[Congressional Record Volume 155, Number 200 (Wednesday, December 23, 2009)]
[Senate]
[Pages S13796-S13866]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




             SERVICE MEMBERS HOME OWNERSHIP TAX ACT OF 2009

  The ACTING PRESIDENT pro tempore. Under the previous order, the 
Senate will resume consideration of H.R. 3590, which the clerk will 
report.
  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 homebuyers credit in the case 
     of members of the Armed Forces and certain other Federal 
     employees, and for other purposes.

  Pending:

       Reid amendment No. 2786, in the nature of a substitute.
       REID (for Cardin) amendment No. 2878 (to amendment No. 
     2786), to provide for the establishment of Offices of 
     Minority Health.
       Reid amendment No. 3292 (to amendment No. 2878), to change 
     the effective date.

  The ACTING PRESIDENT pro tempore. Under the previous order, the time 
until 10 a.m. will be equally divided between the two leaders.
  The Senator from Alabama is recognized.
  Mr. SESSIONS. Mr. President, I just received this morning--and I am 
sure it is on the CBO Web site, the Congressional Budget Office Web 
site--an analysis of the health care bill we are considering today. 
That analysis is crystal-clear and confirms what CMS has told us; that 
is, the proponents of the legislation before us have been double-
counting--double-counting--the savings from Medicare, and as a result, 
it cannot be said that this bill is going to create a surplus in the 
Treasury but, in fact, will put us in a deficit.
  I think every Member of this body needs to read this communication 
before they cast their vote. I know a lot of Members of the Senate who 
voted for the bill did so under the belief that it would be deficit 
neutral. They have said so publicly. The President has repeatedly 
stated--and he did to the Joint Session of Congress--that not one dime 
will be added to the national debt, and that is not so.
  I will reveal what we were told by CBO this morning in their report. 
This is what the CBO said to us, and it is very simple. It is actually 
stunning that we have been confused about this issue when we are 
talking about hundreds of billions of dollars. It is absolutely an 
amazing event that the U.S. Congress can't get its act together when we 
are talking about hundreds of billions of dollars.
  They say this:

       The key point is that the savings to the HI trust fund--

  Talking about Medicare--

     under the PPACA--

  That is the health care bill we are considering--

     would be received by the government only once, so they cannot 
     be set aside to pay for future Medicare spending and, at the 
     same time, pay for current spending on other parts of the 
     legislation or on other programs.

  That is exactly what this bill proposes to do.
  Just 2 days ago at this press conference, the President said:

       Medicare will be stronger and its solvency extended by 
     nearly a decade.

  Then he goes on to say this:

       The Congressional Budget Office now reports that this bill 
     will reduce our deficit by $132 billion over the first 
     decade.

  That is counting the money twice. It cannot be done. That is wrong, 
and it must not be allowed to occur.
  Senator Gregg, the former chairman of the Budget Committee and 
ranking Republican on that committee, proposed an amendment that said 
any savings in Medicare stay in Medicare, and our colleague who voted 
it down--Senator Harkin said: You have to vote it down--to our 
colleagues in his speech on the floor--you have to vote it down because 
it will kill the bill. Why would it kill the bill? Because they are 
planning to use the money both ways, and it cannot be done and ought 
not to be done.
  This is very much consistent, entirely consistent with the 
communication from the Chief Actuary, Richard S. Foster, of the Center 
for Medicare and Medicaid Services. Mr. Foster laid it out. We should 
have seen this back on December 10. It is really what piqued my 
interest in this whole matter because I was wondering how this could be 
done. It didn't make sense to me. And I read his letter, and he says 
this:

     The combination of lower Part A costs--

  And that is Part A of Medicare, the hospital part--

     and higher tax revenues results in a lower Federal deficit 
     based on budget accounting rules.

  He goes on to say:

       However, trust fund accounting considers the same lower 
     expenditures and additional revenues as extending the 
     exhaustion date of the Part A trust fund.

  They are running out of money, and if you cut the cost to Part A, you 
would extend, according to the trust fund accounting, the lifetime of 
the trust fund before it goes broke.
  He adds:

       In practice, the improved Part A financing cannot be 
     simultaneously used to finance other Federal outlays.

  Then he put in parentheses:

     such as the covered expansions under the PPACA--

  Which is the health care bill--

     and to extend the trust fund, despite the appearance of this 
     result from the respective accounting conventions.

  So there are two different accountings. The one from CMS says one 
thing. The one from CBO, which is a unified accounting, a different 
process of accounting for Federal expenditures--both say good 
things. But both can't be accurate. Both Members say, CBO says you 
can't count it twice, and CMS also says that.

  The ACTING PRESIDENT pro tempore. The Senator's time has expired.
  Mr. SESSIONS. I thank the Chair and urge my colleagues to access this 
information on the CBO Web site and mine if they would like.
  The ACTING PRESIDENT pro tempore. Under the previous order, the time 
until 2 p.m. will be controlled in alternating 1-hour blocks of time, 
with the majority controlling the first hour.
  The Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, it has been nearly 5 weeks since the 
majority

[[Page S13797]]

leader moved to proceed to the health care reform bill before us today. 
And it has been more than 2 months since the Finance Committee reported 
its bill, a great deal of which is reflected in the bill before us 
today.
  It has been 3 months since the Finance Committee publicly posted the 
564 amendments that Senators filed for consideration in the committee.
  It has been 7 months since the Finance Committee convened three 
bipartisan roundtable discussions on each of the three major areas of 
reform: delivery system reform, insurance coverage, and options for 
financing reform.
  It has been 7 months since the Finance Committee issued three 
bipartisan policy papers detailing the options from which the committee 
chose to craft its bill.
  It has been 18 months since the Finance Committee convened a 
bipartisan, day-long health care summit at the Library of Congress.
  It has been 19 months since the Finance Committee began holding open 
hearings to prepare for the bill before us today.
  It has been more than 15 long years since the last time that the 
Senate took on this fight to enact comprehensive health care reform.
  It has been 38 years since our late Colleague, Ted Kennedy, proposed 
a plan to extend health insurance coverage to all.
  It has been 44 years since Congress created Medicare, providing 
health care for America's seniors, and Medicaid, providing health care 
for the poorest among us.
  It has been 64 years since President Harry Truman asked the Congress 
to enact a national insurance program ``to assure the right to adequate 
medical care and protection from the economic fears of sickness.''
  It has been 97 years since President Theodore Roosevelt ran on a 
platform that called for ``the protection of home life against the 
hazards of sickness . . . through the adoption of a system of social 
insurance adapted to American use.''
  And it is now only hours until this Senate will pass meaningful 
health care reform.
  It will not be long now until the law will prohibit insurance 
companies from cancelling insurance policies when people get sick.
  It will not be long now until people with preexisting conditions will 
have access to health care.
  It will not be long now until the law will prohibit insurance 
companies from imposing lifetime or annual limits on benefits.
  It will not be long now until parents will be able to include their 
children up to age 26 on their insurance policies.
  It will not be long now until the law will require insurance 
companies to report on the share of premium dollars that goes to pay 
medical care, and the share that doesn't.
  It will not be long now until consumers will be able to shop for 
quality insurance in new Internet Web sites, where insurance companies 
will compete for their business.
  It will not be too long now until millions of uninsured Americans 
will be able to buy insurance on new exchanges with tax credits to help 
make it affordable.
  It will not be too long now until the law will prohibit insurance 
companies from discriminating against women in setting premiums.
  It will not be too long now until the law will limit insurance 
companies in how much more they can charge when people get older.
  It will not be too long now until more than 30 million Americans who 
otherwise would not have health care coverage will finally get that 
peace of mind.
  It will not be too long now until more than 30 million Americans will 
have a better chance to live longer, healthier, less pain-ridden lives.
  It will not be too long now until more than 30 million Americans will 
be able to share their family Christmas free of the fears of medical 
bankruptcy.
  Mr. President, it will not be long now. It has been a long time 
coming.
  I thank God that I have lived to see this day. I thank God for 
sustaining us and for enabling us to reach this time. Let us now, at 
long last, pass this historic legislation.
  Mr. President, I yield 20 minutes to the Senator from Maryland.
  The ACTING PRESIDENT pro tempore. The Senator from Maryland is 
recognized.
  Mr. CARDIN. Mr. President, first, it will not be long now until we 
achieve universal health care coverage affordable care for all 
Americans. I thank Senator Baucus for making this moment possible. I 
know how hard he has worked for so many weeks, so many months, so that 
we could bring very different views together but all focused on the 
goal of achieving affordable health care for every American.
  Senator Baucus never lost sight of that goal. As a result, we are now 
just hours away from the last procedural hurdle until we will have a 
chance in the Senate to vote on a bill that for the 23 years I have 
been in Congress I have told the people of the Third Congressional 
District and the people of Maryland that I am going to fight to change 
our health care system so that every American has access to affordable, 
quality health care.
  We are going to take a giant step forward to reaching that goal in 
the legislation we have before us today. Through the Chair, I thank 
Senator Baucus very much for his extraordinary patience and leadership 
to bring us to this moment.
  Mr. President, there is a lot of discussion on both sides as to what 
the facts of the bill are. I am going to use the CBO because that is 
what we agreed to. That is the objective scorekeeper. They are not 
partisan. Everybody agrees to that.
  The CBO tells us that for the under-65 group we are going to increase 
the number of insured from 83 percent to 94 percent. For all Americans, 
we are going to have 98 percent covered by health insurance. That is 
universal. We are going to have a framework so that at long last 
America joins every other industrialized nation in the world with a 
health care system where everyone is included.
  To me, this is a moral issue. It is an issue of whether health care 
is a privilege or a right. I believe the values of America teach us 
that health care should be a right for all Americans.
  The bill we will be voting on will take us very much in the direction 
of achieving that goal. Today in America too many people fall through 
the cracks. Too many families are literally destroyed because they 
cannot afford access to health care. Therefore, they don't get the 
tests they need, and perhaps a disease that could have been caught 
early or prevented is lost, and a person has to go through tremendous 
health care treatment; perhaps even losing their life.
  We have seen too many families go through bankruptcy because they 
cannot afford the health care they need. We see too many literally 
cutting their prescription pills in half in the hopes of being able to 
keep their medicine for a longer period of time because they cannot 
afford it, knowing full well they are compromising their health.
  I have mentioned the case of Deamonte Driver which, to me, is 
representative of so many tragedies in our community that could be 
avoided. Deamonte Driver, a 12-year-old in Prince George's County, MD, 
very close to here, had a tooth ache. His mom tried to get him to a 
dentist, but he had no insurance, and they couldn't find a dentist. 
They went to a social worker and made dozens of calls and still 
couldn't find a dentist. Deamonte was complaining of severe headaches. 
After weeks of not being able to get to a dentist, he went to the 
emergency room--the only option that was still available. They found 
out the tooth had become abscessed, which went into his brain. He had 
emergency surgery. He lost his life because our health care system 
didn't provide access to affordable, quality care for all Americans.
  Mr. President, that is about to change. I am proud to be a part of 
it. I have been asked by many in recent days as to what is in it for 
the people of Maryland. The people of Maryland are going to get a 
national health care system that makes a lot more sense, a rational 
system for care in America. With the current system, too many people 
are being left out. Small employers have a hard time finding affordable 
products.
  I have gotten many letters from constituents that I have read. I must 
tell you about the letter I received from a small business owner in 
Montgomery

[[Page S13798]]

County. She and her husband had to take out two separate policies to 
cover their family of four. The private insurance companies 
discriminated and said each has preexisting conditions, and the only 
way to have full coverage is to have two policies with two separate 
deductibles--which the family cannot afford--two separate premiums that 
the family cannot afford.
  There is not competition to provide coverage to small businesses in 
America. Small businesses in Maryland want to have the opportunity to 
cover their employees, and they know competition will work, and this 
bill provides for a lot more competition.
  This bill will help those who are losing coverage today. Many people 
in Maryland are losing their health care coverage every day. Hundreds 
lose their health insurance in my State every day. We live in the 
wealthiest Nation in the world, and Maryland is the wealthiest State, 
and we are still losing health coverage today.
  Our Medicare beneficiaries are finding their program under attack. 
They want to have the stability of knowing Medicare will be there not 
just this year but for decades to come. This bill starts to reform 
Medicare by reforming health care so we can sustain it and fill in the 
prescription drug doughnut hole under which so many seniors are finding 
it very difficult to afford their medicine.
  For the people of Maryland, this bill will provide a rational way in 
which they can maintain their existing coverage, find it more 
affordable, and certainly sustain coverage for our Medicare population 
and provide competition for small business owners to find affordable 
health care. It ought to bring down health care costs. Marylanders are 
very interested in that.
  Again, let me use the CBO, the objective scorekeeper. They say for 
the overwhelming majority of Americans, their health premiums will go 
down because health care costs are coming down. This legislation 
invests in prevention and wellness. We know prevention and wellness 
works. We know if you can detect a disease early, you cannot only save 
lives, but you can save health care costs because the preventive 
services only cost a couple hundred dollars, and an operation you can 
avoid is tens of thousands of dollars. Screening and early detection 
works. Management of diseases works.
  Most of our health care costs in America are spent on the leading 
diseases such as cardiac care and diabetes. We know we spend a lot of 
money, but we can manage those diseases more effectively, and this bill 
takes us down that path. We can save money by investing in health 
information technology. Think about that--about how much paper we 
receive every year from our health care system. Think about our own 
medical records and how that could be used to help us each manage our 
own health care and take more responsibility. We are not doing that 
today. We know that we can use a card to go anywhere in the world, and 
they can track our financial records. But for health care, that is not 
true today.
  By investing in health information technology, we can reduce a 
significant amount of administrative costs in health care and better 
manage each of our own health care needs. That is what this bill does.
  This bill will cover 31 million more Americans. That is not what I am 
saying as a Democratic Senator from Maryland; that is what the CBO is 
saying this bill will achieve--31 million more Americans that will not 
have to go to an emergency room to get their primary care needs met.
  Think about how much it costs each one of us when that person whose 
only option is to go to an emergency room, how much that costs us. You 
see, many of those individuals cannot afford those hospital charges, so 
it becomes uncompensated care. It is added to the rates at the hospital 
that you and I pay--those of us who have health insurance.
  The people in Maryland who have health insurance have a hidden tax of 
$1,100 every year. It is not only a waste of money that we have to pay, 
it is an efficient way to work the system. There should be facilities 
available so that everybody can get care in a much more cost-effective 
way. This bill moves us toward those goals. It provides competition so 
we can bring down the cost of health insurance through the local 
exchanges.
  Another provision in the bill that I am very excited about is that we 
can cross State lines for competition, so if you are an employer in 
Maryland and you hire workers in Maryland and Virginia and 
Pennsylvania, you are able to get the regional and national competition 
so you have more choice on the health insurance companies. That will 
also bring down costs but also increase quality, which is what we are 
trying to do.
  For Marylanders, this bill is important. This bill will help reduce 
the Federal deficit. How many of us have talked about that? I know that 
people who watch us say: Gee, I hear a Republican Senator and then a 
Democratic Senator; is this the same bill they are talking about?
  Let's talk about the Congressional Budget Office, the objective 
scorekeeper. The Congressional Budget Office says this bill will reduce 
the Federal deficit by $132 billion--billion, that is a B, billion. 
That is quite an accomplishment when you realize that to get everyone 
covered, the Federal Government is providing subsidies which will cost 
us some additional investments. To make sure small businesses can 
afford it, we provide tax credits. That costs revenues--people insured, 
they have tax preferences. Yet the Congressional Budget Office has 
confirmed that this bill brings down the deficit by $132 billion in the 
first 10 years.
  Let's look at the second 10 years because a lot of us want to look at 
the long-term impact. The Congressional Budget Office, the objective 
scorekeepers, tell us it will reduce the deficit by one-half of 1 
percent of the GDP or about $1.3 trillion. It is quite an 
accomplishment to get everybody covered and reduce the deficit and have 
that confirmed by the Congressional Budget Office. That helps the 
people of Maryland, and that is why the people of Maryland benefit from 
this bill, as do the citizens of every State in the Nation.
  I wish to talk about protecting consumers. Senator Baucus talked 
about this. I wish to make sure people understand what is involved. 
Senator Baucus mentioned a lot of the provisions that are in the bill 
about preexisting conditions and pediatrics for children take effect 
immediately, the caps we bring in, the lifetime caps we deal with 
covering children under the age of 26, the reinsurance program for 55- 
to 64-year-olds, the loss ratios that were added to the bill by the 
managers' amendment to make sure insurance companies are using your 
premium dollar to pay for benefits, the independent review of a 
decision made by an insurance company whether to cover a charge.
  But I wish to talk about the Patients' Bill of Rights because I think 
the people of this Nation would be surprised to find out we have not 
yet enacted the Patients' Bill of Rights.
  It was 1997 when we started talking about a Patients' Bill of Rights, 
about enacting it so we had national protection against the arbitrary 
practices of private insurance companies. In 1998, President Clinton, 
by Executive order, applied the Patients' Bill of Rights to the 
government insurance programs. But today there is still no protection 
against private insurance companies with a Patients' Bill of Rights.
  I am very pleased the managers' amendment has added four very 
important provisions I authored by an amendment, that I have been 
working with Democrats and Republicans over the last decade to get into 
Federal law.
  Access to emergency care--let me talk about that for a moment because 
today there are people who live in New Mexico and live in Montana and 
live in Maryland who go to their emergency rooms. They read the fine 
print of their insurance plan. It says: Before you go to an emergency 
room, you have to call for preauthorization or you need to go to the 
emergency room that is in network or we may second-guess whether you 
needed to go to that emergency room, if, in fact, your final diagnosis 
was you did not have an emergency need or condition. You may have 
sweating, the traditional chest pains, the traditional symptoms for a 
heart attack. You did exactly what a prudent layperson would do: get to 
that emergency room as quickly as possible. Then you find out it was 
not a heart attack. Today the insurance companies can second-guess your 
coverage.
  Thanks to the managers' amendment Senator Baucus helped us put 
together,

[[Page S13799]]

we now are going to cover access to emergency care as a requirement for 
every private insurance company. Prudent layperson standards, no 
preauthorizations, get to the closest emergency room as quickly as you 
can--those are important protections to get into Federal law.
  Then there is the ability to choose your primary care doctor. Your 
primary care doctor is the person you have to have confidence in. If 
you are a woman, if you want it to be OB/GYN, you should have that 
right. Many insurance companies deny you that today. If you are a 
parent and you want a pediatrician for your child, you should be able 
to have a pediatrician as a primary physician for your child. It is not 
guaranteed to today. Many insurance plans deny it. This will make sure 
it is in law.
  I am pleased, and I know the people of Maryland will be glad to know, 
at long last, we get the Patients' Bill of Rights protected.
  There are a lot of groups that supported this over the years. I wish 
to acknowledge the long list of people, the long list of groups, 
bipartisan groups, that have worked on this issue, from AARP to the 
Consumers Union to the NAACP to the SEIU, YMCA--the list goes on and on 
of groups that have supported the Patients' Bill of Rights against 
private insurance companies. At long last, we have the ability, with 
the passage of this bill on the Senate floor, to move it one step 
closer to passage and to be the law of the land.
  I wish to talk about minority health. The reasons I wish to talk 
about minority health are twofold. First, I know my colleagues are 
interested to know that the amendment that is currently pending that 
the leader filed, technically on my behalf, which establishes the 
minority health protections within the different Federal agencies--I 
wish to assure my colleagues that it is in the underlying bill. It is 
in the package. It is in the managers' package which has been adopted.
  I am going to suggest to the body that we withdraw the amendment 
because we do not need it to pass; it is already in the underlying 
bill. This was the original amendment I submitted. I wished to explain 
that because the amendment I filed to establish the Minority Health 
Office at the Department of Health and Human Services and also within 
NIH will be in the underlying bill because of the managers' package.
  This is an important moment because there are huge disparities in our 
health care delivery systems in America, bringing about huge 
disparities among different ethnic communities. The life expectancy of 
African Americans, for example, is 5.3 years lower than Whites. When we 
look at diabetes in America, the incidence of diabetes is two times 
greater among minorities than the general population. That means we 
need to have a strategy to deal with it. We need to know how can we 
reach out to minority communities to deal with their special needs. 
Unless you have a focus within the Department of Health and Human 
Services, unless you have a focus within NIH and the other agencies, 
you will not deal with it as effectively as we should. I, again, thank 
Senator Baucus, Senator Dodd, Senator Reid, and the rest who understood 
this and put it into the managers' package because we can then develop 
a national strategy to help deal with the issues of the minorities.
  I also will mention heart disease. African Americans have a 33-
percent higher death rate due to heart disease. The list goes on and 
on. That is why this bill codifies the Office of Minority Health in the 
Office of the Secretary of Health and Human Services, establishes 
individual Offices of Minority Health at the Centers for Disease 
Control and Prevention, Health Resources and Services Administration, 
Substance Abuse and Mental Health Services Administration, Agency for 
Health Care Research and Quality, Food and Drug Administration, the 
Centers for Medicare & Medicaid Services, and it elevates the current 
Center on Minority Health and Health Disparities at NIH into an 
institute. That is good news for this Nation in dealing with this 
issue.
  I, again, thank those who helped me get this into the managers' 
package--and it is now in the bill--that we will be taking up for a 
vote tomorrow.
  I also compliment Senator Sanders--I have done this before--on the 
community health centers. I mention that because as we deal with the 
disparities in health care in America, we deal with minority health 
care issues, yes, we have to get people health insurance, we have to 
get people the financial wherewithal to provide health care, but you 
also have to have the facilities in place if you are going to deal with 
health care needs. It is one thing to say we will cover the costs, it 
is another thing to say we will have the doctors available.

  I met with one of the leaders at Johns Hopkins University, which is 
located in the urban part of Baltimore city. He said: We need help. We 
need more community health centers. We need more primary care doctors. 
We need more nurses. We need help with more people seeking care through 
traditional channels rather than using emergency rooms. That is great 
news. With them being able to afford insurance, that is great news, but 
let us have the facilities.
  There are many underserved in Maryland and around the Nation who just 
need facilities. Thanks to the Sanders amendment, of which I am proud 
to be a cosponsor and worked with him, that is in this bill. We are 
going to see $10 billion to expand community health centers and 25 
million more Americans will be able to get access to care through our 
community health centers. That is good news and that will help and we 
invest in creating more primary care doctors, which is a very valuable 
part of this bill. I applaud all those.
  Let me point out this bill will help families in America. The choice 
is whether we pass this bill which sets up the framework for America to 
finally become a nation that provides universal coverage or we maintain 
the status quo. Let me tell you what happens if we maintain the status 
quo. These are the numbers. Right now, the average cost for a family 
for health insurance is $13,244. If we do not take action, by 2016--
that is not too many years away--it is going to be $24,291.
  The ACTING PRESIDENT pro tempore. The Senator has consumed the 20 
minutes he was yielded.
  Mr. CARDIN. May I have 2 more minutes, if that is possible?
  Mr. BAUCUS. I yield the Senator 2 more minutes.
  Mr. CARDIN. Mr. President, if people are going to be able to maintain 
their existing coverage, we have to act, and this bill will allow us to 
act. That is why the American Medical Association supports the bill. 
This bill will help our Medicare population because it strengthens 
Medicare, as I pointed out before. That is why the AARP supports it. We 
will be able to provide preventive services, such as annual physicals, 
for our seniors. This bill is important for small business owners who 
no longer will be discriminated against by paying 20 percent more than 
comparable large companies pay for the same type of insurance product.
  This bill is good for Marylanders. It is good for every American. It 
moves us toward universal coverage. The bill is not perfect. I am 
disappointed with some of the things in the bill and some of the things 
that did not make it into the bill. But this bill establishes the 
framework for universal, affordable, quality care for every American. 
It speaks to the values of our Nation.
  I am proud to support this legislation, and I know we will look back 
at this day as being one of the bright moments for America, where we 
said to the people of our Nation that, indeed, we will provide 
affordable, quality health care for every American.
  I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Montana is 
recognized.
  Mr. BAUCUS. I yield 15 minutes to the Senator from Delaware, Mr. 
Kaufman.
  The ACTING PRESIDENT pro tempore. The Senator from Delaware is 
recognized.
  Mr. KAUFMAN. Mr. President, I thank the manager not just for this but 
for the many things he has done to make this bill a possibility. It is 
truly historic, transformational. To a large degree, it is because of 
his hard work. I appreciate that.
  Also, I yield him 30 minutes of my postcloture time.
  The ACTING PRESIDENT pro tempore. The time will be so yielded.

[[Page S13800]]

  Mr. KAUFMAN. Mr. President, I rise, once again, to express my support 
for this historic health care legislation before us. After more than a 
year of debate and months and months of negotiations, I welcome the 
extraordinary opportunity finally to enact meaningful health care 
reform. Yes, I mean years and months, since this reform effort has been 
a long and deliberative process, not the rush job opponents of this 
effort have been claiming.
  I must admit, however, there were times during this debate when I was 
not sure if we were ever going to reach this point. In fact, I was 
convinced we were not. But I found in my life that when you think 
things are never going to happen, as with every important thing I have 
ever done, you reach a point when you say this is never going to 
happen, and this is another example. There are many times I never 
thought this would happen.
  From the bogus charge of death panels--which was just named 
politifact.com's ``Lie of the Year''--to the tension over whether the 
bill will contain a public option, which I supported, there were some 
long days where it was hard to see how we were going to get to the end 
point.
  But thanks to the hard work of the majority leader, as well as 
Senators Baucus, Dodd and Harkin and their staffs, we are finally here.
  As many of you know, I have worked in and around the Congress for 
more than 36 years. I have learned quite a bit about how things operate 
in the Senate.
  The Senate is commonly referred to as the most deliberative body in 
the world. But such deliberations are not always pretty. Sometimes 
tempers flare, sometimes debate does not reach the level we aspire to 
or the American people deserve. Sometimes the most important 
legislation actually fails to get the votes necessary to pass.
  We all know what happened to health care reform the last time we 
attempted a major overhaul 15 years ago when President Clinton tried to 
pass his version of health care reform. The debate was just as 
passionate with charges and countercharges on both sides of the aisle. 
Because of the coarseness of that debate, because of the seemingly 
intractable opposition to health care reform, Congress has been wary in 
the intervening 15 years to take up this cause again, and it is 
understandable.
  But over the past 15 years, our health care system has gotten more 
expensive. Rising medical costs, skyrocketing premiums, increasing 
numbers of the uninsured and the strain on both business and providers 
have brought the critical need for health reform back to the Senate 
this year.
  Make no mistake, we need health care reform now. The status quo--what 
I call the present health care system--is simply unsustainable.
  Medical costs account for one-sixth of domestic spending and are 
headed upward. In 1979, we spent approximately $220 billion as a nation 
on health care. In 1992, we spent close to $850 billion. In 2009, we 
will spend $2.5 trillion on health care. Listen to this: $220 billion 
in 1979, $850 billion in 1992, and $2.5 trillion in 2009. How can 
anyone argue it is not time to deal with health care reform and that 
the need is urgent? The trajectory of our national health care 
expenditures is out of control.
  In addition, one of the biggest--if not the biggest--forces behind 
our Federal deficit, which we hear so much about on this floor, are the 
skyrocketing costs of Medicare and Medicaid. In 1996, Medicare and 
Medicaid accounted for only 1 percent of all government expenditures; 
they now account for 20 percent. If we do nothing to start bending the 
cost curve down for Medicare and Medicaid, we will eventually spend 
more on these two programs than on all other Federal programs combined. 
We must slow the level of growth in the Medicare and Medicaid Programs 
if we are to ever get our budget situation under control.
  In addition to the fiscal pressures crushing our Federal and State 
governments, the present health care system is also crushing families 
and workers. Just look at the rise in the insurance premiums in my home 
State of Delaware. In 2000, the average premium for family health 
coverage was just over $7,500. That is $7,500. By 2008, the number had 
jumped to $14,900--that is $14,900--almost doubling in just 8 years. If 
we fail to enact the pending health care reform legislation, the same 
premium for family coverage is expected in Delaware to reach $29,000 in 
2016.
  Let me repeat that: $29,000 for family coverage in Delaware in 2016 
if we don't pass health care reform now.
  States around the country will see similar increases, which are 
simply unaffordable. Too many people are going bankrupt paying for 
their medical care. Today, the inability to pay for skyrocketing 
medical bills accounts for more than 60 percent of U.S. personal 
bankruptcies, a rate of 1\1/2\ times what it was just 6 years ago. Keep 
this in mind: More than 75 percent of families entering bankruptcy due 
to health care costs actually have health insurance.
  Let me repeat this because it is a critical point: Three-quarters of 
all Americans filing for bankruptcy because of medical bills already 
have insurance. We also need reform to stop the worst abuses in the 
health insurance industry. In my year as serving as the Senator from 
Delaware, I have heard from far too many constituents who have been 
refused an insurance policy because they have a preexisting condition.
  I have heard from fathers who were denied family insurance coverage 
because they were told their children had preexisting conditions too 
expensive to cover. Much to my shock--and I have talked about this on 
the Senate floor--I have received letters from women who have been 
turned down for coverage because their pregnancy was considered a 
preexisting condition. Pregnancy a preexisting condition? That is 
simply intolerable. Even worse, however--if that is possible--is the 
practice of rescission, where insurance companies drop coverage for 
individuals the moment they get sick and need their insurance the most. 
Being denied coverage after you have already paid your premiums is just 
plain cruel.
  For all those reasons and more, we must reform the present health 
care system. Thankfully, we now have the opportunity to bring about 
meaningful health care reform through the Patient Protection and 
Affordable Care Act, and I would like to take just a couple more 
minutes to discuss why this legislation has earned my support.
  First off, it is fiscally responsible. President Obama laid down a 
marker that any health care reform legislation that landed on his desk 
could not add to our Nation's debt. I am happy to say this legislation 
passes this test.
  According to the Congressional Budget Office, the Patient Protection 
and Affordable Care Act will reduce the deficit by $132 billion over 
the first 10 years. This bill is fully paid for.
  Second, the bill helps stabilize Medicare and Medicare Programs. In 
the absence of this legislation, the Medicare trust fund is expected to 
go bankrupt in 2017. According to the head actuary at the Centers for 
Medicare and Medicaid Services, passing this bill would extend the 
solvency of the trust fund for an additional 9 years--9 years. Medicare 
is a sacred trust with Americans, and this bill ensures this trust is 
preserved.
  In addition to reducing the deficit and shoring up the Medicare 
Program, this bill contains numerous provisions that will help 
Americans afford their premiums and prevent them from filing for 
bankruptcy protection. Starting next year, insurers will no longer be 
able to place lifetime caps on health care benefits. For the next 
several years, insurers will also be restricted in the annual limits 
they can place on benefits, and then these will be eliminated 
altogether in 2014.
  These are huge changes for people with debilitating diseases and 
those who experience unexpected catastrophic events costing millions of 
dollars in treatment.
  In addition, premium subsidies for families with incomes under 400 
percent of the poverty level--or $88,000 for a family of four--will be 
available to help them afford their premiums once the new insurance 
exchange is up and running. There will also be annual limits on out-of-
pocket costs for individuals, and dependents will be able to be covered 
under their parents' insurance policies until the age of 26.
  All of these are meaningful reforms that will dramatically lower the 
rate of bankruptcies associated with medical costs.

