tax
Act of 2009, shall be brought to a close? The yeas and nays are
mandatory under the rule.
The clerk will call the roll.
The legislative clerk called the roll.
Mr. KYL. The following Senator is necessarily absent: the Senator
from Ohio (Mr. Voinovich).
The PRESIDING OFFICER. Are there any other Senators in the Chamber
desiring to vote?
The result was announced--yeas 60, nays 39, as follows:

[Rollcall Vote No. 353 Leg.]

YEAS--60

Akaka
Baucus
Bayh
Begich
Bennet
Bingaman
Boxer
Brown
Burris
Byrd
Cantwell
Cardin
Carper
Casey
Conrad
Dodd
Dorgan
Durbin
Feingold
Feinstein
Franken
Gillibrand
Hagan
Harkin
Inouye
Johnson
Kaufman
Kerry
Kirk
Klobuchar
Kohl
Landrieu
Lautenberg
Leahy
Levin
Lieberman
Lincoln
McCaskill
Menendez
Merkley
Mikulski
Murray
Nelson (NE)
Nelson (FL)
Pryor
Reed
Reid
Rockefeller
Sanders
Schumer
Shaheen
Specter
Stabenow
Tester
Udall (CO)
Udall (NM)
Warner
Webb
Whitehouse
Wyden

NAYS--39

Alexander
Barrasso
Bennett
Bond
Brownback
Bunning
Burr
Chambliss
Coburn
Cochran
Collins
Corker
Cornyn
Crapo
DeMint
Ensign
Enzi
Graham
Grassley
Gregg
Hatch
Hutchison
Inhofe
Isakson
Johanns
Kyl
LeMieux
Lugar
McCain
McConnell
Murkowski
Risch
Roberts
Sessions
Shelby
Snowe
Thune
Vitter
Wicker

NOT VOTING--1

Voinovich
The PRESIDING OFFICER. On this vote, the yeas are 60, the nays are
39. Three-fifths of the Senators duly chosen and sworn having voted in
the affirmative, the motion is agreed to.
(Disturbance in the galleries.)
The PRESIDING OFFICER. Expressions of approval are not allowed.
Under the previous order, all postcloture time is yielded back, and
the motion is agreed to.
The clerk will report the bill by title.
The assistant legislative clerk read as follows:

A bill (H.R. 3590) to amend the Internal Revenue Code of
1986 to modify the first-time home buyers credit in the case
of members of the Armed Forces and certain other Federal
employees, and for other purposes.

Amendment No. 2786

Mr. REID. Mr. President, I call up my amendment that is at the desk.
The PRESIDING OFFICER. The clerk will report the amendment by title.
The legislative clerk read as follows:

The Senator from Nevada [Mr. Reid], for himself, Mr.
Baucus, Mr. Dodd, and Mr. Harkin, proposes an amendment
numbered 2786.

Mr. REID. Mr. President, I ask unanimous consent that the reading of
the amendment be dispensed with.
The PRESIDING OFFICER. Without objection, it is so ordered.
(The amendment is printed in the Record of Thursday, November 19,
2009, under ``Text of Amendments.'')
Mr. McCONNELL. I ask for the yeas and nays.
The PRESIDING OFFICER. Is there a sufficient second?
There is a sufficient second.
The yeas and nays were ordered.
The PRESIDING OFFICER. The majority leader.

____________________