[[Page S13801]]

  The bill also contains some other great consumer protections that 
don't currently exist in our present health care system. I have already 
highlighted the problems in the current system with insurers denying 
coverage for people with preexisting conditions and rescinding coverage 
when people get sick. Under this bill, Americans will finally be freed 
from the shackles of preexisting clauses that have kept so many from 
obtaining much needed health insurance.
  Starting next year, insurers will no longer be able to deny coverage 
to children with preexisting medical conditions. This ban on not 
covering preexisting conditions will be extended to all Americans in 
2014.
  The bill also forbids insurers from rescinding health insurance after 
Americans have already paid their premiums. Americans will no longer 
lose their coverage when they get sick and need it most.
  In addition, the bill dramatically expands coverage of prevention and 
wellness services. It provides incentives for employers to implement 
wellness programs and offers a new annual wellness checkup for seniors 
enrolled in Medicare.
  These are all good, positive reforms to our health care system.
  Now that we are close to finishing this debate, the media has focused 
its attention on particular deals that benefit certain Senators and 
specific States, but I want to point out that all the benefits I have 
talked about--all of them--are available to every American in every 
State.
  Most every Senator has brought something to this debate and to this 
bill. I am very pleased that the managers' package includes the health 
care fraud enforcement amendment, which I introduced, along with 
Senators Leahy, Specter, Klobuchar, and Schumer as cosponsors. Again, 
this benefits all Americans not just Delawareans.
  The National Health Care Anti-Fraud Association conservatively 
estimates that 3 percent of all health care spending--some $72 
billion--is lost to health care fraud in both public and private health 
care plans. That is $72 billion lost in health care fraud in both 
public and private health care plans. Other estimates place the figure 
as high as 10 percent over $220 billion.
  Fraud hits every one of us in every corner of our Nation where we can 
least afford it--our health care premiums--while simultaneously driving 
down the quality of, and our trust in, the health care system. This 
amendment increases funding for fighting fraud in public programs.

  It improves screening of providers and suppliers and requires 
implementation of meaningful compliance programs. This section tightens 
requirements for claims submissions and provides new tools to deter 
fraud and abuse in the private insurance market.
  It also strengthens criminal investigations and prosecution. Today, 
outdated laws and punishments insufficient to provide effective 
deterrence hamper prosecutors and agents. This may seem incredible, but 
many criminals have told law enforcement officers that they switched to 
health care fraud from the drug trade because the reward-to-risk ratio 
is so much higher. Can you imagine that? There is actually an incentive 
for crooks in the present health care system to commit health care 
fraud.
  This antifraud amendment can begin to reverse this trend. 
Significantly reducing costs attributable to fraud will go a long way 
toward bending the cost curve down. What this bill does is it increases 
the sentencing requirements for people who commit health care fraud to 
make it much less attractive for them to get into the health care fraud 
business. It gives us the prosecutors and the agents we need--just like 
we did in the financial regulatory reform--to go after these folks and 
catch them, then put them in jail. With these new sentencing 
guidelines, we can put them there for a longer time, discouraging 
people from getting into the health care fraud business to begin with.
  In addition, the package of amendments I cosponsored with my fellow 
freshman Democrats will also improve the bill and benefit all 
Americans.
  I am lucky to be a member of a dynamic freshman class, including the 
Presiding Officer, and I have enjoyed teaming up with them in our 
morning speeches and colloquies to push the health care reform effort 
forward. I am pleased that our amendment package was accepted by the 
bill's managers and that it provides commonsense, practical solutions 
that help further contain costs, improve value, and increase quality.
  For example, it quickens the implementation of uniform administrative 
standards, allowing for more efficient exchange of information among 
patients, doctors, and insurers. It provides more flexibility in 
establishing accountable care organizations that realign financial 
incentives and help ensure that Americans receive high-quality care. It 
provides greater incentives to insurers in the exchange to reduce 
health care disparities affecting underserved minority communities.
  For all the reasons listed above, from the original text to the 
additions added to the managers' package, this bill should and must be 
passed. It brings quality, affordable health care within the reach of 
all Americans, including more than 30 million Americans who are 
currently uninsured. It strengthens the Medicare Program, extending its 
insolvency for 9 years. It helps restore fiscal order by reducing the 
deficit by approximately $132 billion over 10 years and more than $1 
trillion over 20 years. It offers much needed consumer protections that 
provide stable coverage at an affordable cost.
  In closing, I again want to acknowledge the hard work of Senators 
Baucus, Reid, Dodd, Harkin, as well as their staffs--especially their 
staffs--because the staff has done incredible work on this piece of 
legislation. They have enabled us to reach this historic legislative 
moment.
  I have ended many speeches by noting that it is time to gather our 
collective will and do the right thing to join this historic 
opportunity by passing health care reform. I think we may have finally 
reached that goal. We certainly can't afford to wait any longer. We 
need to act now. We can do no less. The American people deserve no 
less.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER (Mr. Kirk). The Senator from Montana is 
recognized.
  Mr. BAUCUS. Mr. President, I yield the remainder of the time we have 
in our hour to the Senator from North Dakota, Mr. Conrad.
  Mr. CONRAD. Mr. President, I rise this morning not to talk about 
health care but to talk about the other critical matter that faces this 
body before we leave this session for the holidays and that is the 
matter of extending the debt limit of the United States. Let me start 
by saying it is imperative that we extend the debt limit. If we do not, 
the United States would default on its debt. The consequences for this 
country and the global economy would be nothing short of catastrophic.
  If you think about the problems created in world markets by the fact 
that Dubai defaulted on $40 billion of debt, think of what it would 
mean to global markets if the United States were to default on $12 
trillion of debt.
  For those who say this is Obama's fault--no. This is not Obama's 
fault. He has been in office 11 months. I remind everyone that he 
walked into the biggest mess in 70 years--deficits and debt exploding, 
joblessness skyrocketing, economic growth plummeting. All that was 
happening before Barack Obama became President of the United States. He 
did not create the economic mess, he inherited it. He did not create 
the fiscal mess, he inherited it. Those are things he had to take on as 
the new President.
  There were record deficits and a doubling of the national debt, there 
was the worst recession since the Great Depression, financial market 
and housing crises, ongoing wars in Iraq and Afghanistan, and an 
unsustainable long-term budget outlook with everything going in the 
wrong direction.
  This is what was happening to deficits before President Obama took 
office. The deficits were skyrocketing. In fact, we have never held 
Presidents responsible for the fiscal affairs during the first year of 
their term of office because everybody here knows they inherit a budget 
from the previous President for the first year. That is not Barack 
Obama's responsibility, that is the responsibility of the previous 
administration.
  For those who say President Obama made things worse--no, he didn't 
make

[[Page S13802]]

things worse, he made things better. Yes, he added short term to the 
deficit, about $300 billion in 2009 because of the economic recovery 
package, but I remind people the difference the economic recovery 
package has made. We have gone from private-sector job losses of 
749,000 jobs a month when he came in--this is January of 2009, the 
month he came in. Job losses had mounted to 749,000 jobs a month. Look 
at the trend. Because of the recovery package and other measures that 
were put in place, the changes in private nonfarm payrolls have 
improved dramatically, from losses of over 700,000 a month in January 
to losses of 18,000 last month. We now believe that, in the first 
quarter of next year, those job losses will have become job gains.
  The same thing happened on economic growth. Economic growth was 
sharply negative when President Obama came into office. In the last 
quarter, we now know the economy actually grew at a rate of 2.2 
percent. That is a dramatic change. The fact is President Obama made 
things better. He inherited a disaster and he went to work to get 
America back on track.
  Let's look for a moment at the debt. This is what happened under the 
previous administration. The gross debt of the United States 
skyrocketed, more than doubling under the previous administration. So 
this is what the current President inherited. He did not create it. He 
wasn't the architect of it. He didn't produce these deficits and debt. 
He inherited them.
  It is true we are still on a course for long-term debt that is 
unsustainable. This was the cover of Newsweek on December 7, Pearl 
Harbor day. The Newsweek cover said this: ``How great powers fall; 
steep debt, slow growth, and high spending kill empires--and America 
could be next.''
  When you went inside to the story, it said this:

       This is how empires decline. It begins with a debt 
     explosion. It ends with an inexorable reduction in the 
     resources available for the Army, Navy, and the Air Force . . 
     . If the United States doesn't come up soon with a credible 
     plan to restore the Federal budget to balance over the next 5 
     to 10 years, the danger is very real that a debt crisis could 
     lead to a major weakening of American power.

  I don't know what could be more clear than that. Here is what has 
happened since 2001. Again, most of this is on the shoulders, the 
responsibility of the previous administration, because the debt 
absolutely skyrocketed under their watch. But it is continuing to grow 
and we must face up to that.
  What is even more alarming is the longer term outlook. On the trend 
we are on, the debt, which will reach over 100 percent of the gross 
domestic product by 2019, is projected to hit 400 percent of gross 
domestic product by 2050. That is the trendline we are on. That is the 
trendline we have been on since 2001, a trendline of massively growing 
debt. The question is, can we face up to it? Do we have the strength, 
do we have the will to take on the burgeoning debt?
  This is what the National Journal wrote on November 7 of this year:

       The debt problem is worse than you think. Simply put, even 
     alarmists may be underestimating the size of the (debt) 
     problem, how quickly it will become unbearable and how poorly 
     prepared our political system is to deal with it.

  The reality we confront tomorrow morning is whether we will extend 
the debt limit of the United States. We have no choice. If we fail to 
pay the debts we have already accrued, the United States and other 
markets around the world would collapse. That is just the fact. We 
cannot permit that to happen.
  How we got to this point is very clear to me. The previous 
administration put forward a fiscal policy that doubled the debt of the 
United States and put us on track to continue doubling it every 8 
years. The current administration has taken action to get the economy 
moving and growing again. Had they not taken those steps, which add to 
the deficit in the short term, the long-term debt outlook would be even 
worse. That does not take away from the fact that we have to deal with 
the reality that confronts us now. That reality is we are on a 
trendline that is absolutely unsustainable.
  To those who say if you deal with the debt, you are going to have to 
do something about Social Security and Medicare and revenue--I say yes. 
That is true. We are going to have to do something about all of those. 
To those who say dealing with the debt means facing up to the hard 
reality that confronts this country and the fact that we are on a 
course that is unsustainable--I say yes. That is true. We are going to 
have to make changes in the entitlement programs. We are going to have 
to make changes in the revenue system.
  When I say that, I don't mean by that the first thing we do is raise 
taxes. The first thing we ought to do is collect the taxes that are 
already owed but are not being paid because of these offshore tax 
havens and abusive tax shelters and all the rest. We can get more 
revenue. We do not need to raise taxes to get more revenue. We need to 
collect the revenue that is currently owed and we need to get it from 
the people who are cheating all the rest of us by engaging in these tax 
schemes--offshore tax havens, abusive tax shelters. We even have 
companies now that are leasing sewer systems, buying them from European 
cities in order to depreciate them on the books in the United States to 
reduce their taxes here, then leasing those same sewer systems back to 
the European cities that built them in the first place. That is 
happening right now.
  If you doubt we are losing money to offshore tax havens, Google 
``offshore tax havens'' and see how many hits you get. You get over a 
million. Those sites describe a life of luxury, living offshore, tax 
free, on income received in this country, income on which taxes are 
owed in this country but not paid. That is the kind of thing that has 
to be stopped.
  Mr. President, how much time do I have remaining?
  The PRESIDING OFFICER. The Senator has 5\1/2\ minutes.
  Mr. CONRAD. Let me talk for a minute about what Senator Gregg and I 
have proposed: a bipartisan task force to deal with this long-term debt 
threat. Our proposal has 35 cosponsors now. The idea is to give a group 
of our colleagues and members of the administration the responsibility 
to come up with a plan to reduce the deficits and debt. If a plan 
enjoyed a supermajority among the group of 18 who would be given the 
responsibility to come up with such a plan--if 14 of the 18 could agree 
on a plan--it would have to come here for a vote. It would come here 
for a vote. Every Senator would retain their rights to vote up or down. 
Every Senator would retain their rights. And it would require 60 votes 
in the Senate to pass, it would require 60 percent of the House to pass 
and the President would be able to veto it if he didn't like it.

  I think it is clear that we have a real challenge facing our country 
and it is going to take some special process to deal with it. What we 
have outlined would put everything on the table with 18 Members, 10 
Democrats, 2 from the administration, and 8 Republicans. All task force 
Members would need to be currently serving in Congress or the 
administration. If 14 of the 18 could agree, that report would have to 
come to the Congress for a vote. The report would be submitted after 
the 2010 election and there would be fast-track consideration in the 
Senate and the House. There would be a final vote before the 111th 
Congress adjourned.
  To those who say that is going to shred Social Security and 
Medicare--I say no. What threatens Social Security and Medicare is our 
doing nothing. Both of those programs are already cash negative. The 
trustees of Medicare tell us the program will be insolvent by 2017 if 
we do nothing. The answer can not be to do nothing. I believe this is a 
challenge that requires us to come together now, Republicans and 
Democrats, House, Senate, the administration, as we came together to 
deal with fiscal crises in the past. The Social Security Commission in 
the 1980s, the Andrews Air Force Base Summit in the 1990s--those were 
special procedures to deal with a special challenge and that is what is 
required now. We are on a course that is absolutely and utterly 
unsustainable.
  Let me go back to the vote tomorrow, because a group of us have said 
we are not going to vote for any long-term extension of the debt 
without consideration of a special process to deal with the debt, but 
we are also prepared to extend the debt on a short-term basis. That is 
absolutely essential. That is

[[Page S13803]]

the responsible thing to do. A failure to extend the debt tomorrow 
would send a message to markets around the globe that the United States 
is not going to pay its debt. The United States cannot renege on its 
commitment to pay the $12 trillion of debt that has already been run 
up. Those are not future debts but debts that have already been 
incurred. Those are debts that are due now and will be due in the weeks 
to come.
  The United States has never defaulted on its debt and it never can 
without grave consequences to our economy and to the world economy.
  Let me say again as clearly as I can: for those who want to blame 
President Obama, that won't wash. He has been in office only 11 months. 
He walked into the biggest mess in over 70 years--deficits and debt 
exploding, job losses skyrocketing, economic growth plummeting. 
President Obama didn't create that economic mess, he inherited it. He 
did not create the fiscal mess, he inherited it.
  Tomorrow will be a key vote for this country. Those of us who are 
concerned about the growing debt and are willing to take it on must 
also be responsible about making certain that the United States does 
not default on its already accrued debts. To do otherwise would be 
disastrous for this country.
  How much time do I have remaining?
  The PRESIDING OFFICER. The Senator has 10 seconds.
  Mr. CONRAD. Perfect. Merry Christmas.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Tennessee.
  Mr. CORKER. Mr. President, I would inquire how much time is allotted 
to me?
  The PRESIDING OFFICER. The minority has 60 minutes.
  Mr. CORKER. I have 10 minutes. I wonder if the Presiding Officer 
might let me know when I have 2 minutes remaining.
  The PRESIDING OFFICER. The Chair will do so.
  Mr. CORKER. I thank the Chair.
  Mr. President, I have watched this body over the last period we have 
been discussing health care. The body itself, the integrity of this 
body has been challenged. I have watched as individuals have challenged 
each other's integrity as it relates to this bill. I choose not to do 
that today.
  I wish to say, as I do constantly in my State, that I consider it a 
privilege to wake up each day and come to work in this body. Obviously, 
things don't always go as one might expect, but I do consider it a 
privilege. I thank the folks back home for allowing me to serve and to 
deal with these important issues.
  I don't think I will ever quite understand why this bill was put 
together the way it was. I certainly understand there are differences 
of opinion and differences of interest, but I don't think I will ever 
understand why Medicare moneys, from an insolvent program, were used to 
fund a new entitlement.
  CBO has come out this morning clearly stating what we have been 
saying for over 6 months. The fact is, taking Medicare savings and 
using them to create another entitlement does not work. It takes away 
from the solvency of Medicare itself. It is kind of late, but I am glad 
CBO has actually come out and said today, finally, after months of 
debate, what we have been saying from day one, that you could not take 
Medicare savings and use them to create a new entitlement without 
challenging the solvency of Medicare itself.
  I will never understand why that building block, a flawed building 
block, was used to create this bill. Everybody knows it was that use of 
inappropriate funding that began this whole partisan divide. My guess 
is, we might have ended up with a bill that would stand the test of 
time had we not utilized that basic flawed building block in the bill.
  There has been one, though, that I have found equally problematic; 
that is, the whole issue of creating an unfunded mandate for the State 
of Tennessee and for States across the country. The challenge to 
people's personal integrity has been centered more around this issue 
than anything else, as various Senators trying to protect their States 
from an unfunded mandate have been challenged in that regard.
  Many people who serve in this body used to be mayors, they used to be 
Governors, people who had to deal with budgets in their own States. 
Years ago, in a bipartisan effort, a bill was passed to ensure that we 
in Washington didn't pass laws that increased costs for cities. I was a 
mayor of a city. I was commissioner of finance for a State. In those 
capacities, there was nothing that was more offensive than for the 
Federal Government to pass a law and send down a mandate to a city or a 
State that costs money and yet not send the money that went with it. 
There was nothing more infuriating. We had to actually balance our 
budgets. We didn't have the ability to borrow money from overseas and 
to continue to operate in the red.
  Back in 1995, a law was passed called the Unfunded Mandates Reform 
Act. It was done to do away with the arrogance that existed up until 
that time--and unfortunately, continues to exist--where the Federal 
Government would create laws that would increase costs on cities and 
States. It was passed in a bipartisan way. As a matter of fact, 15 
Members from the other side of the aisle supported this law, voted for 
this law, and put this law in place. Many of the people who made this 
bill, created this bill participated. The chairman of the Finance 
Committee voted for this law. The majority leader voted for this law. 
The distinguished chairman of the Budget Committee voted for this law. 
The chairman of the HELP Committee who drafted a big part of this bill 
voted for this law. What this law said was that we could not pass 
legislation out of this body, out of Congress, that placed an unfunded 
mandate on States, on cities, and caused them to have to do things that 
raised expenses by laws we created without sending the money 
themselves.
  Our Governor of Tennessee is a Democrat. He is on the other side of 
the aisle. We have worked closely on a number of economic development 
issues. I have talked with him all the way through this process. He 
actually had hoped to work with this administration on health care and 
on health care legislation. He has been involved in health care all of 
his life. He has managed our State well. He has dealt with many 
challenging health care issues. Much has been documented about the 
travails our State has had as it relates to Medicaid and our desire to 
try to fix that. He has called this bill, which appears to be ready to 
pass this body, the mother of unfunded mandates. He has talked about 
the more than $750 million in cost this bill is going to cause the 
State of Tennessee to deal with at a time when they are hoping their 
State's revenues will be at 2008 levels by the year 2014.
  Again, I will never understand why we have raided an insolvent 
entitlement to create a new entitlement, weakening Medicare. I will 
never understand why we have done that to create this bill. I will 
never understand why this body chose to create such a large unfunded 
mandate for States through the provisions we have put in place as it 
relates to Medicaid, telling States they have to raise the levels at 
which they insure citizens across their State to 133 percent of federal 
poverty.
  There is no question this bill violates the law put in place in 1995.
  The PRESIDING OFFICER. The Senator has 2 minutes remaining.
  Mr. CORKER. I thank the Chair.
  I talked about the fact that it is a privilege to serve in this body. 
Generally speaking, people try to live up to the standards this body 
has set for all of us and that citizens across the country expect us to 
live up to. For that reason, I am going to raise a budget point of 
order. There is no question, per what CBO has said, the fact that this 
bill is going to cause cities and States to pay more for the health 
insurance of their employees--CBO has stated that clearly. There is no 
question this bill is going to cause States to have to utilize dollars 
that otherwise might be used for education or public safety.
  I raise a point of order. Section 425(a)(2) of the Congressional 
Budget Act of 1974 makes it out of order to consider any legislation 
that contains an unfunded intergovernmental mandate in excess of the 
statutory limit unless the bill provides new direct spending authority 
or includes an authorization for appropriations in an amount equal to 
or exceeding the direct cost of such mandate in the Senate.

[[Page S13804]]

  The pending bill includes an unfunded intergovernmental mandate in 
excess of the annual statutory limit of $69 million within the next 5 
years. Therefore, I raise a point of order against the substitute 
amendment pursuant to section 425(a)(2) of the Congressional Budget Act 
of 1974.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I move to waive the point of order for 
consideration of the pending legislation and ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be.
  The yeas and nays are ordered.
  The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, I ask my friend from Montana, Senator 
Baucus, to be alert because I want to raise a similar request to set 
aside. But before I do that, I want to explain why I am doing this. I 
worked for 6 years to pass the Congressional Accountability Act, which 
was signed into law by President Clinton in 1995. I worked so hard 
because I strongly believed there should only be one set of laws in 
this country.
  Prior to 1995, there were two sets of laws--one for Capitol Hill and 
one for the rest of the country because Congress exempted itself. That 
is why, following on that practice of 1995, I offered an amendment 
during the Finance Committee markup to require that Members of Congress 
and congressional staff get their employer-based health insurance 
through the same exchanges as our constituents. That is something for 
which I also heard complaints from the grassroots of Iowa during my 
town meetings. I did offer that amendment, and it was adopted without 
objection.
  But then after careful consideration and examination of the bill 
Senator Reid put together--and this was done by the Congressional 
Research Service--it was revealed that my amendment was changed under 
this closed-door merger process. Something cute happened. Under the 
bill we now have before us, this requirement would not apply to staff 
for committees of the Congress or leadership offices, it would apply to 
Members and their personal staff but not leadership. That is a real 
cute thing, to give exemptions for some people on Capitol Hill but not 
for others.
  I ask unanimous consent to have printed in the Record an analysis 
from the Congressional Research Service.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                               Congressional Research Service,

                                     Washington, DC, Dec. 2, 2009.


                               MEMORANDUM

     To: Senate Finance Committee. Attention: Andrew McKechnie.
     From: Ida Brudnick, Analyst on the Congress, Government and 
         Finance Division; Todd B. Tatelman, Legislative Attorney, 
         American Law Division.
     Subject: Potential Statutory Interpretation of 
         1312(d)(2)(D)(ii)(II) of H.R. 3590, The Patient 
         Protection and Affordable Care Act.
       This memorandum responds to your request for a review and 
     potential statutory interpretation of 1312(d)(2)(D)(ii)(II) 
     of H.R. 3590, The Patient Protection and Affordable Care 
     Act.\1\ Specifically, you have asked whether the definition 
     of the term ``congressional staff'' could be interpreted to 
     exclude committee staff, leadership staff, or other employees 
     of the Congress. The definition used by the bill covers ``all 
     full-time and part-time employees employed by the official 
     office of a Member of Congress, whether in Washington, DC or 
     outside of Washington, DC.'' \2\ In addition, you have asked 
     CRS to review the language used by S. 1796, America's Healthy 
     Future Act of 2009, which was reported from the Senate 
     Finance Committee.\3\ S. 1796 used the term ``congressional 
     employee,'' which it defined as ``an employee whose pay is 
     disbursed by the Secretary of the Senate or the Clerk of the 
     House of Representatives.'' \4\ Finally, you have requested 
     that CRS examine what, if any, other Legislative Branch 
     employees might be covered should language similar to that in 
     S. 1796 ultimately be adopted.
       Based on our review of the financial practices of the 
     Congress with respect to payment of employees, the bill 
     language, and applicable canons of statutory construction, it 
     appears possible to argue that the definition of 
     ``congressional staff' used by 1312(d)(2)(D)(ii)(II) excludes 
     any staff not directly affiliated with a Member's individual 
     or personal office. Should this interpretation be adopted by 
     an implementing body or a court, it would appear that it 
     would exclude professional committee staff, joint committee 
     staff, some shared staff, as well as potentially those staff 
     employed by leadership offices including, but not limited to, 
     the Speaker of the House, Majority Leader of the Senate, 
     Minority Leader of the House, Minority Leader of the Senate, 
     as well as the Whip offices in both the House and Senate. 
     Moreover, this interpretation would arguably exclude other 
     congressional employees, for example, those employed by 
     the Office of the House Clerk, House Parliamentarian, 
     House Historian, Secretary of the Senate, Senate Legal 
     Counsel, House and Senate Legislative Counsel offices.


               Legislative Branch Appropriations Accounts

       The legislative branch appropriations acts funds the: 
     Senate; House of Representatives; Joint Items; \5\ Capitol 
     Police; Office of Compliance; Congressional Budget Office; 
     Architect of the Capitol, including the Capitol Visitor 
     Center; Library of Congress, including the Congressional 
     Research Service; Government Printing Office; Government 
     Accountability Office; and Open World Leadership Program.
       Both the House and Senate portions of the annual 
     legislative branch appropriations bills contain one line item 
     that provides for salaries and expenses within Member 
     offices. The House and Senate sections contain additional 
     line items for employees of leadership offices, committees, 
     and officers.
       In the Senate, the Senators' Official Personnel and Office 
     Expense Account provides each Senator with funds to 
     administer a personal office. It consists of an 
     administrative and clerical assistance allowance, a 
     legislative assistance allowance, and an official office 
     expense allowance. The funds may be interchanged by the 
     Senator, subject to limitations on official mail. The FY2010 
     legislative branch appropriations act provided $422 million.
       The Senate portion of the bill includes the following 
     additional headings: Expense Allowances and Representation; 
     Salaries, Officers, and Employees; Office of Legislative 
     Counsel; Office of Legal Counsel; Expense Allowances for 
     Secretary of Senate, Sergeant at Arms and Doorkeeper of the 
     Senate, and Secretaries for the Majority and Minority of the 
     Senate; and Contingent Expenses. The ``Contingent Expenses'' 
     account includes funding for Inquiries and Investigations; 
     Expenses of the United States Senate Caucus on International 
     Narcotics Control; Secretary of the Senate; Sergeant at Arms 
     and Doorkeeper of the Senate; Miscellaneous Items; and, 
     Official Mail Costs.
       Staff in personal offices in the House of Representatives 
     are paid through funding provided for Members' 
     Representational Allowances (MRA). The MRA, which was 
     preceded by multiple allowances for each Member covering 
     different categories of spending, was first established in 
     1996.\6\ The FY2010 legislative branch appropriations act 
     provided $660.0 million for MRAs.
       The House ``Salaries and Expenses'' account provides 
     funding under the following additional headings: House 
     Leadership Offices; Committee Employees; Salaries, Officers 
     And Employees; And Allowances And Expenses. Many of these 
     categories include multiple line items. In FY2010, the 
     ``House Leadership Offices'' heading provided funding for 
     the: Office of the Speaker; Office of the Majority Floor 
     Leader; Office of the Minority Floor Leader; Office of the 
     Majority Whip; Office of the Minority Whip; Speaker's Office 
     for Legislative Floor Activities; Republican Steering 
     Committee; Republican Conference Committee; Democratic 
     Steering and Policy Committee; Democratic Caucus; Nine 
     Minority employees; training and program development--
     majority; training and program development--minority; 
     Cloakroom Personnel--majority; and Cloakroom Personnel--
     minority. ``Committee Employees'' provides funding in 
     separate headings for ``Standing Committees, Special And 
     Select,'' and ``Committee on Appropriations.'' Funding for 
     ``Salaries, Officers And Employees'' is divided among 
     various financial, administrative, legal, ceremonial, and 
     security offices, including, for example, the offices of 
     the Clerk of the House, Chief Administrative Office, 
     Sergeant at Arms, Inspector General, and General Counsel.


                   Potential Statutory Interpretation

       When interpreting the meaning of legislative language, 
     courts will often use methods of statutory construction 
     commonly referred to as ``canons,'' or general principles for 
     drawing inferences about language. Perhaps the most common 
     ``canon of construction'' is the plain meaning rule, which 
     assumes that the legislative body meant what it said when it 
     adopted the language in the statute. Phrased another way, if 
     the meaning of the statutory language is ``plain,'' the court 
     will simply apply that meaning and end its inquiry.\7\ As the 
     United States Supreme Court stated in Connecticut National 
     Bank v. Germain:

       [I]n interpreting a statute a court should always turn 
     first to one, cardinal canon before all others. We have 
     stated time and again that courts must presume that a 
     legislature says in a statute what it means and means in a 
     statute what it says there . . . .

[[Page S13805]]

     When the words of a statute are unambiguous, then, this first 
     canon is also the last: judicial inquiry is complete.\8\

       Applying the plain meaning canon to the language in H.R. 
     3590, it appears possible to argue that the phrase ``official 
     office of a Member of Congress'' most naturally refers to 
     Member's personal offices and, therefore, excludes other 
     employees that a Member may utilize for other purposes. For 
     example, Members who serve as committee chairman or ranking 
     members may have staff affiliated with their service on a 
     given committee. While the Member may have control over 
     hiring, promotion, and even termination, those staff are paid 
     by the committee and not the Member. Moreover, the Member's 
     position on the committee is not commonly considered their 
     ``official office,'' as committee assignments may change 
     during a Congress and are determined by the chamber caucuses. 
     Furthermore, it is worth noting that CRS has been unable to 
     locate any previous use of the phrase ``official office of a 
     Member of Congress'' in statute or appropriations laws.
       Alternatively, applying the plain meaning canon to the 
     language used in S. 1796, it appears possible to argue that 
     this language includes committee staff, leadership staff and 
     most other congressional employees. The language, unlike that 
     in H.R. 3590, turns on who the disbursing agent of the funds 
     is, rather than who the employer is. As a result, the 
     language in S. 1796 appears to be much broader, as most 
     ``congressional employees'' have their pay disbursed from 
     either the Secretary of the Senate or the Chief 
     Administrative Office (CAO) of the House, regardless of 
     whether they are employed in a Member's personal office, by a 
     committee, leadership official, or in another capacity by the 
     Congress. Moreover, unlike the language in H.R. 3590, similar 
     text to that in S. 1796 has been used previously to 
     categorize congressional staff for salary and benefits 
     purposes.\9\


                         Other Potential Issues

       The language in H.R. 3590 raises additional possible 
     concerns in light of the way that the House and Senate 
     conduct business. For example, one potential issue with 
     proposing different standards for employees in Member office 
     accounts and employees paid through other House and Senate 
     accounts arises from the use of shared staff. Although the 
     House and Senate have different rules regarding shared staff, 
     both chambers allow types of shared staffing arrangements 
     that could result in an employee being both on the payroll of 
     a Member office and another type of office.
       In the Senate, 2 U.S.C. 61-la authorizes limited sharing of 
     staff:

       Notwithstanding any other provision of law, appropriated 
     funds are available for payment to an individual of pay from 
     more than one position, each of which is either in the office 
     of a Senator and the pay of which is disbursed by the 
     Secretary of the Senate or is in another office and the pay 
     of which is disbursed by the Secretary of the Senate out of 
     an appropriation under the heading ``Salaries, Officers, and 
     Employees'', if the aggregate gross pay from those positions 
     does not exceed the maximum rate specified in section 61-
     1(d)(2) of this title.

       The Senate Handbook summarizes these laws, stating:\10\

       An employee may be on the payroll of more than one 
     Senator's office or on the payroll of a Senator's office and 
     a leadership or administrative office, providing the 
     aggregate pay received does not exceed the maximum annual 
     salary for a Senator's office (2 U.S.C. 61-1a). An employee 
     can only be shared between offices which are funded through 
     the appropriations, ``Senators' Official Personnel and Office 
     Expense Account'' (Senators' personal staff), and ``Salaries, 
     Officers, and Employees''.

       The House Member's Handbook, as compiled by the Committee 
     on House Administration, states the following about shared 
     employees: \11\

       The term shared employee means an employee who is paid by 
     more than one employing authority of the House of 
     Representatives.

       Two or more employing authorities of the House may employ 
     an individual.

       Such shared employees must work out of the office of an 
     employing authority, but are not required to work in the 
     office of each employing authority. The pay from each 
     employing authority shall reflect the duties actually 
     performed for each employing authority. The name, title, and 
     pay of such an individual will appear on each employing 
     authority's Payroll Certification. Such employees may not 
     receive pay totaling more than the highest rate of basic pay 
     in the Speaker's Pay Order applicable to the positions they 
     occupy.

       Employees may not be shared between a Member or Committee 
     office and the office of an Officer of the House if the 
     employee, in the course of duties for an Officer, has access 
     to the financial information, payroll information, equipment 
     account information, or information systems of either Member, 
     Committee, or Leadership offices.

       Applying the interpretation of H.R. 3590 suggested above, 
     it is possible that certain shared staff could be covered by 
     the provision, while other shared staff, even in the same 
     office, would not be covered.
       Because the bill does not propose a standard for 
     determining coverage, it is potentially left to the 
     implementing authority to establish such a standard. The 
     implementing authority would appear to arguably have wide 
     discretion in setting such a standard. As a result, it is not 
     unreasonable to assume that an implementing authority could 
     use a majority time or similar standard in making coverage 
     determinations. In other words, shared employees would need 
     to declare whom they spent a majority of time working for. If 
     the staffer's declaration was the Member's official office, 
     they could arguably be covered. On the other hand, if the 
     majority of a staffer's time was spent on committee or 
     leadership work, they may arguably not be covered. It is 
     important to note that this is but one possible standard and 
     that unless otherwise stated in the bill, it will up to the 
     implementing authority to determine the standard.
       The language of S. 1793 arguably avoids this problem as it 
     appears to encompass all shared employees because they all 
     receive salaries through either the CAO or Secretary of the 
     Senate.
       Another potential issue is the scope of the disbursing 
     authority of the CAO of the House and the Secretary of the 
     Senate. The CAO has served as the disbursing officer for the 
     House of Representatives since 1995. The Secretary of the 
     Senate serves as the disbursing officer for the Senate. Both 
     of these officers are required to publish reports on 
     disbursement.\12\ Pursuant to the FY2010 legislative branch 
     appropriations act, the Secretary and CAO are each 
     responsible for the disbursements for two accounts included 
     as ``joint items.'' Additional disbursements by the Secretary 
     include salaries and expenses of the Joint Economic Committee 
     and Office of Congressional Accessibility Services.\13\ The 
     CAO serves as the disbursing officer for the Joint Committee 
     on Taxation and the Office of Attending Physician. In 
     addition, the CAO and Secretary also have disbursing 
     authority for a number of House and Senate revolving 
     funds.\14\ Thus, it appears possible to argue that, should 
     the language of H.R. 3590 be interpreted as suggested above, 
     these employees would be excluded from coverage. Conversely, 
     should the language from S. 1793 be utilized, it would appear 
     that employees of these committees would be covered as they 
     are paid by the CAO or Secretary of the Senate.
       Finally, there is the issue of what, if any, other entities 
     or employees of the Legislative Branch the CAO and/or 
     Secretary of the Senate may serve as the disbursing officers. 
     Our research indicates that although the CAO and Secretary of 
     the Senate served as the disbursing officers for the U.S. 
     Capitol Police (USCP) prior to 2003, the Chief of the Capitol 
     Police currently serves as the disbursing officer for the 
     USCP.\15\ Moreover, it appears that other Legislative Branch 
     agencies such as the Architect of the Capitol and the 
     Congressional Budget Office each have their own disbursing 
     agents and do not use either the CAO or the Secretary of the 
     Senate. In addition, it appears that the CAO and/or Secretary 
     of the Senate may serve as the disbursing agent for some, but 
     not all, congressional commissions. Thus, some employees of 
     such commissions may be covered by the language used in S. 
     1793, however, none would appear to be covered by the 
     language used in H.R. 3590.


                                endnotes

       \1\ Patient Protection and Affordable Care Act, H.R. 3590, 
     Sec. 1312(d)(2)(D)(ii)(II), 111th Cong. (2009).
       \2\ See id.
       \3\ America's Healthy Future Act of 2009, S. 1796, 
     Sec. 2231(3)(C), 111th Cong. (2009).
       \4\ Id.
       \5\ In the FY2010 legislative branch appropriations act, 
     these included the: Joint Economic Committee, Joint Committee 
     on Taxation, Office of the Attending Physician, Office of 
     Congressional Accessibility Services.
       \6\ Committee Order No. 41, effective September 1, 1995, in 
     notes to 2 U.S.C. Sec. 57; P.L. 104-53, 109 Stat. 519 (Nov. 
     19, 1995); U.S. Congress, House Committee on Appropriations, 
     Legislative Branch Appropriations Bill, 1996, report to 
     accompany H.R. 1854, 104th Cong., 1st sess., H. Rept. 104-141 
     (Washington: GPO, 1995), p. 10; P.L. 104-186, 110 Stat. 1719 
     (Aug. 20, 1996); 2 U.S.C. Sec. 57b; P.L. 106-57, 113 Stat. 
     415 (Sept. 29, 1999).
       \7\ See Hartford Underwriters Insurance Co. v. Union 
     Planters Bank, N.A., 530 U.S. 1 (2000); see also Robinson v. 
     Shell Oil Co., 519 U.S. 337 (1997); Connecticut National Bank 
     v. Germain, 503 U.S. 249 (1992); Mallard v. United States 
     District Court for the Southern District of Iowa, 490 U.S. 
     296, 300 (1989).
       \8\ Connecticut National Bank, 503 U.S. at 253-54 
     (citations and quotation marks omitted).
       \9\ See, e.g., 2 U.S.C. Sec. 60a-1 (2006); 2 U.S.C. 
     Sec. 60j (2006); 2 U.S.C. Sec. 130b (2006); 2 U.S.C. 
     Sec. 1301 (2006); 2 U.S.C. Sec. 1977 (2006); 5 U.S.C. 
     Sec. 5306 (2006); 5 U.S.C. Sec. 5515 (2006); 18 U.S.C. 
     Sec. 207 (2006).
       \10\ U.S. Senate, Committee on Rules and Administration, 
     Senate Handbook, version of Nov. 2006, 1V-31.
       \11\ U.S. House of Representatives, Member's Handbook, 
     available at, http://cha.house.gov/staff.aspx.
       \12\ 2 U.S.C. Sec. Sec. 104a and 104b.
       \13\ P.L. 111-68, 123 Stat. 2030, Oct. 1, 2009.
       \14\ For additional information, see: CRS Report R40939, 
     Legislative Branch Revolving Funds, by Ida A. Brudnick and 
     Jacob R. Straus.
       \15\ P.L. 108-7, Feb. 20, 2003, 117 Stat. 366; 2 U.S.C. 
     1907.

  Mr. GRASSLEY. This carve-out creates a double standard and is totally

[[Page S13806]]

unacceptable. This amendment goes beyond just going where my original 
amendment went to cover all people on Capitol Hill. The amendment I am 
asking consent for would also include the President, Vice President, 
political appointees, and senior-level staff of the executive branch. 
It is only fair that if this bill becomes law, these leaders should 
themselves be subject to the reforms that make our constituents go 
through the exchange.
  I ask unanimous consent to set aside the pending amendment in order 
to offer amendment No. 3178 which is at the desk.
  The PRESIDING OFFICER. Is there objection?
  Mr. BAUCUS. I object.
  The PRESIDING OFFICER. Objection is heard.
  Mr. GRASSLEY. Mr. President, Democratic leadership and the White 
House have spent months talking about accountability. With this 
objection, the majority will not even consider an amendment to make 
sure the White House and all Members employed on Capitol Hill, not just 
those in our personal offices, live under the same new health care 
system the rest of the country lives under. That sure doesn't sound 
like accountability to me.
  There is widespread agreement that the health care system in this 
country has serious problems. Costs are rising at three times the rate 
of inflation. Many Americans are uninsured. Millions more fear losing 
their insurance in a weak economy or because of preexisting conditions. 
Doctors are ready to close their doors over high malpractice costs and 
lower government reimbursements, and we do not do anything in this bill 
about high malpractice costs.
  Something has to be done, everyone seems to agree. But tomorrow the 
Senate will vote on a bill that makes a bad situation worse. It is 
unfortunate that we are voting on a bill that a significant majority--
61 percent--of Americans oppose. The American people, providers, 
advocacy groups as well, are simply reacting to the fact that this bill 
slid rapidly down the slippery slope to more and more government 
control of health care.
  It contains the biggest expansion of Medicaid since 1965. It creates 
a long-term care insurance program called the CLASS Act that the CMS 
Actuary says runs a significant risk of being unsustainable, and one of 
the most significant Members of this body referred to it as a Ponzi 
scheme similar to what Madoff did. It imposes an unprecedented Federal 
mandate for coverage backed by the enforcement authority of the 
Internal Revenue Service. It increases the size of government by $2.5 
trillion when fully implemented. It creates dozens of new Federal 
bureaucracies and programs to increase the scope of the Federal role in 
health care. That is a lot of power over people's lives concentrated in 
the Federal Government, and there are 1,697 delegations of authority to 
the Secretary of HHS to do things beyond authorities specifically given 
in this legislation.
  The excesses of this bill appear willfully ignorant of what is going 
on in the rest of the economy outside of health care. These excesses 
make it far worse than doing nothing.
  At this point in our Nation's history, we are facing very challenging 
economic times. We have seen the auto industry go into bankruptcy. We 
have seen banks shutter their doors. The chart behind me shows how the 
Federal debt has increased by $1.4 trillion since inauguration. The 
chart also shows the growing amount of debt the Federal Government is 
taking on. The amount of increased debt added just since inauguration 
puts $11,000 more of debt on each household, and that total debt now 
exceeds $12 trillion for the first time in history.
  At the beginning of this debate, one of the key promises of health 
care reform was that it would bring down health care costs. This needs 
to be done before health spending sinks the Federal budget and saddles 
taxpayers. I have a chart that illustrates the upward expenditures of 
health care costs by $160 billion over the next decade, and that comes 
from this bill. The red area on this chart is the net additional 
Federal health spending according to not this Senator but the 
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 is a good idea. From rationing care to 
infringing on the doctor-patient relationship, this government-run 
system will guarantee U.S. taxpayers a staggering tax burden for 
generations to come.
  When the debate began last year, interested legislators of both 
parties set forth benchmarks that were at the time no-brainers and 
still are. But this bill does not conform. Health care reform should 
lower the cost of premiums. It should reduce the deficit. Now, this 
bill does over the 10-year window, but if you look at when the program 
really starts, 4 years from now, and look ahead 10 years at that time, 
you will find it does not. It should bend the cost curve of health care 
the right way, but it does not do that. The Reid bill does not do any 
of these things we set out to do at the beginning of the debate.
  As we end this debate, I urge my colleagues to listen to the American 
people. The Reid bill is the wrong direction.
  Mr. President, with widespread agreement that our health care system 
has serious problems, why do we have a partisan debate?
  There is a column from the Financial Times by a commentator, Clive 
Crook, that sheds some light on the cause of the partisanship.
  Mr. Crook, a Brit, is sympathetic to the goals and methods of my 
friends on the other side. But, as one who knows a system of the 
universal coverage our friends on the other side seek, he is sober 
about the consequences.
  I ask unanimous consent that a copy of Mr. Crook's article entitled 
``The Honest Case for a Bungled Health Care Reform,'' be printed in the 
Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

               [From the Financial Times, Dec. 20, 2009]

            The Honest Case for a Bungled Healthcare Reform

                            (By Clive Crook)

       The US system of government has a lot in its favour, in my 
     view, but if you wanted to argue the opposite, the fiasco of 
     healthcare reform has it all.
       The measure being fought over in the Senate--if a bill gets 
     passed, ordeal by House-Senate conference comes next--is 
     detested with equal passion by left and right. A majority of 
     the public is now opposed as well. Even its supporters do not 
     like it all that much. Yet if the system fails to spit this 
     thing up for the president's signature, the country will be 
     deemed ungovernable and the Obama administration will be 
     pronounced dead. Expect the rending of garments either way.
       It does not matter that conservatives oppose this reform. 
     Of course they do. Conservatives are unmoved by the plight of 
     the uninsured, want to block this administration's domestic 
     initiatives regardless, and are incapable of uniting behind 
     an alternative proposal. They have nothing to offer on the 
     issue.
       It does not matter that the loony left of the Democratic 
     party opposes this reform either. In fact, that is a plus. 
     Progressives who want to kill the most far-reaching US social 
     reform in decades because it would send more customers, 
     public subsidy in hand, to private insurance companies are as 
     stone-hearted on this matter--and as far from understanding 
     the concerns of most voters--as their hard-right enemies. 
     Their opposition is an endorsement.
       What matters is the failure to rally the country behind an 
     initiative that, at the outset, voters strongly supported. A 
     telling instance of the administration's ineffectiveness as a 
     spokesman for its own project came just last week. Howard 
     Dean, speaking for the progressive wing of the Democratic 
     party, said the reform would do more harm than good--that 
     this was the policy the insurance companies had dreamed of. 
     White House spokesmen rushed to explain that, on the 
     contrary, the insurance companies hate the bill.
       Think about that. At the beginning Barack Obama promised 
     people that if they liked their existing insurance 
     arrangements--which are mostly private, of course--nothing 
     would change. This entire effort is based on preserving, by 
     popular demand, a mostly private model of insurance. And here 
     is the administration endorsing the progressives' view that 
     private insurers are evil, and citing the companies' 
     opposition to the reform as an argument in its favour.
       The White House cannot have it both ways. If progressives 
     are right about the wickedness of private insurance, they are 
     right that the whole reform is misconceived. The 
     administration cannot appease leftist opinion and also make 
     the strongest possible case for this reform to the middle of 
     the electorate. Since it cannot appease leftist opinion in 
     any case, why even try? Make a virtue of opposition from that 
     quarter. Mr Obama's reluctance to cross that line has hobbled 
     his administration from the start.

[[Page S13807]]

       Be that as it may, the healthcare bill in its current form 
     is a mess--and an unpopular mess to boot. Popular fears that 
     the bill will drive up insurance premiums and add to public 
     borrowing are probably justified. The measure is timid about 
     changing incentives to promote efficiency: it proposes lots 
     of experiments, but little compulsion.
       Adverse selection is likely to be a bigger problem than the 
     reformers say: new rules would stop insurance companies 
     denying coverage to the sick, and the quid pro quo of 
     mandatory insurance may be insufficient to offset this. If 
     the insurers' risk pools deteriorate, premiums will rise. 
     Deep cuts in Medicare, the public insurance programme for the 
     elderly, are needed to balance the books, but are unlikely to 
     materialise in full. Higher taxes as well as higher premiums 
     are the likely result of this reform.
       Would it therefore be better to abandon the effort 
     altogether and start again? One can think of simpler, better 
     blueprints, but the politics that led the country here would 
     still be the same--and so would the economic constraints. It 
     is delusional to suppose that you can significantly widen 
     access to healthcare at no net public cost. You cannot both 
     transform a system and leave its basic structure unaltered. 
     Trying to squirm around these unavoidable realities has 
     brought the effort to its current pass. Why expect things to 
     be different next time?
       In the end, I think, everything depends on the weight one 
     attaches to achieving security of coverage as quickly as 
     possible. In my view, this is the overriding consideration. 
     Abandoning the effort now might postpone that goal for 
     another decade or more. The country should regard this as 
     unacceptable. Once the reform is law, though, the real work 
     begins. Getting a grip on costs will be even more urgent than 
     it is already--especially when you recall the broader fiscal 
     calamity that awaits the country during the next decade.
       The honest case for reform along the lines of the Senate 
     bill is not that it fixes US healthcare; still less that, as 
     the White House blithely maintains, it alleviates the 
     country's fiscal distress. The truth is, it will create more 
     problems than it solves. But the one big thing it gets 
     right--the assurance of affordable health insurance for all 
     Americans--is of surpassing importance.
       Enacting this reform is not the end of the healthcare 
     argument, but the beginning. If it does pass, it may well be 
     looked back on as a mistake once its financial implications 
     sink in. Yet the principle of universal coverage will have 
     been accepted, and with luck there will be no going back. The 
     price will be high, but is worth it.

  Mr. GRASSLEY. I am going to try and break through the partisan wall 
and connect with my friends on the other side.
  Costs are rising at three times the rate of inflation.
  Many Americans are uninsured, millions more fear losing their 
insurance in a weak economy or because of preexisting conditions.
  Doctors are ready to close their doors over high malpractice costs 
and low government reimbursement rates.
  Something has to be done. Everyone agrees on that much.
  But tomorrow, the Senate will vote on a bill that makes a bad 
situation worse. Mr. Crook describes the state of play well:

       [t]he health care bill in its current state is a mess--and 
     an unpopular mess to boot.

  It is unfortunate that we are voting on a bill that a significant 
majority--61 percent--of Americans oppose.
  The American people, providers, and advocacy groups are simply 
reacting to the fact that this bill slid rapidly down the slippery 
slope to more and more government control of health care.
  Mr. Crook states:

       Popular fears that the bill will drive up insurance 
     premiums and add to public borrowing are probably justified. 
     The measure is timid about changing incentives to promote 
     efficiency: it proposes lots of experiments, but little 
     compulsion.

  All through this process, it is as if Republicans and Democrats have 
been living in parallel universes. Republicans have focused on the 
elements of the policy and asked tough questions about the cost of the 
change.
  Mr. Clive captures that sobering reality:

       Adverse selection is likely to be a bigger problem than 
     reformers say: new rules would stop insurance companies 
     denying coverage to the sick, and the quid pro quo of 
     mandatory insurance may be insufficient to offset this. If 
     the insurers' risk pools deteriorate, premiums will rise. . . 
     . Higher taxes as well as higher premiums are the likely 
     result of this reform.

  Members on this side of the aisle, at each stage of the process, have 
focused on this reality. While recognizing the worthy goal of expanding 
coverage, we have been concerned about the effect on the currently 
insured.
  This bill contains the biggest expansion of Medicaid since it was 
created in 1965.
  It cuts Medicare by a staggering half a trillion dollars over the 
next decade.
  It creates a long-term care insurance program called the CLASS Act 
that the CMS Actuary says runs a significant risk of being 
unsustainable.
  It imposes an unprecedented Federal mandate for coverage backed by 
the enforcement authority of the Internal Revenue Service.
  It increases the size of the government by $2.5 trillion when fully 
implemented.
  It creates dozens of new Federal bureaucracies and programs to 
increase the scope of the Federal role in health care.
  That is a lot of power over people's lives concentrated in the 
Federal Government.
  And the excesses of this bill appear willfully ignorant of what is 
going on in the rest of the economy outside of health care.
  The cost of these excesses make this bill far worse than doing 
nothing.
  This summer, official scorekeepers fleshed out the size of this cost 
of achieving the other side's noble, but costly goal of expanded 
coverage. As on who agrees with the goal of universal coverage, Mr. 
Crook acknowledges it:

       It is delusional to suppose that you can significantly 
     widen access to healthcare at no net public cost. You cannot 
     both transform a system and leave its basic structure 
     unaltered. Trying to squirm around these unavoidable 
     realities has brought the effort to its current pass.

  And yet, despite these cold hard facts, our Democratic friends 
continue to quest for the Holy Grail of expanded coverage. Mr. Cook 
captures that sentiment:

       In the end, I think, everything depends on the weight one 
     attaches to achieving security of coverage as quickly as 
     possible. In my view, this is the overriding consideration. 
     Abandoning the effort now might postpone that goal for 
     another decade or more. The country should regard this as 
     unacceptable.

  Does anyone doubt this is where our Members on the other side are 
coming from? Some are explicit about it, like my friend, the majority 
whip. I recognize that transparency. But to them the price--for 
everyone else, the insured, businesses, Federal and State taxpayers, 
and Medicare patients--is secondary.
  Go back and look at the many pages in the Record and you will see two 
themes prove my point. One is the Democratic theme. Most of the debate 
from those on the other side has been about what they want this bill to 
do. They want it to expand the role of the Federal Government in health 
care. Hence, the prideful references to past efforts, successful and 
unsuccessful, in that regard. They want it to solve all problems the 
uninsured face. They recite case after case of uninsured and 
underinsured. The stories they tell are compelling. On our side, we see 
the point the other side is making.
  Go look at all those pages of debate again. You will see another 
theme. It is the Republican theme. That theme is not about what we want 
the bill to do for the uninsured. It is about understanding and 
explaining what the costs and benefits of this bill are to all 
Americans: Insured and uninsured, young, middle-aged, and elderly, 
suburban, and rural. In this regard, Republicans reflect where the vast 
majority of Americans are right now.
  Mr. Crook, again, firmly where our friends on the other side are, 
captures the polarity of the debate:

       Once the reform is law . . . the real work begins. Getting 
     a grip on costs will be even more urgent than it is already--
     especially when you recall the broader fiscal calamity that 
     awaits the country during the next decade.

  Mr. Crook is correct. At this point in our Nation's history, we are a 
Nation facing very challenging economic times. We have seen the auto 
industry go into bankruptcy. We have seen banks shutter their doors.
  The Federal debt has increased by $1.4 trillion since inauguration. 
This chart shows the growing amount of debt that the Federal Government 
is taking on. Just the amount of increased debt added just since the 
inauguration is $11,535 per household.
  It now exceeds $12 trillion for the first time in history.
  In these perilous times, Mr. Crook notes the public is extremely 
sensitive to the fiscal consequences of the bill before the Senate. And 
that is where Republicans have focused all along. Mr. Crook describes 
the tension between

[[Page S13808]]

the goal he shares with our Democratic Members and the public's focus 
on the questions Republicans have asked for almost a year now. On one 
side of that tension are the answers to Republican inquiries:

       The honest case for reform along the lines of the Senate 
     bill is not that it fixes U.S. healthcare; still less that, 
     as the White House blithely maintains, it alleviates the 
     country's fiscal distress. The truth is, it will create more 
     problems than it solves.

  On the other side of that tension is the goal Democratic Members 
seek. Their goal of trying to achieve ``universal coverage'' overrides 
all other considerations. As Crook puts it ``of surpassing 
importance.''
  And, if the other side prevails, what does it mean for the future. 
From Mr. Crook, who shares my Democratic friends' goals, I quote:

       Enacting this reform is not the end of the healthcare 
     argument, but the beginning. If it does pass, it may well be 
     looked back on as a mistake once its financial implications 
     sink in. Yet the principle of universal coverage will have 
     been accepted, and with luck there will be no going back, The 
     price will be high, but is it worth it?

  What is that price, Mr. President? To a certain extent, what we do 
know is that it is high for everyone, but the uninsured population. To 
the extent we don't and cannot know, it is likely to be higher.
  From rationing care to infringing on the doctor-patient relationship, 
this government-run system will guarantee U.S. taxpayers a staggering 
tax burden for generations to come.
  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 reduce the deficit. It 
should bend the growth curve in health care the right way.
  How does the Reid bill measure up?
  CBO tells us premiums rise.
  What about health spending? As this chart here illustrates, this bill 
bends the Federal spending curve further upward by $160 billion over 
the next decade. The red area on this chart is that net additional 
Federal health spending according to the Congressional Budget Office.
  How about deficit reduction? 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 is a good idea.
  The Reid bill doesn't measure up on any of those things.
  The unfortunate state of this partisan floor debate goes to the 
tension Mr. Crook identified:

       I was raised by FDR Democrats. From a lifetime of public 
     service, I know a little bit about my Democratic friends' 
     political DNA. A big part of that political DNA is one 
     principle. It is this. Expanding health insurance trumps 
     everything else.

  I respect and understand that view.
  Where we, on our side, differ, is whether it is an absolute or 
relative principle. Does the principle of universal coverage trump 
everything else? Does it trump cost containment? Does it trump the tax 
burden it brings with higher Federal and State taxes?
  Does it trump the financial burden it places on small businesses and 
other employers? Does it trump the financial burden related premium 
cost increases will bring? Does it trump the negative impact it will 
have on the Medicare Program that our seniors count on?
  For those of us, on this side, expanding coverage is a worthy goal. 
But it is not an absolute goal. We prefer to expand coverage through 
better access and affordability. But that goal of expanded coverage 
must be balanced with other goals.
  We view it as relative to those other goals. It is relative to 
whether the related Federal and State tax burden is bearable. It is 
relative to realistic cost containment reforms. It is relative to 
whether the cost burden on employers, especially small businesses, is 
bearable. It is relative to whether the impact on Medicare services and 
solvency is bearable.
  The American people have tuned into this debate. They don't like the 
partisanship. They agree with all of us that reform is needed. They 
have been telling us that expanding coverage is important, but not 
absolute.
  I urge the other side to make the honest case for reform to the 
American people. That will lead to a bipartisan response, process, and 
product. Americans don't want bungled health care reform.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from New Hampshire.
  Mr. GREGG. Mr. President, I want to associate myself with the 
comments of the Senator from Iowa. In fact, I would like to incorporate 
them by reference in my comments because they were so on point on the 
issue of substance as to what this bill does not do and what it does 
do. In both instances, he is absolutely right. The bill does not 
accomplish what we set out to do, which was cover all Americans, which 
was to bend health care costs down, which was to let you keep your 
insurance if you had it and not have your premiums go up. It does just 
the opposite.
  It is a $2.3 trillion increase in health care spending--$2.3 
trillion. That is how much it grows the government. Health care costs 
go up by over $230 billion in the first 10 years. We know premiums are 
going up.
  Now we have this interesting issue involving Medicare. We have heard 
a lot of talk from the other side of the aisle about how Medicare is 
not being cut, and if it is being cut, it is just being used to help a 
new entitlement, and therefore it should be counted as part of the 
basic effort to bring fiscal responsibility to this bill. Well, that is 
hokum, just pure unadulterated hokum. Medicare is being cut by $500 
billion the next 10 years, $1 trillion over the first 10 years of full 
implementation, and $3 trillion over the first 20 years. And then the 
money is being spent not to make Medicare more solvent, not to make 
Medicare stronger so it does not have a huge unfunded liability, it is 
being spent to create this brandnew entitlement--an entitlement that is 
massively going to expand the size of government by $2.3 trillion.
  The American people understand this does not work. Common sense kicks 
in with the American people. They know--they know--from common sense 
that you cannot possibly cut Medicare by $3 trillion, spend it on a new 
entitlement, and have fiscal responsibility around here and claim 
Medicare is better off for it. And they do not have to know it through 
common sense; all they have to do now is listen to the CBO, which has 
now written us a letter. Let me quote from this letter because it is a 
devastating letter. I just wish this bill was going to be on the floor 
long enough for it to actually be open to public view and have some 
sunshine on it. It is being rushed through here just before Christmas 
so nobody can see what is actually in it. But here is what CBO says:

       The key point is that the savings to the HI trust fund--

  That is the Medicare trust fund--

     under the [bill]--

  They use the acronym for it--

     would be received by the government only once, so they cannot 
     be set aside to pay for future Medicare spending and, at the 
     same time, pay for current spending on other parts of the 
     legislation or on other programs.

  Exactly what this bill does: It spends the Medicare money on other 
programs.
  They go on to say--and this is CBO speaking, not me:

       To describe the full amount of the [Medicare] trust fund--

  Again, they use ``HI trust fund''--

     savings as both improving the government's ability to pay 
     future Medicare benefits and financing new spending outside 
     of Medicare would essentially double-count--

  I repeat: ``double count''--

     a large share of those savings and thus overstate the 
     improvement in the government's fiscal position.

  The simple fact is, what is happening here is a scam, a pure and 
simple scam on the American people and especially on the seniors in 
this country because Medicare is being cut by billions of dollars in 
order to create a new entitlement, and it is going to have a massively 
negative effect on the fiscal health of this Nation because we know 
that new entitlement will not be fully funded and we know Medicare has 
$35 trillion of unfunded liability out there.
  If you are going to cut Medicare by $3 trillion, as the other side of 
the aisle is proposing, if you are going to eliminate Medicare 
Advantage for a large number of seniors--except those who live in 
southern Florida--then that money ought to be used to reduce the debt 
so that the Medicare system becomes more solvent. It is that simple in 
the

[[Page S13809]]

long run. It is not being done here. CBO has pulled the curtain back 
from this game and made it very clear that it is not going to be done. 
Of course, nobody is going to learn this because they are going to pass 
this bill through here before anybody can figure that out and even 
listen to CBO.
  It is just an outrage the way this bill was put together. We all know 
that. Dark of night, back rooms, deals everywhere, only a few people in 
the room; those people who really drafted the bill, very small crowd. 
Nobody else was allowed in. No cameras, no information about what was 
going on. And then you would bring in a Senator here and a Senator 
there and say: What do you need from me to get your vote, and something 
would appear in the bill, I guess. Then the bill arrived here.
  It is not unusual around here to have earmarks in bills. If they were 
within the budget and the budget was reasonable, I would even ask for 
earmarks. But this goes way beyond the concept of earmarks--this bill. 
This bill fundamentally changes policy--that has never happened around 
here--for one part of the country versus another part of the country. 
In other words, all of America--all American seniors--will have to live 
by massive cuts in Medicare Advantage. That is a pretty good health 
insurance program for a lot of seniors; I think there are 11 million 
seniors on that program. All of America has to live by that policy 
except for three counties in southern Florida. All of America has to 
live by an insurance situation where insurance companies are taxed at a 
certain rate, except insurance companies in Nebraska. All of America 
has to live by Medicaid reimbursement rates, which are going to cost 
the States billions of dollars--New Hampshire, $120 million over 10 
years--except for Vermont and Massachusetts. And then there is a 
special exemption in here for New York and a couple of other States--
Louisiana, $300 million. That is a total corruption of the concept of 
policy. Policy in America is supposed to cover everyone. When the 
Federal Government acts, it is supposed to be a policy that affects 
everyone equally. You are not supposed to have little cadres of 
exceptions for those policies.
  This bill has been called historic--historic--by my colleagues on the 
other side of the aisle. Well, the most historic thing about this bill 
is the fundamental damage it has done to the concept of open, thorough, 
and public debate that was at the heart of the thought process of Adams 
and Madison, our Founding Fathers, when they created the checks and 
balances system, with the Senate at the center. The Senate was supposed 
to be the place where bills come to the floor, they are open to debate, 
there are amendments, and you have a process where things get aired and 
there is sunshine. No sunshine here--no, not at all. This is not 
majority rule, as conceived by our Founding Fathers in Philadelphia. 
This is closer to the single-party state system we see in Europe--or 
have seen in Europe. The minority is ignored, and there are no checks 
in this process on the autocratic rule of the majority. The irony, of 
course, is that the bill never went through the public's consideration, 
never went through committee, and was drafted behind closed doors and 
has been on the floor for less than 72 hours. As a result, we are 
delivered a health care bill that has been corrupted by special 
interests, especially on the issue of policy, that is extraordinarily 
expensive and has a massive expansion in the Federal bureaucracy, to 
which, if you applied the word ``reform,'' you would have to call 
Bernie Madoff ``honest.'' The terms just simply do not apply here.
  Unfortunately, this bill in its present form, I believe, will lead to 
fundamental harm to the fiscal health of this Nation. There is no 
question in my mind but that if we load $2.3 trillion of cost onto our 
government, expand our government in this manner, our children are 
going to be passed a nation where they have less opportunity than our 
generation had. Further, I do not think it is going to help the 
Nation's people, our people relative to their health care. I think it 
will lead to a significant contraction of the quality of health care, 
especially for seniors but for all Americans, as we lose the 
innovation, the energy for innovation, and the resources for 
innovation. As a result, this bill, in my opinion, should be sent back 
to the drawing boards and should be reconsidered.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER (Mr. Kaufman). The Senator from Texas.
  Mr. CORNYN. Mr. President, over the last few days, as we have dug 
into this bill and the process by which it was written behind closed 
doors, we have discovered the bill is chock-full of sweetheart deals.
  When Americans voted to change Washington last year, they did not 
think it would be politics as usual here, but unfortunately it has sunk 
to a whole new level. It is painful for me to read the editorials in 
hometown newspapers back in Texas and elsewhere around the country to 
see what editorial opinion and other opinion leaders are saying about 
the process by which this bill was written, but let me read a couple of 
lines from the Fort Worth Star-Telegram:

       The tawdry use of earmarks to bury the doubts of 
     recalcitrant moderate Democrats was a cynical display of 
     ends-justifies-the-means horse-trading that President Barack 
     Obama campaigned against as a Senator and a candidate.
       This was an administration that was elected on the campaign 
     slogan: ``Change You Can Believe In.''

  But when David Axelrod, one of the masterminds of the campaign, one 
of the advisers to the President, was asked about that, he said:

       Well, this is just the way it is. This is the way 
     Washington works.

  I, for one, want to stand up and say this is not the way it should 
work. I know Presidents campaign for office saying they are going to 
change Washington, but the truth is the hardest fight is to keep 
Washington from changing you. Unfortunately, it seems as though that is 
what has happened here.
  Rather than listening to the American people, the creators of this 
health care bill started with the special interests first. That is 
where the meetings behind closed doors started--with the pharmaceutical 
industry, to cut a deal with them; with the insurance industry, to cut 
a deal with them. The insurance industry will get $476 billion worth of 
tax credits from this bill alone, and the hospital industry, and the 
list goes on and on.
  Colleagues will stand up and tout the endorsement of organizations 
such as AARP that has backed nearly $\1/2\ trillion in cuts out of 
Medicare because, as it turns out, they are in the insurance business 
and they can sell more Medigap policies when they cut Medicare 
Advantage, as this bill does.
  In order to get the 60 votes for cloture on the motion to proceed, we 
didn't hear high-minded and idealistic debates about what is the right 
policy for this country when it comes to reforming our health care 
system. If this bill could have passed or mustered 60 votes because it 
was such great policy and the American people were embracing it, you 
wouldn't need to make all the sweetheart deals that were made behind 
closed doors to induce recalcitrant Senators to vote for cloture, not 
because they think it is the right policy but because their State got a 
special deal.
  We know well about what happened in Louisiana and now in Nebraska, 
but of course there were special deals for Vermont that included $600 
million in the managers' package. We know that in California, the so-
called ``Botax'' has been replaced now by another tax on tanning beds 
at the insistence of one of the businesses named Allergan out in 
California which led the lobbying campaign to defeat the cosmetic 
surgery tax.
  We have heard this is all about keeping insurance companies honest, 
but the fact is there were special deals here for insurance companies 
in Nebraska--what has been coined the ``Omaha Prime Cuts,'' the carve-
out from new fees for Mutual of Omaha and other insurance companies 
doing business in Nebraska that no other insurance company in the 
Nation is going to benefit from.
  Then there is the so-called ``Gator Aid'' special deal for insurance 
companies in Florida.
  There is a $100 million hospital deal in Connecticut--something 
called ``U Con.''
  And, of course, there were deals for Montana that were slipped in the 
bill. Although, you know what, no one actually had the courage to 
mention the name of the State. You had to start to dig into it, like 
the Louisiana deal. At

[[Page S13810]]

least the Senator from Nebraska was brazen enough to actually have 
Nebraska listed by name. The rest of them you have to dig out by trying 
to figure out: Who benefits from this deal and who doesn't?
  I want to ask: What about the other States? My State, under this 
unfunded mandate in this legislation, will have to pay the State 
taxpayers $21 billion in unfunded Medicaid liabilities over the next 10 
years. We didn't make a sweetheart deal to vote for bad policy because 
my State could get some extra money, because I think that is 
unprincipled. I wouldn't do it. But what about the other States that 
voted for the bill without getting the sweetheart money, such as 
Arkansas, which faces an unfunded Medicaid mandate of $335 million; 
Colorado, $624 million; California, $3.5 billion--a State that is 
already nearly bankrupt. This is going to make their situation 
enormously worse, as Governor Schwarzenegger has acknowledged.
  I am not saying other States should somehow get the sweetheart deals 
that were negotiated for these other votes, but I am saying this entire 
bill is a bad deal and we need to kill it and start over, strip out all 
the earmarks, and bring the kind of transparency the President 
campaigned on and that I think the American people have a right to 
expect.
  These sweetheart deals are egregious in and of themselves. What is 
worse--and I have been on the telephone talking to constituents back in 
Texas--there are some people who paint with such a broad brush, they 
say, Well, we think all of you are corrupt, because this verifies some 
of the most cynical suspicions that people have about government. I, 
for one, resent it. We have many honest and honorable people who serve 
in public life, and this taints us all with a broad brush and, simply 
stated, makes me furious. I resent it. I resent those who brought us to 
this position, because I think it sullies the reputation of the Senate.
  In a moment I am going to offer a point of order, but let me first 
note that one of Senator Reid's first acts as majority leader was to 
pass the Honest Leadership and Open Government Act. Let me tell my 
colleagues the name of that again. It is called the Honest Leadership 
and Open Government Act.
  In 2007, President Obama, then Senator, said:

       To earn back the trust to show people that we are working 
     for them and looking out for their interests, we have to 
     start acting like it.

  Unfortunately, for the American people, Washington has not yet 
started to act like it.
  This landmark ethics reform legislation required Senators to publicly 
disclose earmarks and who requested them. Senator Grassley and I have 
both made parliamentary inquiries about whether this provision has been 
complied with, which is now contained in rule LXIV of the Senate 
Standing Rules, and we found that the majority leader has so far not 
complied with these public disclosure rules that he himself championed. 
Since my friends on the other side of the aisle don't seem to care a 
lot about this, we have to insist that this provision be complied with. 
In a moment I will raise a point of order about this violation of the 
Senate rules. We need to force the Members of this body to be honest 
about who has required special favors and earmarks, tax treatments and 
benefits in this bill.
  I have a parliamentary inquiry.
  According to rule XLIV, paragraph 4(a) of the Standing Rules of the 
Senate states:


 =========================== NOTE =========================== 

  
  On page S13810, December 23, 2009, the Record reads: According 
to rule LXIV, paragraph . . . . . . Senate rule LXIV . . . 
Paragraph 4(a) of rule LXIV . . .
  
  The online Record has been corrected to read: . . . rule XLIV . 
. .


 ========================= END NOTE ========================= 


       If during the consideration of a bill or joint resolution, 
     a Senator proposes an amendment containing a congressionally 
     directed spending item, limited tax benefit, or limited 
     tariff benefit which was not included in the bill or joint 
     resolution as placed on the calendar or as reported by any 
     committee, in a committee report on such bill or joint 
     resolution, or a committee report of the Senate on a 
     companion measure, then as soon as practicable, the Senator 
     shall ensure that a list of such items (and the name of any 
     Senator who submitted a request to the Senate for each 
     respective item included in the list) is printed in the 
     Congressional Record.

  I would simply inquire of the Chair: Is the Chair aware whether this 
list of congressionally directed spending items and their Senate 
sponsors has been printed in the Congressional Record?
  The PRESIDING OFFICER. The Chair is not aware if such a disclosure 
has been made.
  Mr. CORNYN. Mr. President, under those circumstances, I raise a point 
of order that the amendment is not in order since it violates the 
provisions of Senate rule XLIV, paragraph 4(a).
  The PRESIDING OFFICER. Paragraph 4(a) of rule XLIV requires that the 
Senator who proposes an amendment containing any congressionally 
directed spending item ensure as soon as practicable that the list of 
such items be printed in the Congressional Record. The provision is not 
enforceable and no point of order lies.
  Mr. CORNYN. Mr. President, I appeal the ruling of the Chair and I ask 
for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I move to table the appeal of the ruling 
of the Chair and I ask that the vote occur upon the expiration of all 
postcloture time.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. BAUCUS. I ask for the yeas and nays on the motion to table.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be.
  The yeas and nays are ordered.
  The Senator from Missouri is recognized.
  Mr. BOND. Mr. President, last week I had a little fun with an old 
holiday classic: Clemente Clark Moore's ``The Night Before Christmas'' 
which you can still find on YouTube, by the way. While I meant this 
parody to bring some much needed levity to the process, the points I 
made are very serious. For the American people, there is nothing more 
serious than the reform bill we are considering today.
  The majority's so-called reform package will restructure one-sixth of 
our struggling economy, drive health care costs higher, force millions 
off their current plan, put health care decisions in the hands of 
bureaucrats, cut seniors' Medicare, raise taxes, and hurt small 
businesses and cost jobs.
  There is nothing funny about this health care bill. Americans faced 
with rising premiums asked for bipartisan reform to make health care 
costs affordable. But the Democratic bill fails to give the American 
people what they want, which is why Senator Reid has written bill after 
bill behind closed doors with no Republicans. The majority party 
doesn't want Americans to know they are getting a lump of coal for 
Christmas until it is too late.
  But Leader Reid has outdone himself on the latest deal he cut. His is 
Chicago-style politics at its worst: a 2,700-page backroom deal written 
behind closed doors, full of political payoffs, vampire votes in the 
dead of night, all to pass a health care bill before Christmas that the 
American people don't want, that will increase health care costs, raise 
taxes, and cut Medicare for seniors, operating under an arbitrary 
deadline which seems designed to minimize transparency, understanding, 
and public involvement.
  But I want the American people to know what they are getting from the 
majority this holiday season. I don't want my good friend from Nevada 
to be known as Hurry-up-and-Reid, so let's talk about what is in this 
bill.
  Under the majority's latest backroom deal, Americans are getting more 
taxes. This deal imposes about $500 billion in fees and taxes on 
individuals, families, and businesses.
  Under the majority's latest backroom deal, Americans who own small 
businesses--the backbone of our economy--are getting more taxes and 
costly regulation. For small businesses who employ a large number of 
those currently uninsured, this bill does nothing to help make 
insurance more affordable or accessible.
  The bill contains a costly employer mandate which destroys job 
creation opportunities for employers. It doesn't take a rocket 
scientist or an economist to figure out that the multiple penalties 
small businesses will pay for full-time workers will result in these 
companies forcing workers from full time to part time and discouraging 
new hiring. Companies are going to have to think twice before hiring 
new full-time

[[Page S13811]]

workers if it is going to cost them a pretty penny, at a time when the 
companies are trying to pinch pennies.
  There is also a paperwork mandate which is a new administrative 
burden on small business which, according to the National Federation of 
Independent Business, will impose a direct $17 billion burden on 
businesses.
  Unfortunately for small businesses, unlike larger businesses or 
unions, the news gets even worse. Unlike large businesses, most small 
businesses can only find and purchase health insurance in the private 
insurance marketplace. That means to insure their employees, small 
businesses have to go to the big insurance companies on which the Reid 
bill is placing hefty new fees. Most folks don't have a problem with 
putting more fees on insurance companies. It seems to be politically 
popular, but it is economics 101 that these insurance companies are not 
going to suck it up and swallow all of these new fees themselves. CBO 
has stated so explicitly. Instead, they will pass the fees on to small 
businesses that will have no choice but to purchase their services.
  One of the gimmicks the majority is using to hide the cost of the 
bill is a weak tax credit that is supposed to help small businesses in 
purchasing health insurance.
  The hitch is that small businesses will only receive the full tax 
benefits if they have less than 10 employees. If they hire that 11th 
employee, the tax credit is reduced. At 25 employees the tax credit is 
no longer available.
  In addition, a small business can only get full credit if it pays its 
employees an average of $25,000 a year or less. So no salary increase, 
no wage increases.
  In other words, in what is already a horrible economic situation, 
where businesses are shuttering their doors and workers are being laid 
off, we are actually going to punish small businesses for hiring new 
employees and paying workers more.
  This tax credit is also a case of bait and switch. If your small 
business happens to fit in the narrow qualifications, it is only 
temporary--after 6 years the credit goes away--but the mandates and 
burdens on small businesses stay.
  That is why the National Federation of Independent Businesses, in 
their strong opposition to the majority's plan, stated that it:

       will not only fail to reduce and control the constantly 
     climbing healthcare costs small business owners face, but it 
     will result in new and greater costs on their businesses. 
     Reform that was supposed to be all about small business has 
     turned out to be more about big business and other late-night 
     dealmakers, all at the expense of our nation's job creators.

  That is not the kind of reform small businesses can afford.
  Under the majority's latest backroom deal, Americans are getting 
hundreds of millions of dollars in cuts to critical health care 
programs, such as $118 billion in cuts to Medicare Advantage, as well 
as cuts to hospitals, nursing homes, home health agencies, and 
hospices.
  When government forced through massive cuts to home health in the 
late 1990s, the unintended consequences were costly and tragic in 
Missouri. A significant number of agencies closed, forcing patients 
into more expensive care.
  One example is in one county in Missouri, the county's only home 
health agency closed. The provider had 40 patients they served in homes 
at a cost of $400,000 a year. When those patients were cut off, 30 were 
forced into hospitals or nursing homes. The cost skyrocketed for these 
patients to a staggering $1.4 million on the government tab or a $1 
million larger hit to taxpayers. We don't even know what happened to 
the other 10 patients who lost this critical care.
  This is not the kind of reform Americans can afford. Under the 
majority's latest backroom deal, States are also getting hit hard. For 
example, the majority's big plan is to expand Medicaid, but their big 
plan for paying for it is to put the burden on the States; that is, 
unless you were able to cut a backroom deal like Nebraska, which leaves 
other States holding the bag for their costs.
  That brings me to my next point. Under the majority's latest backroom 
deal, Americans are forced to fund a number of political payoffs. There 
are such a large number of political payoffs, which is why this bill is 
starting to be dubbed ``cash for cloture.''
  There is a carve-out for the insurance industry in Michigan and 
Nebraska. There is an extra $300 million in Medicaid funding for 
Louisiana, now known as the ``Louisiana purchase.'' What was the 
mysterious $100 million for a ``health care facility'' turns out to be 
a hospital in Connecticut.
  Sadly, this isn't even the entire list of sweetheart deals in Reid's 
latest backroom deal. That is not the kind of reform Americans want.
  With Chicago politics and backroom deals such as this, it is no 
surprise that poll after poll makes clear the American people are 
saying no to the Democrats' proposals.
  The latest poll released by Quinnipiac University found that American 
voters ``mostly disapprove'' of the plan--53 to 36 percent.
  A recent Washington Post/ABC News poll, detailed in a Post article, 
found the American public generally fearful that a revamped system 
would bring higher costs while worsening the quality of their care.
  The American public is absolutely right. Americans don't want this 
bill. In the classic tale called ``The Christmas Carol,'' Scrooge is 
given the opportunity to see the ghosts of Christmas past, present, and 
future. While the Democrats are trying to paint the GOP as ``Scrooge,'' 
they would do well to look at what the Christmas future would look like 
if their bill were to pass.
  We don't want to wake up next Christmas and have Americans paying 
more for health care or being unable to get it or losing their jobs. 
But under the majority's latest backroom deal, that is the future.
  Next Christmas, we don't want to see small businesses that still 
cannot afford to offer health insurance to employees or, worse, small 
businesses struggling to keep their doors open because of the costly 
new burdens in this bill. Under the majority's latest backroom deal, 
that is the future. A year from now we don't want to hear that seniors 
have lost access to services and care. Unfortunately, that is the 
Christmas future we face if the bill passes. Christmas future--several 
years from now--could look even worse.
  That is why in my ``The Night Before Christmas'' parody it was not 
funny as much as it was scary and true when I said:

       But I could not catch the holiday spirit myself; how far 
     away from common sense we've been led, our kids and our 
     grandkids have their futures to dread.

  In the last year, my colleagues on this side of the aisle watched 
with dismay as the wheels have come off Federal spending; a trillion 
dollars of taxpayer money here and a trillion dollars there. Got a 
problem? Throw money at it. Will historians look back and say the 111th 
Congress is where the decline of American economic power began in 
earnest? I don't want that on my watch. We can reform health care 
without spending trillions of our children's and grandchildren's money.
  If the majority were to bring up a bill that made health insurance 
more affordable for small business owners to purchase for their 
employees, that eliminated frivolous lawsuits, that emphasized wellness 
and prevention programs, they could go a long way to solving the 
problems of the uninsured and underinsured, and they could probably get 
80 or 90 truly bipartisan votes. Instead, what they want, apparently, 
is to take over health care, at a tremendous cost to individuals, 
families, and businesses, and to increase the dependency on the Federal 
Government. That is not a Christmas present I want, and I don't want to 
give it to the American people.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Wyoming is recognized.
  Mr. ENZI. I thank the Senator from Missouri for his comments. He has 
been chairman of the Small Business Committee. Small business plays a 
huge role, the biggest role, in the economy of the United States.
  We could have, and we should have, spent the last 4 weeks talking 
about what needed to be done with small business. It is a big issue and 
it is important. I appreciate the emphasis the Senator from Missouri 
has put on it through the years.
  I want to talk about the whole bill today, because a quote I ran into 
was that ``absolute power corrupts--absolutely.''
  The Democrats have absolute power right now. Under the biggest 
requirement for votes, it only takes 60 in the

[[Page S13812]]

Senate. The Democrats have 60 votes. In the House, they have a clear 
majority of the votes, and that is all that is required to pass a bill 
there. They are under the impression that they won the election, so 
they get to write the bills. Never before has that happened on a major 
piece of legislation.
  Everyone in this country should be upset when the majority refers to 
bills like ending slavery and civil rights and Medicare and welfare 
reform and paint the Republicans as the opposition. Substantial numbers 
on both sides of the aisle made those bills possible. I am pretty sure 
people remember that it was Lincoln, a Republican, who led the fight to 
abolish slavery. Leader Mansfield gives Everett Dirksen, a Republican 
from Illinois, credit for the leadership that made the civil rights 
bill possible. In every instance, until now, Republicans have had a 
leadership role and both sides have substantially participated in 
making and voting for those laws. In politics, that is how it has to 
work for our country to be successful.
  Only one party, and especially one person, ``gains'' from this so-
called health care reform bill. The President will be able to show how 
he was able to accomplish something against all odds. Why against all 
odds? Because the Democrats of the Senate wrote off the 40 votes of the 
Republicans. That is right, we were written off from the start. Oh, 
yes, we were allowed to participate to see if we couldn't be persuaded 
to take what the Democrats wanted to write and foist on America. 
Anything short of buying the whole Democratic plan and we could be and 
would be thrown overboard because our votes aren't needed. We were 
thrown overboard with the excuse of phony time deadlines, when it was 
needing to do just the Democratic ideas.
  Senator Kennedy and I were able to work through an incredible number 
of bills because we recognized that both sides had good ideas and both 
sides had bad ideas. The trick was to take as many of the good ideas as 
possible and have the courage to tell some on both sides that their 
idea wasn't ready for prime time. With evenhandedness and both leaders 
promoting the surviving ideas, many of the bills were unanimous on both 
ends of the building. Were there flaws in some of the bills? Yes. No 
bill is perfect. On the simplest solutions, nobody, particularly those 
who have never been involved in that business or that area, can 
comprehend all of the unintended consequences. But when it is both 
parties acting in concert, when problems come up, solutions are sought. 
When bills are done by one party--and no all-encompassing bill has been 
done this way ever before--when the bills are done by one party, those 
inevitable flaws result in justified finger pointing.
  You can't change such a basic part of the economy--something that 
affects every single person--by ignoring many who have experience in 
the business and in the area and not expect major flaws. The American 
people even recognize the flaws--already. Of course, everybody has some 
knowledge of health care, since it affects us all. When those flaws 
develop, and they will, in an avalanche, everybody will point to one 
party, the Democratic party, and say why did you have to prove your 
power? Why didn't you work to get it right? Why did you have to 
polarize the issue to show you were the only ones concerned about 
people?
  Of course, the Republicans will be compelled to pull out the proof 
that we warned about the flaws but were ignored, because the Democrats 
are focused on proving that they won the election. Normally, there is 
plenty of blame to go around, but not on this one.
  The Republicans were thrown overboard. That only left the 60 votes 
needed to pass the bill. Well, you cannot get 60 people to agree on 100 
percent of anything. You could not get 60 people to agree on a place to 
eat dinner. But all 60 had to agree. That is where you have to move 
away from legislating and into dealmaking. That is when you have to 
start playing games like ``Let's Make a Deal'' or ``The Price is 
Right.'' I don't want to downplay how masterful the leader was. 
Everyone has to be in awe of his ability to give much to a few and none 
to many and get 100 percent to stay on what they can see from the polls 
is a sinking ship. How can a person discriminate between Members, 
between States? Usually, we do earmarks in appropriations bills. Now we 
are starting to do them in policy bills. Why? To buy votes. The leader 
is buying votes with taxpayer money for things the majority of the 
taxpayers will never benefit from.
  I don't have time to go into the way the groups have made hidden 
deals for this bill, such as the American Medical Association and big 
pharmaceuticals.
  I don't have time to talk about how taxes will go up and premiums 
will be up. As an accountant in the Senate, you are going to be shocked 
by the numbers--but not until it is too late. I don't have time to 
explain to you how the Democrats are planning to spend the same money 
twice. That is a pretty neat trick, too.
  I don't have time to explain how the government will tell you what 
the minimum amount of insurance is. It is more insurance than most 
Americans have right now. If you don't find a way to buy this better 
package, there will be fines for you to pay. If the government can 
force you to buy insurance and force you to buy what Washington thinks 
is the best, what is next? Will they be able to tell you what kind of 
car to buy? Remember, the government now owns a car company.
  I hope I have time to remind you we all agree that Medicare is going 
broke. But this bill takes almost $500 billion of Medicare money and 
uses it to do new programs--new programs outside of Medicare--that will 
go on forever and need money forever, even after Medicare is broke. 
They even recognize the problem and form a commission to tell us where 
to cut Medicare. That is so they can shift the blame to a commission. 
But the difficulty is they have made special deals that take away the 
commission's ability to make cuts--except to the benefits of seniors. 
They are the only ones left standing. There will have to be cuts--real 
cuts.
  They made a deal. I saw a letter from those who said they support the 
bill. For a while, they had a whole year's worth of change in their 
pay. Now they have 2 months where they will be paid what they think is 
less than adequate but OK to stay in business. Evidently, they think 
that even though the Senate turned it down, because they couldn't 
afford to pay for it, $250 billion in adjustments to what they get paid 
because it wasn't paid for, and we are going to come back and do that 
without it being paid for. It could have been paid for out of the 
Medicare money if they were using it for Medicare only.
  I ask unanimous consent to have printed in the Record the Effects of 
the Patient Protection and Affordable Care Act on the Federal Budget 
and the Balance in the Hospital Insurance Trust Fund.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

       CBO has been asked for additional information about the 
     projected effects of the Patient Protection and Affordable 
     Care Act (PPACA), incorporating the manager's amendment, on 
     the Federal budget and on the balance in the Hospital 
     Insurance (HI) trust fund, from which Medicare Part A 
     benefits are paid. Specifically, CBO has been asked whether 
     the reductions in projected Part A outlays and increases in 
     projected HI revenues under the legislation can provide 
     additional resources to pay future Medicare benefits while 
     simultaneously providing resources to pay for new programs 
     outside of Medicare.


                      how the HI trust fund works

       The HI trust fund, like other Federal trust funds, is 
     essentially an accounting mechanism. In a given year, the sum 
     of specified HI receipts and the interest that is credited on 
     the previous trust fund balance, less spending for Medicare 
     Part A benefits, represents the surplus (or deficit, if the 
     latter is greater) in the trust fund for that year. Any cash 
     generated when there is an excess of receipts over spending 
     is not retained by the trust fund; rather, it is turned over 
     to the Treasury, which provides government bonds to the trust 
     fund in exchange and uses the cash to finance the 
     government's ongoing activities. This same description 
     applies to the Social Security trust funds; those funds have 
     run cash surpluses for many years, and those surpluses have 
     reduced the government's need to borrow to fund other federal 
     activities. The HI trust fund is not currently running an 
     annual surplus.
       The HI trust fund is part of the Federal government, so 
     transactions between the trust fund and the Treasury are 
     intragovernmental and leave no imprint on the unified budget. 
     From a unified budget perspective, any increase in revenues 
     or decrease in outlays in the HI trust fund represents cash 
     that can be used to finance

[[Page S13813]]

     other government activities without requiring new government 
     borrowing from the public. Similarly, any increase in outlays 
     or decrease in revenues in the HI trust fund in some future 
     year represents a draw on the government's cash in that year. 
     Thus, the resources to redeem government bonds in the HI 
     trust fund and thereby pay for Medicare benefits in some 
     future year will have to be generated from taxes, other 
     government income, or government borrowing in that year.
       Reports on HI trust fund balances from the Medicare 
     trustees and others show the extent of prefunding of benefits 
     that theoretically is occurring in the trust fund. However, 
     because the government has used the cash from the trust fund 
     surpluses to finance other current activities rather than 
     saving the cash by running unified budget surpluses, the 
     government as a whole has not been truly prefunding Medicare 
     benefits. The nature of trust fund accounting within a 
     unified budget framework implies that trust fund balances 
     convey little information about the extent to which the 
     Federal government has prepared for future financial burdens, 
     and therefore that trust funds have important legal meaning 
     but little economic meaning.


  the impact of the PPACA on the HI trust fund and on the budget as a 
                                 whole

       Several weeks ago CBO analyzed the effect of the PPACA as 
     originally proposed on the HI trust fund (http://www.cbo.gov/
ftpdocs/107xx/doc10731/Estimated_Effects_of 
     PPACA_on_HI_TF.pdf). CBO and the staff of the Joint Committee 
     on Taxation (JCT) estimated that the act would reduce Part A 
     outlays by $246 billion and increase HI revenues by $69 
     billion during the 2010-2019 period. Those changes would 
     increase the trust fund's balances sufficiently to postpone 
     exhaustion for several years beyond 2017, when the fund's 
     balance would have fallen to zero under the assumptions used 
     for CBO's March 2009 baseline projections.
       The improvement in Medicare's finances would not be matched 
     by a corresponding improvement in the Federal government's 
     overall finances. CBO and JCT estimated that the PPACA as 
     originally proposed would add more than $300 billion ($246 
     billion + $69 billion + interest) to the balance of the HI 
     trust fund by 2019, while reducing Federal budget deficits by 
     a total of $130 billion by 2019. Thus, the trust fund would 
     be recording additional saving of more than $300 billion 
     during the next 10 years, but the government as a whole would 
     be doing much less additional saving.
       CBO has not undertaken a comparable quantitative analysis 
     for the PPACA incorporating the manager's amendment, but the 
     results would be qualitatively similar. The reductions in 
     projected Part A outlays and increases in projected HI 
     revenues would significantly raise balances in the HI trust 
     fund and create the appearance that significant additional 
     resources had been set aside to pay for future Medicare 
     benefits. However, the additional savings by the government 
     as a whole--which represent the true increase in the ability 
     to pay for future Medicare benefits or other programs--would 
     be a good deal smaller.
       The key point is that the savings to the HI trust fund 
     under the PPACA would be received by the government only 
     once, so they cannot be set aside to pay for future Medicare 
     spending and, at the same time, pay for current spending on 
     other parts of the legislation or on other programs. Trust 
     fund accounting shows the magnitude of the savings within the 
     trust fund, and those savings indeed improve the solvency of 
     that fund; however, that accounting ignores the burden that 
     would be faced by the rest of the government later in 
     redeeming the bonds held by the trust fund. Unified budget 
     accounting shows that the majority of the HI trust fund 
     savings would be used to pay for other spending under the 
     PPACA and would not enhance the ability of the government to 
     redeem the bonds credited to the trust fund to pay for future 
     Medicare benefits. To describe the full amount of HI trust 
     fund savings as both improving the government's ability to 
     pay future Medicare benefits and financing new spending 
     outside of Medicare would essentially double-count a large 
     share of those savings and thus overstate the improvement in 
     the government's fiscal position.

  Mr. ENZI. Mr. President, I ask unanimous consent to have printed in 
the Congressional Record a December 22 article from the Casper Star 
Tribune, by nationally syndicated columnist Cal Thomas.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

             [From the Casper Star Tribune, Dec. 22, 2009]

                               Snow Jobs

                            (By Cal Thomas)

       There were two snow jobs in Washington over the weekend. 
     One came from the sky as a record December snowfall blanketed 
     the city. The other came from Capitol Hill where the Senate 
     labored to cover up the real effects of its massive ``health 
     care reform'' bill.
       All you need to know about this monstrosity is contained in 
     a paragraph from page four of the Congressional Budget 
     Office's 21-page letter to Senate Majority Leader Harry Reid: 
     ``According to CBO and (the Joint Committee on Taxation's) 
     assessment, enacting the Patient Protection and Affordable 
     Care Act with the manager's amendment would result in a net 
     reduction in federal budget deficits of $132 billion over the 
     2010-2019 period. In the subsequent decade, the collective 
     effect of its provisions would probably be continued 
     reductions in federal budget deficits if all of the 
     provisions continued to be fully implemented. Those estimates 
     are subject to substantial uncertainty.''
       So uncertain are they that the CBO later noticed an error 
     in its calculations and a day later on Sunday, Dec. 20 
     delivered another letter to Senate leaders that said: 
     ``Correcting that error has no impact on the estimated 
     effects of the legislation during the 2010-2019 period. 
     However, the correction reduces the degree to which the 
     legislation would lower federal deficits in the decade after 
     2019.''
       The public is being asked to swallow a bill that most 
     senators haven't read, contains cost projections that are 
     substantially uncertain, and touts outcomes that can be 
     reasonably predicted to be nothing that resembles what 
     Democrats are promising.
       Senator Ben Nelson, Nebraska Democrat and a supposedly 
     staunch pro-lifer, agreed to vote for the bill after, as the 
     Washington Post put it, he got ``abortion language'' he 
     wanted and ``also secured other favors for his home state.'' 
     That's what it's ultimately about: getting favors for your 
     home state so you can be re-elected. Re-election trumps the 
     Constitution and the will of the people, most of whom oppose 
     the Senate and House health care ``reform'' bills.
       Even one's stand on a moral issue like abortion can be 
     compromised for the right deal. Inserting language that 
     supposedly restricts federal funding of abortion in order to 
     provide political cover to Sen. Nelson turns out to be a 
     sham. According to House Minority Leader John Boehner, whose 
     office wrote a critique of Reid's 383-page Manager's 
     Amendment, ``Everyone enrolled in these (health) plans must 
     pay a monthly abortion premium and these funds will be used 
     to pay for the elective abortion services. The Reid amendment 
     directs insurance companies to assess the cost of elective 
     abortion coverage and charge a minimum of $1 per enrollee 
     every month.''
       Some defenders of this deal argue that federal money will 
     be magically segregated when it comes to abortion and that 
     money going to abortion providers will be for other 
     ``services.'' Even if this were true--and there is little 
     truth coming out of Washington these days--that is like 
     saying the government won't pay for the actual procedure, but 
     it will subsidize other costs, such as the electric bill and 
     the rent on the clinic's office space.
       Republicans have done a good job highlighting the multiple 
     flaws in the Senate bill (and the similarly long House bill). 
     Most importantly for seniors, the Senate bill slashes 
     hundreds of billions of dollars from Medicare to pay for a 
     new-government program. It includes massive tax increases on 
     individuals businesses, which means businesses are unlikely 
     to hire workers at a time of double-digit unemployment. It 
     includes a massive new entitlement program--the CLASS Act 
     (short for Community Living Assistance and Support 
     Services)--which Budget Committee Chairman Kent Conrad has 
     described as ``a Ponzi scheme of the first order'' and which 
     was recently opposed by a bipartisan majority, including 11 
     Democrats.
       To their credit, Republicans have stood together in 
     opposition to this health care fiasco. Their pledge to voters 
     in the November 2010, election should be to repeal the 
     measure and to offer real insurance and health care reform 
     that will not include an abortion provision, new taxes, more 
     entitlements and a bigger bureaucracy.
       Yes, it can be done.

  He says:

       There were two snow jobs in Washington over the weekend. 
     One came from the sky as a record December snowfall blanketed 
     the city. The other came from Capitol Hill where the Senate 
     labored to cover up the real effects of its massive ``health 
     care reform'' bill.

  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. ENZI. Mr. President, I ask unanimous consent to have printed in 
the Record a Wall Street Journal article called ``ObamaCare's 
Longshoremen Rules.''
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                     [From the Wall Street Journal]

                     ObamaCare's Longshoremen Rules

       President Obama praised the Senate yesterday for clearing a 
     60-40 procedural vote on his health plan in the dead of night 
     and ``standing up to the special interests who've prevented 
     reform for decades and who are furiously lobbying against it 
     now.'' They're furiously lobbying all right--not against 
     ObamaCare but for the sundry preferences in the Senate bill.
       Start with the special tax carve-outs included in the 
     ``manager's amendment'' that Harry Reid dropped Saturday 
     morning. White House budget director Peter Orszag has claimed 
     that the bill's 40% excise tax on high-cost insurance plans 
     is key to reducing health costs. Yet the Senate Majority 
     Leader's new version specifically exempts ``individuals whose 
     primary work is longshore work.'' That would be the 
     longshoremen's

[[Page S13814]]

     union, which has negotiated very costly insurance benefits. 
     The well-connected dock workers join other union interests 
     such as miners, electrical linemen, EMTs, construction 
     workers, some farmers, fishermen, foresters, early retirees 
     and others who are absolved from this tax.
       In other words, controlling insurance costs is enormously 
     important, unless your very costly insurance is provided by 
     an important Democratic constituency.
       The Reid bill also gives a pass on the excise tax to the 17 
     states with the highest health costs. This provision applied 
     to only 10 states in a prior version, but other Senators made 
     a fuss. So controlling health costs is enormously important, 
     except in the places where health costs need the most 
     control.
       Naturally, the Secretary of Health and Human Services will 
     decide how to measure ``costs'' and therefore which 17 states 
     qualify. (Prediction: Swing states that voted for Mr. Obama 
     in 2008 or have powerful Democratic Senators.)
       These 11th-hour indulgences make a hash of Mr. Orszag's 
     cost-control theories and Mr. Obama's cost-control claims. 
     Their spin has been that wise men would convene and make 
     benevolent decisions about everyone's health care based only 
     on evidence and the public good. But as the Reid bill shows, 
     politics will always dominate when Washington is directing a 
     U.S. health industry that is larger than the economy of 
     France.
       Or take a separate $6.7 billion annual ``fee'' on insurance 
     companies that is supposed to be divvied up by market share. 
     This beaut doesn't claim to be anything more than a revenue 
     grab, but at the behest of Michigan Senator Carl Levin 
     Democrats chose to apply it to some insurers and not others. 
     Select companies incorporated as nonprofits will be exempt, 
     even though nonprofits typically have net income exceeding 
     for-profit companies because they pay no taxes.
       Since this new tax will merely be passed through as higher 
     premiums, the carve-outs mean that cost increases will be 
     even higher for workers whose employer contracts with a 
     nonfavored insurer. These gyrations to tax law are so complex 
     that it still isn't clear which nonprofits would qualify, but 
     the protections are sure to apply to certain insurers in 
     Michigan, Illinois and California. The poor saps stuck with 
     higher premiums everywhere else can thank Mr. Levin and 
     Senators Debbie Stabenow, Dick Durbin, Barbara Boxer and 
     Dianne Feinstein.
       The press corps is passing this favoritism off as sausage-
     making necessary to ``make history,'' but that's an insult to 
     sausages. What this special-interest discrimination 
     illustrates in how all health-care choices will soon be made 
     as Washington expands its political control over one-seventh 
     of the U.S. economy.

  Mr. ENZI. It points out how there will be an excise tax in 17 States 
with the highest costs, but yet we made an exception for a number of 
unions, particularly the longshoremen's union not being subject to some 
of the taxes in the bill.
  Mr. President, I ask unanimous consent to have printed in the Record 
a letter from a number of contractors.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                                December 21, 2009.
     U.S. Senate,
     Washington, DC.
       Dear Senator: We are writing to express our strong 
     opposition to language contained in the Manager's Amendment 
     to H.R. 3590, which excludes the construction industry from 
     the small business exemption contained in the bill. We regret 
     that this is our first opportunity to address this issue, 
     though the fact that the Manager's Amendment was made public 
     less than two days before the first vote on the matter has 
     increased the difficulty of playing a constructive role in 
     the legislative process.
       In recognition of the negative impact that a mandate to 
     provide health insurance will have on employers, H.R. 3590 
     exempts employers with fewer than 50 employees from the fines 
     levied on those who cannot afford to provide their employees 
     with the federal minimum standard of health insurance. 
     However, the Manager's Amendment singles out the construction 
     industry by altering the exemption so that it applies to only 
     those firms with fewer than 5 employees.
       This narrowly focused provision is an unprecedented assault 
     on our industry, and the men and women who every day make the 
     bold decision to strike out on their own by starting a 
     business. Our members' benefit packages reflect the reality 
     of their business models, and they proudly offer the best 
     health insurance coverage that they can afford. It is 
     unreasonable to presume that small business owners can bear 
     the increased cost of these new benefits simply because 
     Congress mandates that they do so.
       In the real world, where the rhetoric surrounding this 
     legislation will meet the stark reality of the employer 
     struggling to make payroll, this special interest carve out 
     is simply another bill to pay in an industry that, with an 
     unemployment rate exceeding 18% and more than $200 billion in 
     economic activity lost in the past year, already is 
     struggling to survive.
       And, we would be remiss if we failed to question the 
     justification for singling out the construction industry to 
     bear such a burden. We are unaware of any data or evidence 
     that suggests that the needs and struggles of a construction 
     contractor with fewer than 50 employees are so different from 
     those of small business owners in other industries, and 
     absent such convincing evidence, we are left to assume that 
     this specific provision is merely a political payoff to 
     satisfy the desires of a small constituency.
       As Congress moves forward in the legislative process for 
     H.R. 3590, we strongly encourage you to address this onerous 
     provision that needlessly single out small construction 
     industry employers.
           Sincerely,
         Air Conditioning Contractors of America, American 
           Institute of Architects, Associated Builders and 
           Contractors, Associated Equipment Distributors, 
           Associated General Contractors, Association of 
           Equipment Manufacturers, Independent Electrical 
           Contractors, National Association of Home Builders, 
           National Federation of Independent Business, National 
           Lumber and Building Material Dealers Association, 
           National Ready-Mixed Concrete Association, National 
           Roofing Contractors Association, National Utility 
           Contractors Association, Plumbing-Heating-Cooling 
           Contractors--National Association, Small Business & 
           Entrepreneurship Council U.S. Chamber of Commerce.

  Mr. ENZI. It points out how most businesses have an exclusion of 50 
employees or less, but they have singled out the construction industry 
with an exemption of 5 employees.
  Mr. President, I ask unanimous consent to have printed in the Record 
a Wall Street Journal article that covers that same topic.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

             [From The Wall Street Journal, Dec. 22, 2009].

        Senate Health Bill Unfair to Construction Industry--NAHB

       ``In their rush to pass massive health care reform before 
     Christmas, Senate Democrats included a last-minute provision 
     overtly targeting the construction industry, including home 
     builders,'' the National Association of Home Builders said in 
     an e-mail alert to its 200,000 members Monday. ``In order to 
     find the 60 votes needed to pass health-care reform, a 
     provision was slipped into the health-care bill to exclude 
     the construction industry from the small business health-care 
     exemption contained in the bill.''
       Employers with more than 50 employees would be required to 
     offer insurance or pay a fine of up to $750 per employee if 
     any employee obtains federal subsidies for coverage. But the 
     builder group says the bill singles out the construction 
     industry by ``only giving construction firms an exemption 
     from the bill's employer mandates if a firm employs less than 
     five people. Every other industry is granted an exemption if 
     they have fewer than 50 employees.''
       Many home builders are small, private organizations working 
     to survive the worst downturn in decades. More than half of 
     the NAHB's members have fewer than five employees. ``You 
     might as well take an industry that has been a cornerstone of 
     the economy and kick it while it's down,'' said Jerry Howard, 
     the Washington-based group's chief executive. ``It makes no 
     sense . . . and it's really bad public policy.''
       The NAHB is urging its members to quickly contact their 
     senators to derail the measure. The Senate, however, is 
     marching toward a Christmas Eve vote. The Senate version 
     needs to be reconciled with a House-passed bill, but is 
     likely to form the core of any final legislation presented to 
     President Barack Obama for his signature.
       If the Senate bill passes and goes to a conference 
     committee with the House, as expected, the House is likely to 
     do most of the reconciling. That's because Senate Majority 
     Leader Harry Reid--after battling for weeks to get the 
     minimum number of votes needed to avert a Republican 
     filibuster--has little room to maneuver. The House passed its 
     version on Nov. 7 on a 220-215 vote.
       President Obama hopes to sign a final bill before his State 
     of the Union address after the first of the year so he can 
     turn to other issues, in particular the economy and jobs.

  Mr. ENZI. Mr. President, the Department of Labor recently reported 
that our Nation's unemployment rate is 10 percent. In States such as 
Michigan, California, Rhode Island, and Nevada, the average rate is 
over 12 percent.
  Millions of Americans have lost their jobs and millions more go to 
work every day worried about keeping the job they have. Businesses of 
all sizes are struggling to keep their doors open and are finding it 
harder and harder to make ends meet.
  Unfortunately, the policies in the Reid health care reform bill will 
only make matters worse for America's businesses and the workers they 
employ.
  When I am home in Wyoming, which is nearly every weekend, my 
constituents ask me: What does health care reform mean for me? 
Unfortunately I

[[Page S13815]]

have to tell them that if the Reid bill is passed, their jobs and their 
paychecks will be in danger.
  The bill being pushed through the Senate imposes $28 billion of new 
taxes on businesses that will eliminate jobs and reduce wages.
  Many business owners cannot provide health insurance. They cannot 
afford insurance for their workers or for their own families. They have 
looked at their bottom lines and understand that they cannot afford to 
buy insurance and continue to stay in business--health insurance simply 
costs too much.
  Rather than addressing the issue and enacting reforms that would 
lower health insurance costs, the majority's health care bill instead 
increase the taxes that these businesses will have to pay.
  These are the same businesses that are already barely making it. 
These are the same businesses that are laying off workers to try to 
survive.
  We know what the new employer taxes in the Reid bill will do, and who 
will ultimately have to pay the price for this misguided policy. These 
taxes will eliminate jobs and be paid for on the backs of American 
workers.
  The Congressional Budget Office has told us that the new job killing 
taxes in the Reid bill will lower wages across this country by $28 
billion.
  We have shed 3.5 million jobs since January of this year and the 
average workweek is now down to 33 hours for the American worker. Yet 
the bill before us today will actually make that situation worse.
  The workers who will be the hardest hit by the job killing tax in the 
Reid bill are those already making the lowest wages and with the fewest 
job opportunities. According to the Congressional Budget Office, 
employer mandates like those included in the Reid bill would quote 
``reduce the hiring of low-wage workers.''
  Low-income workers are already hit hard by the current economic 
conditions. These low-income workers typically have less formal 
education and find it even more difficult to find work. Workers without 
a high school diploma have a 50 percent higher unemployment rate than 
workers with higher education levels.
  Harvard Professor Kate Baicker reported that an employer mandate, 
like the one in this bill, will mean that ``workers who would lose 
their jobs are disproportionately likely to be high school dropouts, 
minority and women''.
  This is in part due to the fact that many of these workers are only 
making minimum wage. Their employers cannot reduce their wages, so 
consequently they will either have to reduce the number of hours these 
employees work or simply get rid of them to make up for the costs of 
the next tax.
  Employer mandates and the job killing taxes that go with them are 
paid on the backs of low-income workers. The job killing taxes in this 
bill fall disproportionately on the people who struggle the most--
putting the jobs they have at risk and making it even more difficult to 
find a new one.
  At a time when Americans across this country are looking for signs of 
an economic recovery, the Senate should be debating a bill that helps 
the situation, rather than a bill that makes it worse.
  The job killing tax in the Reid bill will also discourage employers 
from hiring new workers and growing their business. Any small business 
that currently has 50 or fewer employees will do everything they can to 
avoid hiring that 51st employee in order to avoid these new taxes.
  I filed an amendment to the Reid bill that would protect businesses 
and their workers from the worst effects of the job killing tax. My 
amendment would simply suspend the employer mandate any time the 
unemployment rate goes above 6 percent.
  Between 1999 and 2008, the unemployment rate was about 5 percent. But 
when our economy began to struggle, we saw the unemployment rate rise 
to a point that now we are seeing more than 10 percent unemployment.
  It seems only logical to me that if our economy is struggling and 
people are losing their jobs, we would want to protect workers from 
having their wages cut and even losing their jobs because of the job 
killing tax in the Reid bill.
  I thank the Chair and yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I now yield to Senator Murray from 
Washington--I suggest she be recognized to speak for 7 minutes.
  The PRESIDING OFFICER. The Senator from Washington.
  Mrs. MURRAY. Mr. President, the health insurance system in our 
country has been broken for a very long time. For far too long, 
families and businesses across my home State of Washington have been 
forced to make some tough decisions, spending nights struggling or 
whispering after their kids go to bed about how to pay the bills and 
praying they do not get sick.
  I am proud to say that is about to change. Over the course of months 
of work on this issue, I have noticed it is very easy for this debate 
to tip into the realm of abstractions, to focus on numbers and charts--
to devolve into petty partisanship or ideological inflexibility. Too 
often real people get left out of this conversation--mothers and 
fathers who are scared they are going to lose their jobs; families 
scared they are going to lose their insurance; people with preexisting 
conditions who cannot get coverage and who know they are one hospital 
visit away from bankruptcy; small business owners who cannot afford 
another premium increase and who want to cover their employees but they 
cannot keep up with the rising costs; senior citizens who are forced to 
cut their pills in half to make them last twice as long; people who pay 
their premiums and like their doctors, but when they get sick they find 
out that some of the most personal choices in their lives are being 
made by their insurance companies.
  These are the real people who need real health insurance reform. Most 
Americans seem to fall into one of those categories.
  Over the past few months, I have tried to ensure that the struggles 
of people in my home State are represented in this debate. I told my 
colleagues the stories that I have received in over 10,000 letters and 
e-mails and at roundtables and on the phone, stories told to me too 
often by men and women with tears in their eyes or a quiver in their 
voice, people who are not looking for a handout or a free ride but who 
are pleading for a fair system--a system that works for families or 
businesses like theirs.
  I shared the story of Janet from Seattle. She lost her job, lost her 
insurance, and succumbed to cancer after being forced to wait 6 weeks 
to see a specialist after her throat began to hurt. Janet's story is 
why we need to reform the health insurance system.
  I told my colleagues the story of Joseph and his wife who was denied 
an MRI after complaining of pain in her chest, and only after 3 years 
of fighting her insurance company were they able to determine she had 
breast cancer and begin the treatment she desperately needed. Their 
story is why we need real health insurance reform.
  I told the story of Mark Peters from Port Townsend who owns a small 
technology company. He told me he is being crushed by skyrocketing 
premiums. He offers health insurance to his employees. He does the 
right thing. But he told me he just got a letter from his insurance 
company raising his rates by 25 percent. Mark told me his small 
business cannot sustain increases such as that; no business can. But in 
our current health insurance system, small businesses are often at the 
mercy of the insurance companies. This company's story is why we need 
to reform the health insurance system.
  I told the story of Patricia Jackson from Woodinville who has private 
insurance but cannot keep up with the rising premiums. To provide care 
for her family of four, Patricia told me she paid $840 a month in 2007. 
The next year it was $900 a month, and then $1,186 a month, and again 
her rates were raised recently to a hike of $1,400 a month. That is an 
increase of over 66 percent in just 3 years. Patricia and her family's 
story is why we need to reform the health insurance system.
  I told my colleagues the story of Marcelas Owens. Marcelas Owens is a 
young man I have thought about every single day since I actually met 
him back in June. Marcelas is only 10 years old. He has two younger 
siblings whom you can see in the photo with him. This is his 
grandmother. He and his

[[Page S13816]]

siblings have been through a lot. Two years ago, their mother Tifanny 
lost her life because she was uninsured. She was 27 years old. Tifanny 
was a single mom who worked as an assistant manager in a fast food 
restaurant. She had health care coverage through her job. But in 
September of 2006, Marcelas told me that she got sick, she lost her 
job, she lost her insurance, and ultimately she lost her life. Marcelas 
and his sisters lost their mom.
  Health insurance reform is coming too late for Tifanny. But her story 
and the story Marcelas tells me why we need to reform health insurance.
  Real people, real stories, real needs--that is why we are here now 
and that is why we have to get this done. When we pass this bill, 
Americans will be able to shop for coverage that meets their needs. For 
the first time, insurance companies will have to compete for our 
business, for the business of the American people.
  When we pass this bill, we will end discrimination based on 
preexisting conditions and make it illegal to drop people when they get 
sick.
  When we pass this bill, we are going to give tax credits to small 
businesses and help the self-employed afford care.
  When we pass this bill, we are going to make preventive services 
free, end lifetime coverage limits, and cap out-of-pocket fees. We are 
going to extend the life of Medicare without cutting guaranteed 
benefits while shrinking the doughnut hole gap in drug coverage for our 
seniors.
  When we pass this bill, people such as Mark and Patricia and Joseph 
and his wife will be helped. The memories of people such as Janet and 
Tifanny will be honored. That is why we need to reform the health 
insurance system.
  I thank the more than 10,000 people in my home State of Washington 
who sent me their personal health care stories. Their input has helped 
guide me as I worked on this bill and served as a constant and welcome 
reminder about who I am here to represent.
  I urge my colleagues to stand with these families and with the 
families of the small business owners in their States and across the 
country who desperately need this reform.
  Health insurance reform has been a long time coming. But today we 
stand closer than ever to making it a reality.
  I yield the floor.
  Mr. BAUCUS. Mr. President, I yield 18 minutes to the Senator from 
Minnesota, Mr. Franken.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. FRANKEN. Mr. President, we have been working on this bill for a 
long time, and I am proud of what we are doing here. Every Senator has 
had his or her chance to speak up and help make this a better bill or 
to make their case against the bill.
  Unfortunately, it has been a bit rancorous, and I think that is too 
bad. There have been accusations flying back and forth. Umbrage has 
been taken. This place has become an umbrage factory. I even took 
umbrage once, and I feel badly about that. My colleagues across the 
aisle have taken great umbrage because we have accused them of using 
scare tactics.
  May I point out that the title of the op-ed of my friend from 
Oklahoma in last Wednesday's Wall Street Journal is ``The Health Bill 
Is Scary.'' Exhibit A in our case that the other side has, indeed, used 
scare tactics--the op-ed entitled ``The Health Bill Is Scary.''
  Seriously, when you are talking about people's health, there is more 
than enough fear to go around. Instead of scaring people, we should be 
debating the merits of the proposal in front of us. We have heard a lot 
of stories. We all know our health care system is screwed up. We can 
all agree on that. The most important things to know about the bill are 
what is actually in it and will it help.
  You see, this bill is too important for us to hide it from our 
bosses, the American people. We have a duty to let the American people 
know exactly what we are doing on their behalf. That is why I have been 
so disappointed when my friends and colleagues have said--and I 
actually agree with them--that Americans are confused about what is in 
this bill. They would not be so confused if everyone was being honest 
and forthright about what is in the bill.

  I have heard a lot of misinformation over the last several weeks: 
some on the airwaves and, unfortunately, some right here on the Senate 
floor. Very early Monday morning, I heard a colleague on the floor say 
this bill is going to add $2.5 trillion to our deficit. That is simply 
made up. The nonpartisan Congressional Budget Office, the official 
scorekeeper of Congress, said the bill reduces the debt by $132 billion 
in the next 10 years. They estimate the bill lowers the debt by at 
least five times that amount in the following decade.
  CBO is like a referee, and we all agree to let the referee make the 
call about what things will cost. It is completely possible we will 
disagree on different calls the referee makes during the game. I do not 
always agree with CBO. For example, I do not think they score 
prevention as saving enough. I may be wrong or I may be right, but I 
accept the CBO score because the CBO is the ref. We would not walk away 
from a basketball game saying we won if the other team scored more 
points and just say: It is bad refereeing, we really won.
  So we may not like how CBO scores certain provisions, but it is all 
we can go by. These are the rules of the games to which we agreed. So 
if you are talking on the Senate floor, you cannot just say this bill 
will add $2.5 trillion to the debt when it is not at all what the CBO 
says.
  No wonder people are confused. People who are trying to kill health 
reform are deliberately confusing Americans, and it is working. A 
recent study found that more than half of respondents to health care 
polls say they do not know enough about the bill to give a hard 
opinion. Then opponents use the fact that people are confused as a 
reason to draw out this process.
  The American people are confused and opponents of this bill want more 
time to confuse them even more.
  I have heard a colleague on this floor say this bill would not add 
one day--he said ``not one day''--to the solvency of Medicare. That is 
simply not what the nonpartisan Chief Medicare Actuary found. This is 
the same Actuary who is often cited by opponents of the bill. He has 
determined that it keeps Medicare solvent for an extra 9 years.
  Colleagues on my side are often making statements that might come 
under the heading of overselling, saying that for most people premiums 
will go down. It is true for many Americans, the out-of-pocket costs 
for better, more secure health insurance will go down. But it is also 
true that most health care premiums will continue to go up. It is just 
that they will go up at a slower rate than they would have if this bill 
were not adopted. That is a really good thing.
  This bill is going to pass. So we want people to understand what is 
happening. We are slowing the growth and the cost of health care. I 
want to be crystal clear because I do not want to confuse people 
either. So today I am going to try to cut through all this rhetoric and 
tell you about what is actually in the bill and how it will affect you.
  When I first spoke on this floor on health reform, I related three 
questions that I hear from most Minnesotans. I heard them when I was at 
the State fair, when I spoke with tea-partyers. I heard them in 
Minneapolis and St. Paul. I heard them in Willmar--all across the 
State--and on the Iron Range.
  First, they say health care costs too much; what are we going to do 
about that.
  Second, they ask: What am I going to do if I get sick or my spouse or 
one of my kids get sick and then someone in my family has a preexisting 
condition and then I lose my job? How am I going to get health 
insurance then?
  Third, they ask: If something bad happens to me, am I going to lose 
everything; am I going to go bankrupt?
  Well, now that we are about to pass this bill, let me take each 
question and tell you how this will affect you; what this bill will do 
and what it will not do. Remember, this legislation is an important 
first step but not the final word.
  First, what does this bill do about health care costing so much? 
Let's take a look at a point Dr. Atul Gawande, a Harvard physician, 
makes. He points out that almost half this bill comprises programs to 
try out different ways to lower costs and improve quality. Some have 
criticized this as a

[[Page S13817]]

weakness in the bill, but I think it is a strength. Gawande makes the 
point that when a system is as complex as ours, there is no one-time 
fix. There is not one simple solution. As much as I wish it were true, 
the whole country probably can't be like the Mayo Clinic or 
HealthPartners or other insurance companies in my State or 
InterMountain in Utah or Geisinger in Pennsylvania. So one size may not 
fit all.
  But these projects and pilots will generate solutions to fix the 
biggest problems in health care, such as paying doctors fee for 
service, which rewards volume and not value. For example, thanks to the 
efforts of Maria Cantwell and my colleague, Amy Klobuchar, and others, 
for the first time ever we will include what is called the value index 
in the Medicare payment structure. Doctors and States that provide 
high-quality care at a reasonable cost will no longer be punished for 
that. Instead, they will be rewarded for being effective partners in 
their patients' care.
  The bill also calls for all health insurance companies to use a 
single uniform standard for claims, as we do in Minnesota now, which 
will save our State $60 million just this year. There are lots of 
ideas, and we don't know which ones yet will work the best. But the 
point is, all the key elements are in this bill.
  One program in the bill I am particularly proud of is the Diabetes 
Prevention Program at CDC. I worked on these provisions with my 
Republican colleague, Dick Lugar from Indiana, who is a hero of mine. 
The Diabetes Prevention Program is based on what we have learned in 
Minnesota and in Indiana--prediabetics can avoid becoming diabetic if 
they get access to community services such as nutritional counseling 
and gym memberships. These are proven to cut the risk of developing 
diabetes in half, so people can live healthier lives and their health 
care costs less. We will replicate this program across the country.
  We will also guarantee routine checkups and recommended preventive 
care, such as colonoscopies and mammograms, are covered by all 
insurance plans at no cost. No copays for preventive care.
  I am also happy the bill requires a minimum medical loss ratio, 
something I have been fighting for with Senator Rockefeller. This is 
going to make health insurance companies put at least 85 percent of 
their premiums toward actual health services, not administrative costs, 
marketing campaigns or profits or bloated CEO salaries. Advocates have 
been trying to get these profit restrictions in place in many States, 
but it is usually too hard to fight these companies on a local level. 
So while I am disappointed we don't have the public option, the minimum 
medical loss ratio is a potent measure that will limit insurers' 
profits and put the brakes on skyrocketing premiums.
  Diabetes prevention, minimum medical loss ratio, incentivizing value 
over volume--these are just a few of the innovative ways this bill will 
bring down costs. All the basic ingredients for success are here. Dr. 
John Gruber, professor of economics at MIT, agrees. He says this about 
our bill:

       It's really hard to figure out how to bend the cost curve, 
     but I can't think of a thing to try that they didn't try. 
     They really make the best effort anyone has ever made. 
     Everything is in here. I can't think of anything I'd do that 
     they are not doing in the bill.

  So when two of my colleagues said 2 days ago: There is no health care 
reform in this bill, well, that is confusing.
  The next question I hear from Minnesotans is: What if I get sick and 
lose my job, what will I do?
  This bill reforms the insurance markets, guaranteeing that having 
health insurance equals security. Some of these reforms will kick in 
when the bill passes, others will kick in 4 years from now.
  I wish we could do everything at once, but we are making a complex 
set of reforms and it will take time to implement them and generate the 
cost savings necessary to pay for the benefits you will receive.
  For the Minnesotans who can't afford the coverage they have because 
they are sick or have a preexisting condition, what will this bill do 
for them?
  Well, 6 months after this bill is passed, we will get rid of all 
preexisting condition exclusions for kids, and young adults will be 
able to stay on their parents' insurance until they turn 27. That is 
big.
  Within 90 days, families who get turned down because of preexisting 
conditions will have access to nonprofit insurance coverage designed to 
cover people who can't pay for insurance on their own. These are called 
high-risk pools, and many States, as well as Minnesota, have these 
plans in some form. The good thing is, this bill will invest $5 billion 
to help people afford premiums in the high-risk pools.
  In 2014, anybody who doesn't have an affordable plan through work or 
has been denied coverage will be able to go to a Web site and purchase 
coverage through a new insurance marketplace called the exchange. No 
one will be turned away or charged more because of their health status 
or because they happen to be a woman. It will let you compare plans and 
prices. What you pay will be based on your income. No one will pay more 
than 10.2 percent of their income toward premiums in the exchange. 
Lower income families will pay significantly less. If the coverage you 
are offered through your employer costs you more than 8 percent of your 
income, you can go to the exchange.
  There are millions of people who have insurance and are worried about 
losing what they have; for instance, Minnesotans who work for small 
businesses that are squeezed by growing health care costs. Beginning in 
2010, this bill will give small businesses tax credits to pay up to 35 
percent of their employees' premiums.
  More small businesses will be able to cover more employees more 
affordably. Then, in 2014, once the exchanges are up and running, small 
businesses can choose to go into the exchange so they can pool their 
risk with other small businesses.
  These reforms will bring coverage to an additional 295,000 
Minnesotans by 2019. There should be no confusion. This is real reform.
  Lastly, Minnesotans ask me: Will I go bankrupt from health care 
costs? I hear from a lot of Minnesotans who have maxed out their health 
insurance or who are getting uncomfortably close to their annual or 
lifetime limits. These arbitrary limits let insurance companies off the 
hook and leave you holding the bill when you are sick and need help the 
most.
  Fifty percent of personal bankruptcies in this country are due to a 
health care crisis. The good news is, within 6 months of passing this 
bill, new plans will not have lifetime limits on benefits and will stop 
companies from imposing annual limits on needed care. When the 
exchanges are operational, the use of annual limits will be banned 
entirely.
  I would like to ban all limits on all plans, new and existing, right 
away. But this is an example of how we have had to compromise in order 
to keep the cost of the bill down so we are being fiscally responsible 
and not adding to the debt. I wish to be very clear on that. When this 
bill is fully implemented, it will give Americans access to affordable 
health care so they can avoid going bankrupt when they get very sick. 
That is very good.

  There is more. We will start closing the Medicare prescription 
doughnut hole in 2010. We will invest in home visits for new mothers, 
more loan forgiveness for primary care providers and for doctors who 
practice in rural areas, the Public Health Investment Fund, stronger 
antifraud laws, support for people with disabilities to stay out of 
nursing homes, and funding for community health centers.
  I said at the beginning of this debate there would be amendments that 
make it an even better bill and there would be amendments that make it 
less to my liking and, therefore, a less good bill from my point of 
view. But I also said I would only support a bill if it makes quality 
health care available to tens of thousands of additional Minnesotans 
and tens of millions more Americans. We have all compromised on many 
fronts, but the bill we have before us is real reform and deserves our 
support.
  The bill deserves our support because Minnesotans and Americans can't 
wait any longer. As Martin Luther King, Jr., once said: ``Of all the 
forms of inequality, injustice in health care is the most shocking and 
inhumane.'' We have the opportunity to express our humanity

[[Page S13818]]

today, to make our country healthier and more secure for generations to 
come.
  I would like to conclude by sharing a letter I received from John 
Goldfine in Duluth, MN. John operates a business on the shores of Lake 
Superior and wrote to share the requests he had received to donate 
money to fellow community members facing financial crises because of 
health care costs.
  John was asked to donate to a cancer benefit for a woman who has 
melanoma.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. FRANKEN. I ask unanimous consent for 2 more minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. FRANKEN. John was asked to donate to a cancer benefit for a woman 
who has melanoma, to attend a spaghetti dinner for an 11-year-old with 
brain cancer, a bake sale for a woman in need of a new kidney, and a 
pancake breakfast for a burn survivor. This is what John says:

       As a business owner in Duluth, these are just a few of the 
     requests that we have received these last few years. We have 
     given a donation towards these fundraisers to help people pay 
     for their medical expenses. As I travel the country and go 
     into grocery stores, restaurants and convenience stores, I 
     always take a minute to look at what is going on in the area. 
     Rare is the time that I do not see a fundraiser to help 
     someone with their health care bills and expenses. I know you 
     know how wrong this is, but I am left wondering what some of 
     your fellow Congressmen and Senators are thinking. Maybe they 
     need to go home and look at some of these community bulletin 
     boards. Every time I look at one of these I want to cry. I 
     know how hard this battle is. I know there will be more 
     compromises, but please do not leave empty handed. There are 
     so many people out there that really need some help.

  I am proud I am voting for this bill to provide help for the people 
who need it.
  I thank the Presiding Officer for the extra time, and I yield the 
floor.
  The PRESIDING OFFICER. The deputy majority leader is recognized.
  Mr. DURBIN. Mr. President, I wish to thank my colleague. That letter 
from his constituent is heartfelt and should be an inspiration to all 
of us to get this job done. We have sacrificed. This is the 24th day 
debating this bill. Some of these sessions have been early in the 
morning and late at night, but I think the time has been well spent. 
People have come to the floor and spoken at great length but no one 
more eloquently than your constituent who sent you that letter.
  Come tomorrow morning, we will have the official vote--very early in 
the morning. I would like to say to my colleagues from West Virginia 
and Minnesota that we have a piece of news. A lot of what has been said 
on the floor has been said by others and said before, but this is a 
piece of news worth reporting. Our bill--the health care reform bill--
has been endorsed by the American Medical Association, the largest 
physician organization in this country; endorsed by the American 
Hospital Association, the largest organization representing our 
hospitals; it has been endorsed by the American Association of Retired 
Persons, the largest senior citizens organization, which focuses 
intensely on the future of Medicare; and today we have received the 
endorsement of what is regarded by most as the most highly respected 
medical organization in America. If you ask most Americans whom do you 
respect the most, it is the nurses. You know why. Because when you are 
in a hospital with someone you love or in the care of a doctor, it is 
the nurse who is with you in those moments that make a lifetime. The 
nurses today have issued their formal endorsement of this health care 
reform bill.
  The nurses today have Rose Gonzalez, director of government affairs 
for the American Nurses Association, who writes:

       Nurses across this country have waited decades for this 
     historic moment and the time is at hand.
       Once again, the need for fundamental reform of the U.S. 
     health care system is critical. ANA and nurses around the 
     country are ready to work with you toward enactment of the 
     strongest possible health care reform legislation.

  For all of our critics from the other side of the aisle, the simple 
fact is this: The people who are on the front line of health care, the 
people to whom we turn every day for critical care and critical 
treatment of the people we love, endorse this measure. They have come 
out foursquare for it. I would rather have their endorsement than any 
political endorsement we might find.
  Now let me tell you how this is significant. This bill will change 
many things. Some on the other side have criticized the bill because it 
is too big; they want a small bill. I want a bill that is large enough 
to treat the problem. It is like saying to a doctor: You can give me a 
prescription but only give me one; I can only take one prescription at 
a time.
  In this bill we address problems existing in our health care system 
that go to the heart of the challenge that faces our Nation. We have 
great doctors and hospitals and nurses. But we spend more than twice as 
much as any other nation on Earth per person for health care in some 
areas. Many countries spend a fraction of what we spend and get much 
better results.
  We know the cost of health care is getting beyond us. We know a 
family of four with a health insurance plan now through their employer 
pays, on average, $12,000 a year for premiums. Ten years ago it was 
$6,000. It is projected to double again in just 8 years. People would 
be working to earn $2,000 a month just to pay for health insurance. 
That is before you take the first penny home for your family. That is 
unsustainable.
  The first thing we do is address affordability, start bringing down 
the increase in cost in health care. That is our first responsibility, 
and this bill does it. The second thing it does is extend the reach of 
health insurance protection.
  As I stand here, one out of every six Americans has no health 
insurance. These are not lazy, shiftless people. These are people who 
can't afford it, who work at a place that doesn't offer it, or happen 
to be unemployed. At the end of the day, 60 percent of those people, 30 
million, will have the protection of health insurance. That is 
critically important.
  This bill provides protections needed by the people who have health 
insurance. How many times have you heard about a friend or a family 
member who has to fight an insurance company for the payment for 
critical care that the doctor has ordered, or over a prescription which 
the doctor believes will keep a person healthy or make that person 
well? Those battles are now going to tip to the side of the consumers 
of America. Health insurance companies will not be able to discriminate 
based on preexisting conditions or put caps on lifetime policies or 
tell kids that at age 24 they can no longer be covered by the family 
health care plans. All of those things are changed in this bill, giving 
consumers across America a fighting chance when it comes to health 
insurance.
  Last night I met with several of my colleagues. We talked over dinner 
about how America is going to react to this. It is hard enough to 
digest the contents of this bill, to expect the average American who 
has so many other concerns to digest it may be too much to ask. But I 
asked my staff to give me a list of the things that most Americans can 
expect to see, the changes they can expect to see on a timely basis--
not the long-term changes where 94 percent of people have health 
insurance or would have a better standing to fight health insurance 
companies when they complain, but what will we be able to see. My staff 
came up with a convenient top 10 list which most of us are familiar 
with from late night television shows.
  Within 6 months or a year after this bill is enacted into law, here 
are the top 10 things Americans will notice changing when they buy a 
new health plan: No. 1, if you own a small business you will start 
receiving within 6 months tax credits to help your business pay for 
health insurance for your employees beginning with tax year 2010. Mr. 
President, 144,000 small businesses in my State of Illinois will be 
eligible for the small business tax credit so that small businesses can 
afford to offer health insurance for the owners of the business and for 
their employees. That is No. 1--and this is all within 90 days of 
enactment.
  No. 2, we are going to create immediate options for people who can't 
get health insurance today. We estimate that 8 percent of the people in 
my State have diabetes; 28 percent have

[[Page S13819]]

high blood pressure, and all of them could be denied coverage because 
of this so-called preexisting condition. We are going to put in place 
high-risk pools so these people who can't buy health insurance today 
because of these preexisting conditions, have an option, a place to 
turn to, to buy health insurance. That is No. 2.
  No. 3, and this is good news for every family and every parent: 
Within 6 months after the enactment of this bill, the parents of loved 
ones--3.6 million kids in my State--will sleep better knowing that 
whatever health insurance they have will be required to cover their 
child regardless of any preexisting condition. Any child under the age 
of 18 with a diagnosis of diabetes or a history of cancer or asthma or 
whatever it may be cannot be denied coverage under the family plan, 
within 6 months of this bill being enacted.
  No. 4, you will no longer need to fear an insurance company dropping 
you from coverage once you get sick. It is called rescission, and it 
means as soon as you need the health insurance, the health insurance 
companies run away and say: We are not covering you anymore. Hire a 
lawyer and fight us if you don't like that. That comes to an end within 
6 months after this bill passes.
  No. 5, you will no longer need to worry if you get sick or get in an 
accident because you are out of town and out of the network of 
hospitals and doctors your insurance policy provides. This bill ensures 
access to emergency care in-network and out-of-network without 
additional cost sharing beginning 6 months after the date of enactment.
  No. 6, you will have the freedom to choose your doctor, the person 
you think is right for you and your family. This bill protects your 
choice by allowing plan members to pick any participating primary care 
provider and prohibit insurers from requiring prior authorization 
before a woman, for example, goes in for a gynecological examination.
  No. 7, you will no longer fear losing your home or going bankrupt 
because of a bad car accident or a serious illness such as cancer. This 
bill, when it becomes law, will bar insurance companies from limiting 
lifetime benefits and severely restricting annual benefits under health 
insurance policy.
  No. 8, this bill will require providing preventive services and 
immunizations without copay. Mr. President, 41 percent of the people in 
my State have not had a colorectal cancer screening; 22 percent of 
women in Illinois over the age of 50 have not had a mammogram in the 
past 2 years. Health insurance reform will ensure that people can 
access preventive services for free through the health care plans. It 
makes sense. It is an ounce of prevention and built into the law 6 
months after it passes.
  No. 9, senior citizens are going to notice the difference within 6 
months. They will have access to dramatic discounts in the purchase of 
name-brand prescription drugs under Medicare Part D beginning July 1, 
2010. Roughly 314,000 Medicare beneficiaries in Illinois hit the so-
called doughnut hole, the gap in coverage. They are going to have 
protection. It is going to be provided by this bill.
  No. 10, seniors across America will be eligible for one free wellness 
visit each year without charge. Think about that: the peace of mind 
which it brings to you and to your family to know that you have had a 
checkup, and the doctor said you are doing fine and takes care of a 
problem before it becomes major.
  Those are the top 10 things to expect in the first 6 months or a 
year, and more to follow. This is a bill worth voting for. This is a 
bill which finally puts us on record as a Nation that health care is 
not just the privilege of the lucky and the wealthy. It is a privilege 
of living in this great Nation. It is a right that comes to all of us. 
If we truly want to enshrine that guarantee of life, let's enshrine in 
this bill guaranteed access to quality health care.
  We have had a long debate. Those on the other side have been critical 
of this bill. They have never offered an alternative--not one 
substitute comprehensive alternative. They just can't do it, and they 
won't. But we know we have the responsibility to do it.
  With votes this afternoon, in just a couple of hours and again 
tomorrow morning, we are going to make this bill a bill that is passed 
by the Senate, on its way to conference with the House, and by the 
first of this new coming year, we will be able to offer that promise of 
quality care which the American people are asking for.
  Madam President, I yield the floor.
  The PRESIDING OFFICER (Mrs. Hagen). The Senator from West Virginia.
  Mr. ROCKEFELLER. Madam President, I thank you. I rise today to join 
with my colleagues, in fact, to stand very proudly with my colleagues, 
in support of the Senate passage of groundbreaking comprehensive health 
care reform. I have wanted to say that for decades. It has taken not 
just the better part of a year but, in fact, the better part of a 
generation.
  The story of health care reform over the last 50 years has been one 
of narrow incremental change, some quite meaningful--the Children's 
Health Insurance Program, for example--but none truly comprehensive in 
the way the Americans want to have their health care.
  It is a history of big ideas left unrealized for lack of political 
will, for lack of time--whatever--of leaders and lawmakers and the 
medical profession all trying boldly yet all failing badly; failing 
fundamentally to take away the fear of so many, the terror of living 
and getting sick in America today; the terror of becoming sick in a 
country that holds itself out as a beacon of hope, a beacon of 
fairness, yet denies men, women, and children access to doctors and 
nurses, tests and medicines that we know will prevent illness or will 
make them well; a country that allows people, especially low-income 
people, but not only low-income people, however, to suffer or watch a 
beloved family member suffer alone and outside the health care system--
all at great cost to our national economy and our national productivity 
and our national sense of self-esteem but, even more importantly, to 
our national soul, to our moral compass, to our conscience.
  Now in the final days of 2009 we have a profound opportunity to 
deliver on years and years of unmet promises and to begin a new decade 
by building a strong, new foundation for the American people, for all 
of them; to wit, a more secure and reliable health care system that 
works for virtually all Americans, where those who are uninsured 
finally have some place to go for health care; where those with 
insurance know that the coverage they count on and pay for will be 
there when they need it--they will know that--and where a profit-driven 
health insurance industry does not play mercilessly with people's lives 
or steal their hope so that the health insurance company can have a 
very prosperous future, a very gloomy chapter in our Nation's business 
history.
  Each of us brings to this moment shared stories about the tragic and 
trying personal experiences of our friends and neighbors back home. We 
are all motivated by this bill. We are all moved by this bill. I know 
that West Virginia's struggles with the health care system are not 
unique in America, but they are unique to me because I represent them. 
They are what drive me to work so hard to make things better. That 
never changes.
  I talked about the Bord family. The Bords are two dedicated 
schoolteachers with health insurance through their employer whose son 
Samuel had leukemia and needed treatment well beyond the onerous annual 
insurance limits imposed upon him, without his knowledge, and, 
therefore, his health insurance stopped producing any care for him at 
all at 8 years old. What was he to know?
  Samuel's parents were desperate, and they feared for the worst. When 
he hit his $1 million cap on annual insurance, my office helped his 
parents to find some more resources, but those ran out too. So the 
Bords were left with two gut-wrenching suggestions: consider getting a 
divorce so that Samuel would qualify for Medicaid, or stop taking their 
other two children to the doctor and giving them health care so they 
could spend the money that they had been spending in part on Samuel--
take it all away from the other two children to help with Samuel as 
best they could. When people are desperate, they try anything. The 
choices are all cruel.

  So you get a device or you choose one child's health care needs over 
another's--that is not what parents want to be like. Those are the 
choices our

[[Page S13820]]

Nation offered to these caring, hard-working parents with a sick child. 
How can that be? How can we allow that to be? The answer is, of course, 
that we cannot.
  They did everything in their power, but this fall Samuel passed away. 
There are no words. It breaks my heart to think of what his parents 
went through, not only the pain of watching their son fight a terrible 
disease but also the uncertainty of paying for his treatment as best as 
they could and then have the coverage they counted on and paid for 
suddenly cease to exist.
  I say to my colleagues, when do we say collectively that enough is 
enough? When do we finally step in and try to solve such an enormous 
set of problems? So much is at stake, so many people's needs and 
expectations are so high, and so are mine and so are yours, I say to 
the Presiding Officer. I know all too well that reform is not about 
shying away from the tough issues or the tough decisions. Reform is not 
about reaching perfect agreements on a perfect piece of legislation. 
Reform is making things better for people, as much as you can for as 
long as you can, with as much money as you can possibly collect to pay 
for it.
  There are real and serious differences of opinion among us, among our 
esteemed colleagues in the House of Representatives as well--the 
Senate, the House, there are differences. Within the Senate--one side 
of the aisle, the other side--there are differences. Within the 
Democratic Party, there are differences. We have struggled to find 
solutions that will make a difference, that we can afford. We have had 
to negotiate and compromise.
  Now we vote in a few short hours. It is an extraordinary moment in 
history. There is nothing like it that I have ever seen. We vote, I 
believe, to improve access to affordable and meaningful coverage; to 
control runaway costs--we have to do that so the Medicare trust fund 
doesn't run out; and to rein in the health insurance industry's 
rapacious and, to me, lugubrious practices. I don't like them, and they 
don't like taking care of us, and they don't.
  Am I disappointed that this legislation does not include a strong 
public option, like the one I first introduced, to keep private 
companies honest? Am I disappointed it does not include a sensible 
Medicare buy-in provision that should be a right for millions of 
Americans? Of course I am. Does that mean I turn my back and walk away 
from all of this because I didn't get everything I wanted? Of course 
not. I am a public official. I represent people, I represent their 
interests, even as they, maybe in the majority, oppose what we are 
doing here because they know not yet entirely what is in this bill. But 
when they do, they will feel differently. Am I disappointed that we 
were unable to expand Medicaid even more for our most vulnerable 
Americans? Yes, of course I am. I live in a State where, in the average 
hospital, 85 percent of all patients are either under Medicaid or 
Medicare. As my colleagues on the Finance Committee heard me say often, 
50 percent of all babies born in West Virginia are born under Medicaid. 
That is the way it is there for the people I represent. Yes, of course 
I am disappointed that we do not have more, but I still believe those 
are among the best and right solutions in this bill for our health care 
system. They are the best we can do at this particular time, and it is 
a great deal that we are doing. It is an unavoidable fact that this 
bill does not do everything I had hoped for but, again, that would not 
justify turning my back on what the bill does achieve.
  Why is it that we always seek out the negative and avoid the 
positive? It is because the negative is easier to talk about. It is 
easier to criticize than to do, than to collect people together under 
an umbrella.
  The ultimate question cannot be what the bill does not do. It cannot 
end there because in so many ways what this bill does do is make good 
on the powerful promise of meaningful reform that millions of people 
have dreamt of, have prayed for, have fought for, for so long.
  Passing health care reform will mean 31 million previously uninsured 
Americans will now get health care coverage. Excuse me, 31 million 
people--extraordinary. It is in the bill.
  Passing health care reform will extend Medicaid so that vulnerable 
populations can get the health care they need.
  Passing health care reform will close, almost, the doughnut hole that 
hurts 3.4 million seniors enrolled in the Medicare prescription drug 
program. Mr. President, 3.4 million seniors is a lot. So we close at 
least half the doughnut hole, and then we give people a bonus for this 
coming year. But by closing half, we are signaling that we are going to 
close it all. Health care now will be done each year, every year, to 
make things better.
  Passing health care reform will mean the elimination of preexisting 
condition exclusions right away for our children. As soon as the 
exchanges are up and running, that will also apply to adults.
  Passing health care reform will mean it is illegal for insurance 
companies to impose arbitrary limits, as they did annually on Samuel, 
or lifetime benefits, such as the Bord family faced so courageously.
  Passing health care reform will mean insurance companies are required 
to spend more of their money--which comes from premiums we give them--
on medical care, not fancy offices and executive salaries. They will be 
required to achieve a medical loss ratio of 85 to 90 percent. We shall 
see. They will have to prove it. We already have the numbers. We know 
where to go to get the numbers. Nobody has done it. So they can play in 
their shifty darkness and deprive people of things, take things away. 
People do not know where to go to complain, and they just get referred 
somewhere else. This will be the very first time they are held 
accountable--and they will be held accountable. They will be held 
accountable by the law, by congressional oversight, by a ferocity of 
attention on what health insurance has done to hurt so many people and 
how, now, they are going to behave in a very different manner whether 
they like it or whether they don't.
  Passing health care reform will mean family coverage must include 
dependent children up to the age of 26. That is exciting. It is also 
immediate. But it is exciting because young people don't tend to get 
health insurance because they think nothing will happen to them. It 
actually doesn't work out like that, and when they get hurt, somebody 
else has to pay. They should have their own health insurance, and so 
they are going to get it. They will not be outside the health care 
system; they will be inside the health care system.
  Passing health care reform will mean protecting the Children's Health 
Insurance Program, or CHIP, which John Chafee and I wrote back in the 
mid-1990s and Ted Kennedy and Orrin Hatch first established through the 
HELP Committee in 1997 in a show of bipartisanship--which, frankly, I 
am nostalgic for these days--which will cover more than 14 million 
children by the year 2013. Today, CHIP covers 7 million, but you see it 
has run out of its 10 years, so it has to be reauthorized. Then we add 
on 2 more years, and the program will keep going on and on, and 
children will have health insurance forever.
  Passing health care reform will mean guaranteed prevention and 
wellness benefits for seniors so they can get the regular checkups that 
are so important. It is a big deal. Somebody told me once that there 
are about 9 million American seniors who live alone. In West Virginia, 
it might be on the tops of hills or it might be on some dusty plain, 
but they are basically alone, by themselves. They are aged, they have 
problems. Does anybody check in on them? Does anybody call them? Do 
they have a telephone? Have you eaten your food today? Do you have 
food? Are you OK? Did you fall down? Did you break your hip? Is there 
somebody to check? We have to do a lot better than that. Through this 
bill, we will.
  Passing health care reform will mean we finally begin to get politics 
and lobbyists out of the business of deciding Medicare payments. That 
is very important for me because we can create new hope--perhaps our 
only hope--for keeping Medicare stable and solvent for the long term.
  The list goes on and on--real, meaningful, life-changing and in some 
cases lifesaving new laws and new policies that will become law. Not 
since the creation of Medicare and Medicaid nearly 45 years ago has 
this body or the

[[Page S13821]]

other body attempted to make a commitment as fundamental to our future 
in health care as we are doing here.
  Fortunately, this commitment will not end with the passage of this 
legislation. We will not have to wait another 15 to 20 years to take up 
the cause of reform. Because of the intensity of the experience, the 
passion of the experience, the depth of the feeling in discussing the 
experience as we have talked back and forth with each other, this now 
becomes an annual commitment. We will be doing health care every single 
year until we get it exactly right. We have not gotten here by accident 
or by chance, and we will not get all the way across the finish line 
without more hard work and, hopefully, good will.
  To those on the left who are disappointed in what this bill does not 
do--and in some cases, those folks are even calling for its demise--I 
implore you to reconsider, to be a part of this solution even as we 
keep working on others, which I promise you I will do, and I think you 
know that I mean what I say when I say it. To those on the right who in 
all these years somehow have not seen fit to accept any of the various 
options and ideas that are put on tables for comprehensive reform, I 
ask you to seek the facts, find the truth, follow the facts, follow the 
truth. There are legitimate disagreements between us about how best to 
solve the problems plaguing our health care system and hurting our 
people. But the status quo is unacceptable. Claims that we are rushing 
this process or have operated in secret are absurd. Claims that we will 
hurt seniors, close hospitals, take away people's choices are reckless 
and disingenuous.
  Our work in this institution affects people's lives every single day 
in all the work we do for good or for ill. In public life, really, 
there is nothing neutral: you either do something that helps or you do 
something that hurts. We have a solemn responsibility to help our 
people in their hour of need, and that is the reason we are here. It is 
the only reason we are here--to achieve meaningful reform, not just in 
health care but in all other needs.
  As somebody who has been involved in this debate from the very 
beginning and fought for strong reforms in the Senate Finance 
Committee, I know how far we have come to get here. And I, for one, am 
not going to allow this moment and its great promise to end in 
failure. The progress will be real. The greatly improved quality of 
life for millions of Americans will be its measure.

  I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Madam President, I ask unanimous consent that after 
Senator Hutchison raises a point of order that the Reid substitute 
amendment No. 2786 is a violation of the Constitution, the point of 
order be set aside until after all postcloture time expires.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from Texas.
  Mrs. HUTCHISON. Madam President, I ask the distinguished Senator from 
Montana if, following the postcloture time, my point of order will be 
put in the queue for the votes if I ask for the yeas and nays?
  Mr. BAUCUS. That is my understanding.
  Mrs. HUTCHISON. Madam President, we truly are in uncharted waters. 
This bill has been written by the majority under a veil of secrecy. We 
are expected to vote on its final passage less than 2 days before 
families across the country will be sitting down for holiday 
celebrations. Over the last weeks, my colleagues and I have spoken 
about some of the things we know to be problematic, ranging from 
unsustainable cuts to Medicare that will result in catastrophic 
reductions in care--make no mistake about that--to oppressive new taxes 
on individuals, medical devices, prescription drugs, and insurance 
companies that will clearly raise costs to consumers and stifle 
innovation, to taxes on small businesses at a time when we know our 
economy is on the brink. We are in a recession. We are asking 
businesses to hire people. Yet we are forcing burdens on them, taxes on 
them that would have the opposite effect. It would cause them not to 
take a chance to hire someone who will have the result of new mandates 
that go beyond all the expenses of an employee today. We have talked 
about that for the last 3 weeks.
  Today I wish to talk about the concerns we have been able to have 
about 3 days to find on the constitutionality of parts of this bill. We 
have not had too much time to consider this. Certainly, constitutional 
issues will take much thought. But we do believe some of the bill's 
provisions do violence to our constitutional protections. Members, 
staff, and legal experts are scrambling by the majority's decision to 
draft a bill that we didn't have a chance to look at in detail because 
it only was released on Saturday, and we haven't had very much debate 
time on these legal issues.
  I commend many of my colleagues for identifying one of my biggest 
concerns. The majority claims the commerce clause of the Constitution 
gives Congress the authority to adopt much of what it is we are looking 
at in this substitute before us. What I disagree with and what I don't 
think has been mentioned is, the power to regulate interstate commerce 
has not been the basis for a robust role in insurance regulation. Our 
States have the experience, the infrastructure in place to carry out 
this important regulatory role. In comparison, the Federal role in 
regulating private insurance has been limited. In fact, following the 
decision by Congress to exclude Federal agencies from any antitrust 
role in the insurance market, it is our States that have been charged 
with providing this regulatory oversight during the last 60 years. Yet 
usurping the role of the States in regulating health insurance is 
precisely what the substitute that has been put forward will do.
  Creating a big role for the Federal Government in health care will 
also usurp States, rights that have been in place for over 60 years. 
Consider, for a moment, that the commerce clause is being suggested to 
allow Congress to not only regulate a channel of commerce that 
historically has been addressed by States but for Congress to actually 
direct the American people to purchase a specific product or service. 
Everyone within the sound of my voice should be alarmed that Members of 
Congress actually believe our Constitution, which enumerates and 
protects our liberties and choices, can be perverted to require 
Americans to purchase something they may not want and may feel they do 
not need. Such a view is totally at odds with our Constitution. I 
believe strongly the individual insurance mandates in this bill are 
unconstitutional.
  The person who has raised the point of order is also on the floor 
with me, Senator Ensign from Nevada. He is going to cover that area. It 
is essential we address it.
  I wish to raise another area where I think we also have transgressed 
over the Constitution. That is the trampling of the rights of our 
States under the 10th amendment. I taught constitutional law. I have 
studied the background of the Constitution. I have looked at many 
facets of it. I can't say I am a constitutional scholar. I am a lawyer. 
I have taught this subject.
  I wish to read the very clear and simple 10th amendment. The 10th 
amendment has made clear the following:

       The powers not delegated to the United States by the 
     Constitution, nor prohibited by it to the States, are 
     reserved to the States respectively or to the people.

  That is it. The beauty of our Constitution is, it is a very limiting 
document. That is why it is short. Everything not specifically given to 
the Federal Government in the Constitution is reserved to the States or 
to the people. That is the beauty of our Constitution. The reason it is 
short is because the powers were meant to be limited. What was reserved 
to the Federal Government was meant to be limited because our Founders 
knew the government closest to the people and the people should be 
responsible for most of the laws of the country.
  Today, in the bill we have before us, we have a State, such as my 
State of Texas and many States across the country, which have taken 
full responsibility for creating, maintaining, and providing oversight 
for a health insurance plan and will now have to justify changes to the 
terms of the insurance plan to the Federal bureaucrats.
  My State of Texas has created a fully self-insured plan for State 
employees and for our teachers so creation, administration, and 
oversight will be

[[Page S13822]]

within the realm of the State. I believe it is very important, when we 
look at the bill before us, to see that the States now are going to be 
required, similar to every insurance provider, to justify with the 
Federal Government changes in premiums. The States are going to have to 
now put forward all the background, what they are doing in their self-
insured plans, and justify it before the States, apparently, will be 
able to go forward.
  Of course, there is going to be a book written on the meaning of 
``justify.'' I can see it coming. What exactly does justify mean? I 
don't think we have to go that far to write the book on what justify 
means because this is an encroachment on the rights of the States 
guaranteed by the 10th amendment. Not only does it walk away from the 
words themselves of the 10th amendment but walks away from what the 
Founding Fathers intended; that is, that it is the prerogative of the 
States to make the laws that affect the people. Even Congress, for the 
last 60 years, has kept the Federal Government restrained pretty much--
not completely but pretty much--from mandates and regulation of 
insurance plans. There are some, but it has largely been left to the 
States. The States have provided the infrastructure for what can be 
offered in a State. But here we go. In what is supposed to be the 
reform of our health care system, we are taking away the rights, the 
prerogatives of the States, and also the expertise the States have come 
to have put together and formed through the years. The big Federal 
Government takeover is going to begin.
  Let me mention a 1992 case by the Supreme Court, which stated, in New 
York v. United States:

       The Framers explicitly chose a Constitution that confers 
     upon Congress the power to regulate individuals, not States.

  I have asked the attorney general of Texas to use every resource at 
his disposal to investigate the provisions in this legislation and to 
challenge any unconstitutional attempt to limit the authority of Texas 
to carry out its regulatory responsibilities in the insurance market or 
to provide for the insurance needs of its employees and the teachers of 
Texas through the State health insurance plans. The attorney general of 
Texas has already said he is going to challenge the constitutionality 
of treating one State differently from all the other 49 and the 
taxation of our residents in Texas because of the exemption of the 
State of Nebraska from the Medicaid responsibilities that every other 
State is going to have. Of course, every other State will pick up the 
tab for this Nebraska exemption. The attorney general of Texas is on 
it, just like the attorney general of South Carolina and probably many 
more by the time we will end this day.
  It is important we also stand on 10th amendment grounds for the 
States to be able to put forward a self-insurance plan for its 
employees without the permission of the Federal Government, and I feel-
duty bound to question the constitutionality of this bill on 10th 
amendment grounds.

  Therefore, Madam President, I make a constitutional point of order 
against the substitute amendment on the grounds that it violates the 
10th amendment of the Constitution, and I ask for the yeas and nays.
  The PRESIDING OFFICER. Under the precedents and practices of the 
Senate, the Chair has no power or authority to pass on such a point of 
order. The Chair, therefore, under the precedents of the Senate, 
submits the question to the Senate. Is the point of order well taken?
  The yeas and nays have been requested.
  Is there a sufficient second?
  There appears to be a sufficient second.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. Under the previous order, the vote on this 
question will occur after all postcloture time expires.
  Mrs. HUTCHISON. Thank you, Madam President. That is my understanding. 
I very much appreciate the opportunity to bring this forward.
  I think now that we are finally beginning to digest this bill, we are 
seeing several areas where points of order have been raised, and I hope 
some of these will send this bill back to the drawing board, where it 
belongs, to have health care reform that will do what we intended to do 
when we started; that is, bring down the cost of health care, make more 
affordable health care possible for more people in this country. If we 
could do that, on a bipartisan basis, I think the people of America, as 
they sit down for their holiday celebrations with their families, would 
have been well served.
  I implore my colleagues to look at the points of order that will be 
voted on postcloture today and think about the consequences of passing 
this monstrous piece of legislation that is going to alter the quality 
of life for every individual, every family, every small business in 
this country.
  Let's start again and do it right. Doing it fast should not be the 
goal. Doing it right is what we should pursue. I hope my colleagues, 
before we finish this process, will come back with something we can all 
be proud of and not something that is going to pass on a strictly 
partisan vote.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Nevada.
  Mr. ENSIGN. Madam President, I wish to first compliment the Senator 
from Texas on her raising a different constitutional point of order. 
There are several ways in which this bill violates the Constitution. I 
have raised a constitutional point of order, where I believe this bill 
violates the enumerated powers under article I, section 8 of the 
Constitution, as well as the fifth amendment takings clause of the 
Constitution.
  I see the senior Senator from Utah is in the Chamber. He is going to 
talk about several other problematic provisions in the bill that is 
before us today.
  This is the Constitution of the United States, which I hold in my 
hand. There are several other documents in here, but that is how short 
the Constitution of the United States is--this short, concise document 
that limits the powers of the Federal Government. Our Founders were 
afraid of a powerful central government, so they put down on paper the 
powers they granted to this body, the House of Representatives, and the 
rest of the Federal Government.
  When each one of us comes to this floor, after we are elected, we 
raise our right hand, put our hand on the Bible, and take an oath to 
defend and protect the Constitution of the United States. We do not 
take an oath to reform health care or to do anything else that we may 
think is good to do. Anything on health care or any other good 
provision we want to enact has to fit within the limited powers that 
are listed within the Constitution of the United States.
  That is the oath, the solemn oath, each and every Senator takes. That 
is what each and every one of us needs to think about when we are 
voting on this constitutional point of order.
  I wish to make a couple points very briefly in one area where I 
think, on the individual mandate, this bill violates the U.S. 
Constitution. Nowhere, at no time, has this government, this Federal 
Government, ever passed a law that requires people who do nothing to 
engage in economic activity. In other words, if this bill passes and 
then you choose not to buy health insurance, this bill requires you to 
purchase health insurance. If you do not do that, it charges you up to 
2 percent of your income. So this bill is telling you, just because you 
exist as a citizen of the United States, you must do something.
  The United States has never, in its history, ever passed something 
such as this. This will dramatically expand the powers of the Federal 
Government, if this bill is passed, and if, God forbid, the Supreme 
Court upholds this piece of legislation.
  I have read a lot of articles--and I submitted several of them 
yesterday--by constitutional scholars, who believe this bill is 
unconstitutional. Even folks who believe it is constitutional, some 
folks on the left, concede that there are legitimate arguments against 
the bill's constitutionality. They also recognize that there is 
potential that it is unconstitutional. So this is not some wild-eyed 
radical debate. This is a legitimate debate about what this document, 
this Constitution of the United States, actually means.
  I am not a lawyer similar to a lot of the other Members of the 
Senate, but I understand the importance of a pretty plain reading of 
the Constitution's text.

[[Page S13823]]

  Within the enumerated powers, and within the fifth amendment, there 
are limitations on what this Congress can do. The Supreme Court has 
held that the interstate commerce clause, for instance--gives this body 
certain power to regulate commercial activity. Even activity of an 
individual that is intrastate in nature can be regulated if it has the 
potential to somehow substantially affect interstate commerce.
  Unfortunately, this bill goes beyond even regulating any kind of 
commercial activity. It goes to regulating noneconomic inactivity. It 
says: If you choose not to do something, we are going to regulate you 
and we are going to tax you if you do not behave. This is a very 
dangerous precedent for the Congress to set. I made the point 
yesterday; others have made this point--if we could just require 
citizens to purchase certain things, why did we need a cash-for-
clunkers bill? The reality is we lack the power to just tell people: Go 
out and buy a car.
  The government is allowed to provide certain incentives for people to 
do activity that maybe they were not going to do. But Congress does not 
have the power to actually tell citizens what to do, in that case, to 
regulate inactivity.
  There are all kinds of things this government could tell people what 
to do if something such as this precedent is upheld today. This is 
incredibly dangerous, and the people of America need to wake up and the 
people who are voting for this bill need to analyze the unintended 
consequences and the massive expansion of power this bill will provide 
for, if this bill passes, and if the Supreme Court does not strike it 
down.
  I am going to yield because I have listened to the senior Senator 
from Utah talk eloquently about the provisions that are 
unconstitutional. He is much more of a constitutional scholar than I 
would ever dream to be. I hope everybody pays close attention to what 
he is saying and thinks about that oath each one of us made when we 
raised our right hand to defend and uphold the Constitution. Are we 
doing that if we vote for this bill?
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Utah.
  Mr. HATCH. Madam President, I thank my gracious colleague, and I am 
grateful for his kind words.
  Each Member of this body has taken an oath to support and defend the 
Constitution of the United States. Not any Constitution, not their own 
personal Constitution, not a fake or pretend Constitution, but the real 
Constitution of the United States. That means that there will come 
times when politics says yes, but the Constitution says no. There will 
come times when the grand plans and good intentions of politicians meet 
the limits of the Constitution. I submit that this is one of those 
times, and the constitutional point of order raised by the Senator from 
Nevada presents each of us with the choice of whether politics or the 
Constitution will win the day. I choose the Constitution and will vote 
to support the point of order.
  America's founders gave us a written Constitution that delegates 
certain powers to the Federal Government, separates those powers among 
three branches, and enumerates the powers given to Congress. They did 
all of that writing, delegating, separating, and enumerating for one 
overriding reason, to set limits on Federal Government power because 
liberty cannot survive without such limits. As Justice Sandra Day 
O'Connor reaffirmed in 1991 when writing the Supreme Court's opinion in 
Gregory v. Ashcroft, our system of federalism and the separation of 
powers ``was adopted by the Framers to ensure the protection of our 
fundamental liberties.' '' Liberty requires limits on government power, 
it always has and it always will. The question for us today is whether 
liberty is still more important than power.
  The Members of this body have our own, independent responsibility to 
ensure that the actions we take are consistent with the Constitution we 
have sworn to support and defend. We cannot simply assume that the 
Constitution necessarily allows us to do whatever we may want to do. 
And we cannot ignore this question by simply punting it to the courts. 
Litigation is likely, to be sure, which means that the courts will be 
asked to decide certain legal questions, including whether this 
legislation is constitutional. Judges also take an oath to support and 
defend the Constitution and must exercise the powers it grants to them. 
Speculating about how courts may decide a hypothetical case in the 
future, however, is no substitute for Senators making a decision about 
an actual piece of legislation today.
  The Constitution cannot limit government if government controls the 
Constitution. If the Constitution means whatever we want it to mean, 
then we might as well take an oath to support and defend ourselves. 
Frankly, that is what it seems like we do sometimes. But we cannot take 
the power the Constitution provides without the limits the Constitution 
sets.
  Turning to the legislation before us, we all want to see a higher 
percentage of Americans covered by health insurance. That is a 
desirable goal, but my friends on the other side of the aisle would 
achieve that goal with a very blunt instrument, an order that Americans 
purchase health insurance. That is a means that the Constitution does 
not permit. While the Constitution gives Congress power to regulate 
interstate commerce, that power does not mean anything and everything 
we want to mean. Those words are not infinitely malleable. I agree with 
the 75 percent of Americans who say that this mandate to purchase 
health insurance is unconstitutional because Congress's power to 
regulate interstate commerce does not include telling Americans what 
they must buy.
  When President Franklin D. Roosevelt chose Frances Perkins as his 
Secretary of Labor, they discussed social policy legislation including 
health insurance. As Secretary Perkins later described it, they agreed 
that such legislation would pose ``very severe constitutional 
problems,'' including fundamentally altering Federal-State 
relationships. That is why the Social Security Act uses the payroll 
tax. Even the Roosevelt administration, which oversaw the most dramatic 
expansion of federal power in our Nation's history, would not go as far 
as the legislation before us today would go. Even they knew that the 
Constitution put certain means off limits.
  The goal of raising the percentage of Americans with health insurance 
could be achieved by constitutionally permissible means. My friends on 
the other side of the aisle know as well as I do, however, that those 
means are politically impossible. And so they have chosen politics over 
the Constitution, and that is why I will support the constitutional 
point of order.
  In 1995, the Supreme Court reaffirmed that there are indeed limits on 
the means Congress may use to achieve its goals. The Court rejected a 
version of the power to regulate interstate commerce that would make it 
hard to imagine any activity by individuals that Congress could not 
regulate. The legislation before us would not only regulate economic 
transactions in which individuals choose to engage, it would require 
that they engage in those transactions. This is the first time that 
Congress has ever ordered Americans to use their own money to purchase 
a particular good or service. Crossing that line would do exactly what 
the Supreme Court said we may not do, and would virtually eliminate 
whatever limits remain on federal government power. That would deprive 
the Constitution not only of its meaning, but of its function as a 
guardian of liberty. I urge my colleagues to put the Constitution ahead 
of politics and support this point of order.
  There is a lot of talk from the majority about why passing this bill 
is the right thing to do for the American people. It is a decision of 
conscience for them. Well, let us take a closer look at these decisions 
of conscience.
  After weeks of closed-door, clandestine negotiations, Senator Reid 
finally emerged with a 383-page Christmas list. This bill is a dark 
example of everything that is wrong with Washington today. Despite all 
the promises of accountability and transparency, this bill is a grab 
bag of Chicago-style, backroom buyoffs. It is nothing more than a 
private game of ``Let's Make A Deal'' with the special interest groups 
financed by American taxpayers.
  So who won and who lost in this game? Well, let's take a closer look. 
The AARP issued a strong statement of support for this bill. The Reid 
bill slashes Medicare by almost a $\1/2\ trillion to finance additional 
government

[[Page S13824]]

spending. So why would the Nation's largest lobbying organization, 
avowed to protect the interests of seniors, support this legislation? 
To find the answer, similar to anything else in Washington, follow the 
money.
  AARP takes in more than half its $1.1 billion budget in royalty fees 
from health insurers and other vendors. The sale of supplementary 
Medicare policies, called Medigap plans, make up a major share of this 
$1.1 billion royalty revenue. AARP has a direct interest in selling 
more Medigap plans. However, there is a strong competitor to Medigap 
policies, and that happens to be the Medicare Advantage plans.
  These private plans provide comprehensive coverage, including vision 
and dental care, at lower premiums for nearly 11 million seniors across 
the country. Seniors enrolled in Medicare Advantage do not need Medigap 
policies. So what happens when the Reid bill slashes this program by 
almost $120 billion? That is with a ``b.''
  Look at the Washington Post front-page story from October 27, 
questioning whether AARP has a conflict of interest. I quote:

       Democratic proposals to slash reimbursements for . . . 
     Medicare Advantage are widely expected to drive up demand for 
     private Medigap policies like the ones offered by AARP, 
     according to health-care experts, legislative aides and 
     documents.

  One of the most disturbing developments in the Reid bill has been the 
perpetuation and even the doubling of the unconstitutional mandate tax 
from $8 billion to $15 billion. You heard me right. This 
unconstitutional mandate tax actually doubled behind closed doors. I 
have long argued that forcing Americans to either buy a Washington-
defined level of coverage or face a tax penalty collected through the 
Internal Revenue Service is highly unconstitutional.
  We hear a lot of rhetoric from the other side about Republicans 
defending the big, evil insurance companies while they are the 
defenders of American families. The insurance mandate is a clear 
example of this partisan hypocrisy. Let me ask one simple question. Who 
would benefit the most from this unprecedented, unconstitutional 
mandate to purchase insurance or face a stiff penalty enforced by our 
friends at the Internal Revenue Service?
  The answer is pretty simple. There are two clear winners under this 
draconian policy--and neither is the American family. The first winner 
is the Federal Government, which could easily use this authority to 
increase the penalty--or impose similar ones--to create new streams of 
revenue to fund more out-of-control spending.
  Second, the insurance companies are the most direct winners under 
this individual insurance mandate because it would force millions of 
Americans who would not otherwise do so to become their customers. I 
cannot think of a bigger giveaway for insurance companies than the 
Federal Government ordering Americans to buy their insurance products. 
If you do not believe me, then just look at the stock prices of the 
insurance companies that have recently shot to their 52-week highs.
  Jane Hamsher, the publisher of the very liberal blog Firedoglake, 
said the following in a recent posting:

       Having to pay 2 percent of their income in annual fines for 
     refusing to comply with the IRS acting as the collection 
     agency just might wind up being the most widely hated 
     legislation of the decade. Barack Obama just might achieve 
     the bipartisan unity on health care he always wanted--
     Democrats and Republicans are coming together to say ``kill 
     this bill.''

  Now that we clearly understand the huge windfalls the Reid bill 
provides AARP and insurance companies, let me take a moment to talk 
about the winners and losers in the so-called abortion compromise.
  The language to prevent taxpayer dollars from being used to fund 
abortions is completely unacceptable. The new abortion provisions are 
significantly weaker than the amendment I introduced with Senator Ben 
Nelson to ensure that the Hyde amendment, which prohibits use of 
Federal dollars for elective abortions, applies to any new Federal 
health programs created in this bill. The Hyde amendment has been 
public law since 1976.
  The so-called abortion compromise does not stop there. The Reid bill 
creates a State opt-out charade. However, this provision does nothing 
about one State's tax dollars paying for abortions in other States. Tax 
dollars from Nebraska can pay for abortions in California or New York.
  This bill also creates a new public option run by the Office of 
Personnel Management that will, for the first time, create a federally 
funded and managed plan that will cover elective abortions.
  When you have Senator Boxer, the distinguished Senator from 
California, and Speaker Pelosi, the distinguished Speaker of the House 
of Representatives--two of the largest pro-abortion advocates in the 
Congress--supporting this sham so-called compromise and everyone from 
the U.S. Conference of Catholic Bishops to the National Right to Life 
Committee and the Family Research Council opposing it, there is only 
one clear loser, and that is the majority of Americans who believe in 
the sanctity of life and oppose the use of Federal dollars for elective 
abortions.
  Last, but not least, I wish to spend a couple of minutes talking 
about the numerous special deals conferred on States in this $2.5 
trillion spending bill.
  How hefty are the price tags for decisions of conscience? Here are 
some highlights: $300 million for Louisiana, $600 million for Vermont, 
$500 million for Massachusetts, $100 million for Nebraska, and that is 
just the beginning.
  At a recent news conference, when the authors of this legislation 
were asked about the Nebraska earmark for Medicaid funding, the 
majority leader simply replied:

       A number of States are treated differently than other 
     States. That's what legislation is all about. That's 
     compromise.

  The next logical question is pretty straightforward: Who will pay for 
these special deals? The answer is simple: Every other State in the 
Union will pay for these special deals, including my home State of 
Utah. All of these States that are collectively facing $200 billion in 
deficits and are cutting jobs and educational services to survive will 
now pay to support these special deals.
  According to the Congressional Budget Office, the Medicaid expansion 
in the Reid bill creates a $26 billion unfunded mandate on our cash-
strapped States.
  Coincidentally, only one State avoids this unfunded mandate; that is, 
the State of Nebraska.
  Of course, let's not forget about the biggest loser in this bill: the 
hard-working American taxpayer. This bill imposes over $\1/2\ trillion 
worth of new taxes, fees, and penalties on individuals, families, and 
businesses. The new fees begin in 2010, while the major coverage 
provisions do not start until 2014. Almost $57 billion in new taxes are 
collected before any American sees the major benefits of this bill, 
which are largely delayed until 2014, assuming they are benefits at 
all.
  It is also no coincidence that through the use of these budget 
gimmicks, the majority can claim this bill reduces our national deficit 
when we all know these reductions will never, ever be realized.
  Based on data from the Joint Committee on Taxation, the nonpartisan 
congressional scorekeeper, this bill would break another one of 
President Obama's campaign promises by increasing taxes on 42 million 
individuals and families making less than $250,000 a year. At a time 
when we are struggling to fight a double-digit unemployment rate, the 
Reid bill not only increases payroll taxes by nearly $87 billion but 
also imposes $28 billion in new taxes on employers that do not provide 
government-approved health plans. These new taxes will ultimately be 
paid by American workers in the form of reduced wages and lost jobs.
  However, it is hard to say we didn't see these new taxes coming. For 
years now, many of us have warned that the out-of-control spending in 
Washington would eventually have to be repaid on the backs of American 
families. In this bill, the repayment comes in the form of stifled 
economic growth, lost jobs, and new and increasing taxes--and they are 
just the first installment of what will be a long and painful extortion 
of taxpayers if Congress doesn't stand up and stop these terrible 
bills. According to a recent study of similar proposals by the Heritage 
Foundation, these new job-killing taxes will place approximately 5.2 
million low-income workers at risk of losing their jobs or having their 
hours reduced and an additional 10.2 million workers would see lower 
wages and reduced benefits.

[[Page S13825]]

  Poll after poll tells us about the growing opposition against this 
tax-and-spend health care bill. The latest Rasmussen poll shows that 55 
percent of Americans are now opposed to this bill. The CNN poll is an 
even higher 61 percent. Among senior citizens, the group most likely to 
use the health care system, only 33 percent are in favor while 60 
percent are opposed. Independent voters are also opposed 2 to 1. 
Opposition in certain State polls such as Nebraska is even higher at 67 
percent.
  So what is the majority doing to address these concerns? Nothing. In 
fact, despite the efforts by many of us here on this side of the aisle 
to express our substantive policy disagreements for months, one Senator 
recently said the following:

       They are desperate to break this President. They have 
     ardent supporters who are nearly hysterical at the very 
     election of President Barack Obama. The birthers, the 
     fanatics, the people running around in right-wing militia and 
     Aryan support groups, it is unbearable to them that President 
     Barack Obama should exist.

  That statement is outrageous. It was made by a very dear friend of 
mine, and I know he probably didn't mean it the way it comes out, but 
it is outrageous.
  Instead of listening to the policy concerns of a majority of 
Americans, the other side is simply dismissing them as rants from the 
far right. If the majority refuses to listen to what Americans are 
telling them now, I am sure they are going to have a rude wake-up call 
later. It should come as no surprise that this kind of arrogance and 
power has led to congressional approval ratings rivaling the most hated 
institutions on the planet at a dismal 22 percent and falling.
  One of the biggest tragedies of letting this bill move forward is 
that it will do nothing to address the fundamental issue of rising 
health care costs in this country. According to the Congressional 
Budget Office, CBO, this bill will actually raise our national health 
care costs by $200 billion. The administration's own Actuary at the 
Centers for Medicare and Medicaid Services, CMS, agrees with this 
assessment.
  When this bill fails to work, Americans will no longer have anything 
in Congress to effectively address the issue of health care reform. The 
opportunity to save Medicare and Medicaid from their impending 
financial collapse will be lost for another generation.

  The historic blizzard in Washington earlier this month was the 
perfect symbol of the anger and frustration brewing in the hearts of 
the American people against this bill. I urge the majority once again 
to listen to the voices of the American people. Every vote for this 
bill is the 60th vote. Let me repeat that again. Every vote for this 
bill is the 60th vote. My Republican colleagues and I are united with 
the American people in our fight against this $2.5 trillion tax-and-
spend bill. I implore my colleagues not to do this to the American 
people. Don't foreclose on their futures. Don't stick them with even 
more government spending and more government intrusion.
  We can fix health care. Many of us have been working to do just that 
for many years. A truly bipartisan bill that would garner 75 to 80 
votes, which has always been the case in the past on these major pieces 
of legislation in the Senate, would be fiscally sound and provide the 
American people with the fixes they are asking for in the health care 
marketplace, and it would be easily achievable if we would just open 
our hearts and work together. Many of us are standing at the ready, and 
have been for months, to step forward and pass meaningful health care 
reform that truly would help American families and please American 
taxpayers. To date, we have been rebuffed by an unfailing determination 
by a few to pursue a nearly Socialist agenda.
  I would ask my colleagues on the other side of the aisle who do not 
believe in the Europeanization of America, who believe in doing truly 
bipartisan work here in the Senate, to step forward and vote against 
advancing this bill and work with those of us on this side of the aisle 
who are committed to making a difference to craft a health care reform 
bill they can be proud to support.
  Having said that, I do praise my colleague and friend from Montana, 
Senator Baucus, who literally did try for months in many meetings with 
first the Gang of 7--I was in that and then finally decided I could not 
support what they were going to come up with and expressed to my 
colleagues that I would have to in good conscience leave the 
negotiations. He tried, but he was too restricted in what he really 
could do, so that in the end no Republican supported what was done. We 
had a totally Democratic bill in the HELP Committee, a totally 
Democratic bill with the Pelosi bill in the House, and the Reid bill 
has been done in back rooms here with the White House, with very few 
even Democrats involved, and many of the things some of my friends 
worked so hard to get in the bill were no longer in it.
  Let me just say there are good people in this body on both sides of 
the floor, but I have suggested in times past and I suggest it again: 
If you can't get 75 or 80 votes for a bill that affects every American, 
that is one-sixth of the American economy, then you know that bill is a 
lousy bill.
  There are many on our side of the aisle who have stood ready, 
willing, and able to try to do something in a bipartisan way. I have 
spent 33 years here, and I have participated in a bipartisan way to 
help bring both sides together on all kinds of health care bills that 
work. This one would work, too, if we would just work in a bipartisan 
way.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Nevada.
  Mr. ENSIGN. Madam President, I wish to make a couple of points 
regarding the constitutional point of order I raised on the individual 
mandate.
  Some folks have said that States mandate car insurance, that is 
require people who drive to carry car insurance; therefore, the Federal 
Government can mandate the purchasing of health insurance to 
individuals. Well, I think that should be pretty obvious that States 
can do things that the Federal Government cannot. The Constitution 
limits the Federal Government as to what it can do and it reserves the 
power for the States and/or the people. Senator Hutchison raised this 
exact point in her constitutional point of order relating to the 10th 
amendment.
  So this mandate of buying car insurance--comparing it to the mandate 
to buy health insurance from the Federal Government is a false 
comparison. The Federal Government cannot mandate you to buy car 
insurance, nor can it mandate you to buy health insurance. It is not 
within the enumerated powers given to this body and to this Federal 
Government in the Constitution.
  This bill is a real threat to liberty because of the precedent it 
sets on the Federal Government being able to tell individuals what to 
do.
  I wish to quote from a couple of articles that have been written. 
This one was written by David Rivkin and Lee Casey. I am quoting:

       But Congress cannot so simply avoid the constitutional 
     limits on its power. Taxation can favor one industry or 
     course of action over another, but a ``tax'' that falls 
     exclusively on anyone who is uninsured is a penalty beyond 
     Congress's authority. If the rule were otherwise, Congress 
     could evade all constitutional limits by ``taxing'' anyone 
     who doesn't follow an order of any kind--whether to obtain 
     health-care insurance [in this case] . . . or even to eat 
     your vegetables.

  It literally sets the precedent to dramatically expand the powers of 
the Federal Government far beyond anything our Founders wrote and 
limited this Congress to doing in the Constitution.
  I see the Republican whip here, and I wish to yield to him because of 
his expertise on the Constitution.
  I want to make a real quick point reading from another article. I 
commend this article to our colleagues by Randy Barnett and Nathaniel 
Stewart and Todd Gaziano. It said:

       Never in the nation's history has the commerce power been 
     used to require a person who does nothing to engage in 
     economic activity.

  There are constitutional experts out there telling us this bill is 
doing something the Federal Government has never done in its history. 
So I go back to this United States Constitution.
  When we take an oath to defend the Constitution, we better take that 
as a solemn oath and think about whether we are violating that oath we 
swore to uphold and defend when we are voting on this bill.
  You must uphold this constitutional point of order. It is not just up 
to the

[[Page S13826]]

Supreme Court; it is up to us. We don't just say we will pass anything, 
whether it is constitutional or not, and let the Supreme Court decide. 
That is the oath we take. It is our responsibility to uphold and defend 
the Constitution. We must think about that when we are passing 
something here. That is the reason we have this authority to bring a 
constitutional point of order, so that this body considers whether it 
is constitutional. That is why we must consider the consequences of 
greatly expanding the powers of the Federal Government in this bill, 
which are so dramatic that the threat to liberty is very real.
  I yield the floor to the Republican whip so he can make some 
comments.
  The PRESIDING OFFICER. The Senator from Arizona.
  Mr. KYL. Madam President, I compliment my colleague who has raised a 
most important constitutional point. It is true, as Senators, we have 
an obligation not just to throw questions to the Supreme Court but to 
use our best judgment as to whether we would be violating the 
Constitution by adopting them.
  I think the point of order he raises with respect to the 10th 
amendment is a very important question and should be carefully 
considered by our colleagues. I think you can only come to one 
conclusion. I support what he is trying to do.
  I also want to make another point, which is that around the country 
people are calling in and raising questions about other aspects of the 
bill, also raising similar questions--the imposition of a supermajority 
rule, for example. Can one Congress bind another in that regard? We are 
only now learning of all of these things, and our constituents are only 
learning of them because the most recent amendment was filed just a few 
days ago.
  As we read through it and begin to realize its implications, a lot of 
questions are being raised. The question I want to raise today goes 
right to the heart of the claim that supporters have made for this 
legislation; that is, that it reduces the Federal budget deficit. Many 
colleagues on the other side of the aisle have said: I could not vote 
for this bill if it did not reduce the Federal budget deficit, or at 
least if it were not deficit neutral.
  It turns out that from information received today from the CBO, it is 
not deficit neutral. In fact, it adds at least $170 billion to the 
deficit, which, of course, is very important since tomorrow we are 
going to be asked to increase the temporary debt ceiling. This 
legislation will add to our Federal debt, not make the situation 
better, as many of our colleagues have claimed.
  I will describe why that is so. I heard another colleague on the 
other side on a talk show this morning say that we are going to extend 
the fiscal life of Medicare by 9 years. That is a claim that directly 
conflicts with the claim that the bill is budget neutral.
  What both the CMS Actuary and the CBO have now said is, no; both are 
not true. There is only one sum of money. You can either extend the 
life of Medicare with that money, or you can buy a new entitlement 
under the bill with that money. But you cannot do both.
  So if that money is spent on the new entitlement, for example, it 
cannot extend the life of Medicare. It cannot show a budget surplus of 
$130 billion.
  In effect, they are saying you can't sell the same pony twice. Here 
is exactly what the Congressional Budget Office had to say about it 
this morning. Incidentally, we were tipped off to this by a comment 
that was in the body of a letter from the CMS Actuary last week, or 
December 10, and as we read through it and tried to analyze the new 
amendment that was just filed, it became clear that, in effect, that is 
precisely what is being done by the other side.
  I am not suggesting duplicity. What I am suggesting is that they, 
too, have been misled by the arcane accounting language, and until it 
became crystal clear with the language today, I can understand why 
there would be confusion--but no longer. You cannot vote for this bill 
this afternoon and claim not to have known that it both buys an 
extension of the trust fund for Medicare and claims to buy a surplus of 
$130 billion.
  Here is what the CBO says today, December 23, which is posted on 
their Web site:

       The key point is that the savings to the HI trust fund 
     under this bill would be received by the government only 
     once, so they cannot be set aside to pay for future Medicare 
     spending and at the same time pay for current spending on 
     other parts of the legislation.

  In other words, the new entitlements that are allegedly paid for 
under the bill. Here is the last sentence:

       To describe the full amount of the HI trust fund savings as 
     both improving the government's ability to pay future 
     Medicare benefits and financing new spending outside of 
     Medicare would essentially double-count a large share of 
     those savings and thus overstate the improvement in the 
     government's fiscal position.

  It would essentially double-count the money. That is the point 
Senator Gregg and Senator Sessions and I tried to make earlier this 
morning.
  This is new information, I grant you. But it is an illustration of 
why we should not try to force this bill to a vote before Christmas, 
when we haven't tried to figure out what this all means and the 
American people haven't had an opportunity to react to it.
  I quoted to you from the CBO, the nonpartisan office that tells us 
what the fiscal impact is. Here is what tipped us off: Richard Foster, 
the CMS Chief Actuary, had sent a letter. This phrase caught our 
attention. He said:

       In practice, the improved part A financing cannot be 
     simultaneously used to finance other Federal outlays, such as 
     the coverage expansion under this bill and to extend the 
     trust fund. Despite the appearance of this result from the 
     respective accounting conventions.

  Despite the fact, in other words, that it appears you can do both 
because of the way the government accounting is, it is only one pot of 
money. You cannot use it to extend the life of Medicare on one hand and 
buy new entitlements and show a budget surplus on the other.
  This is what happens when you try to rush a bill through like this 
too quickly. Many colleagues on the other side of the aisle have said: 
I will not vote for a bill that is not budget neutral or creates a 
budget deficit. Then they cannot vote for this legislation now that CBO 
has said what it has said. Some of them won't realize that. That is why 
I came to the floor.
  I compliment Senator Sessions for talking to the Director of the 
Budget Office last night and confirming this, asking him if he would 
put it in writing, which he did.
  I think this is a game changer, my friends. If, now that you have 
this knowledge, you still go forward and vote for the legislation, 
those of you who have made the pledge not to do so will be violating 
that pledge. You can't use the same pot of money to do two separate 
things, as the CBO said. They describe it this way: You can't do both 
of these things. You would essentially double-count a large share of 
that savings and thus overstate the situation.
  Mr. SESSIONS. Will the Senator yield for a question?
  Mr. KYL. Yes.
  Mr. SESSIONS. The earlier statement from CBO was that the legislation 
would result in reducing the deficit by $132 billion, which was cited 
several times. Well, that was obviously before the statement that was 
issued today. In boiling it down--and the Senator is an accomplished 
lawyer--doesn't this say there is a misimpression created by that 
previous statement and that this statement today clarifies it, making 
absolutely clear that it is not creating a surplus or reducing the debt 
but, in fact, increasing the debt?
  Mr. KYL. Madam President, that is exactly right. The title of the 
document is ``Effects of the Patient Protection and Affordable Care Act 
on the Federal Budget and the Balance in the Hospital Insurance Trust 
Fund.'' He starts out by saying CBO has been----
  Mr. BAUCUS. Will the Senator yield for a question?
  Mr. KYL. Madam President, I will be happy to in a moment. I ask 
unanimous consent that the CMS report, dated December 10, be printed in 
the Record following the colloquy so that people can follow what we 
have done.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:


[[Page S13827]]


         Department of Health & Human Services, Centers for 
           Medicare & Medicaid Services,
                                Security Boulevard, Baltimore, MD.


                         Office of the Actuary

     Date: December 10, 2009.
     From: Richard S. Foster, F.S.A., Chief Actuary.
     Subject: Estimated Effects of the ``Patient Protection and 
         Affordable Care Act'' on the Year of Exhaustion for the 
         Part A Trust Fund, Part B Premiums, and Part A and Part B 
         Coinsurance Amounts.

       In addition to proposals to expand health insurance 
     coverage, the ``Patient Protection and Affordable Care Act of 
     2009'' (PPACA) includes numerous provisions that would reduce 
     Medicare costs and one that would increase the Hospital 
     Insurance payroll tax rate for high-income individuals and 
     families. This memorandum describes the estimated impacts of 
     the PPACA, as proposed by Senate Majority Leader Harry Reid 
     on November 18, 2009, on the date of exhaustion for the 
     Medicare Hospital Insurance (Part A) trust fund, on Part B 
     beneficiary premiums, and on the average level of Part A and 
     Part B beneficiary coinsurance.
       We estimate that the aggregate net savings to the Part A 
     trust fund under the PPACA would postpone the exhaustion of 
     trust fund assets by 9 years--that is, from 2017 under 
     current law to 2026 under the proposed legislation.
       The combination of lower Part A costs and higher tax 
     revenues results in a lower Federal deficit based on budget 
     accounting rules. However, trust fund accounting considers 
     the same lower expenditures and additional revenues as 
     extending the exhaustion date of the Part A trust fund. In 
     practice, the improved Part A financing cannot be 
     simultaneously used to finance other Federal outlays (such as 
     the coverage expansions under the PPACA) and to extend the 
     trust fund, despite the appearance of this result from the 
     respective accounting conventions.
       The estimated postponement of asset exhaustion for the Part 
     A trust fund does not reflect the relatively small impact on 
     HI payroll taxes due to economic effects of the legislation 
     or the small increase in administrative expenses under the 
     legislation. As noted in our December 10, 2009 memorandum on 
     the estimated financial and other effects of the PPACA, 
     reductions in Medicare payment updates to Part A providers, 
     based on economy-wide productivity gains, are unlikely to be 
     sustainable on a permanent annual basis. If such reductions 
     were to prove unworkable within the period 2010-2026, then 
     the actual HI savings from these provisions would be less 
     than estimated, and the postponement in the trust fund 
     exhaustion date would be reduced. 
       The Medicare expenditure reductions under the PPACA would 
     also affect the level of Part B premiums paid by enrollees 
     and the Part A and Part B beneficiary coinsurance amounts. 
     The following table presents these estimated impacts:

------------------------------------------------------------------------
                                                           Coinsurance
                                       Part B Premium    Impact (change
                                     Impact (change in    in yearly per
                 CY                   monthly premium    capita amount)
                                          amount)      -----------------
                                                         Part A   Part B
------------------------------------------------------------------------
2010...............................              $0.00       $0      $90
2011...............................               1.80       -1       22
2012...............................              -3.10       -4      -37
2013...............................              -4.60       -8      -55
2014...............................              -5.30      -13      -64
2015...............................              -7.20      -18      -86
2016...............................              -9.00      -23     -108
2017...............................             -10.80      -28     -129
2018...............................             -12.50      -34     -151
------------------------------------------------------------------------

       As indicated, Part B premiums and average coinsurance 
     payments would initially increase, reflecting higher overall 
     Part B costs under the PPACA in 2010 as a result of the 
     provision to postpone the 21.3-percent reduction in physician 
     payment rates that would be required for 2010 under current 
     law. Thereafter, there would be steadily increasing savings 
     to Part B and associated reductions in the Part B premium and 
     coinsurance averages. Similarly, the Part A savings under the 
     PPACA would result in lower beneficiary coinsurance payments 
     for inpatient hospital and skilled nursing care. As before, 
     all of these results are conditional on the continued 
     application of the productivity adjustments to the Medicare 
     ``market basket'' payment updates.
       Expenditure reductions under Part B translate directly to 
     lower financing requirements from general revenues and 
     beneficiary premiums, since financing is re-established 
     annually to match program costs. Thus, in the case of Part B, 
     the savings under the PPACA are not needed to help pay for 
     future Part B benefit costs, and the full reduction in 
     Federal general revenues attributable to such savings can be 
     used to offset other Federal costs, such as those arising 
     under the PPACA coverage expansions.

  Mr. KYL. I am now happy to yield.
  Mr. BAUCUS. I ask my good friend from Arizona, is it not true that 
the last statement from CBO, on the degree to which the underlying 
legislation does or does not reduce the deficit, stated that the 
legislation reduces the deficit by $132 billion--that is the last 
statement after addressing the deficit--and also stating that at the 
end of the decade, the deficit will be reduced between $630 billion and 
$1.3 trillion? Isn't that the last statement from CBO addressing the 
question on whether this legislation reduces or increases the deficit. 
Isn't that true?
  Mr. KYL. Madam President, I don't know the document that my friend is 
referring to as ``the last document.'' I think that document, dated 
December 23, today, is the last document.
  Mr. BAUCUS. This is from a day or two ago. It is the CBO letter 
commenting on the modification.
  Mr. KYL. I don't know. I am not aware of that. My point is this: The 
document released today, in order to clarify the situation again, said 
the key point is that you can't do both. The government only gets the 
money once. Therefore, they say, to describe the full amount as both 
providing a savings to Medicare and providing a surplus essentially 
double-counts the money and thus overstates the improvement in the 
government's position.
  Mr. BAUCUS. Will the Senator further yield?
  Mr. KYL. I will not yield now. I have a unanimous consent request.
  I ask unanimous consent that a Washington Post op-ed by Michael 
Gerson, dated December 23, be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

               [From the Washington Post, Dec. 23, 2009]

        For Sale: One Senator (D-Neb.); No Principles, Low Price

                          (By Michael Gerson)

       Sometimes there is a fine ethical line between legislative 
     maneuvering and bribery. At other times, that line is crossed 
     by a speeding, honking tractor-trailer, with outlines of 
     shapely women on mud flaps bouncing as it rumbles past.
       Such was the case in the final hours of Senate Majority 
     Leader Harry Reid's successful attempt to get cloture on 
     health-care reform. Sen. Ben Nelson of Nebraska, the last 
     Democratic holdout, was offered and accepted a permanent 
     exemption from his state's share of Medicaid expansion, 
     amounting to $100 million over 10 years.
       Afterward, Reid was unapologetic. ``You'll find,'' he said, 
     ``a number of states that are treated differently than other 
     states. That's what legislating is all about.''
       But legislating, presumably, is also about giving public 
     reasons for the expenditure of public funds. Are Cornhuskers 
     particularly sickly and fragile? Is there a malaria outbreak 
     in Grand Island? Ebola detected in Lincoln?
       Reid didn't even attempt to offer a reason why Medicaid in 
     Nebraska should be treated differently from, say, Medicaid 
     across the Missouri River in Iowa. The majority leader bought 
     a vote with someone else's money. Does this conclusion sound 
     harsh? Listen to Sen. Lindsey Graham of South Carolina, who 
     accused the Senate leadership and the administration of 
     ``backroom deals that amount to bribes'' and ``seedy Chicago 
     politics'' that ``personifies the worst of Washington.''
       This special deal for Nebraska raises an immediate 
     question: Why doesn't every Democratic senator demand the 
     same treatment for his or her state? Eventually, they will. 
     After the Nelson deal was announced, Sen. Tom Harkin of Iowa 
     enthused, ``When you look at it, I thought well, God, good, 
     it is going to be the impetus for all the states to stay at 
     100 percent (coverage by the federal government). So he might 
     have done all of us a favor.'' In a single concession, Reid 
     undermined the theory of Medicaid--designed as a shared 
     burden between states and the federal government--and added 
     to future federal deficits.
       Unless this little sweetener is stripped from the final 
     bill by a House-Senate conference committee in January, which 
     would leave Nelson with a choice. He could enrage his party 
     by blocking health reform for the sake of $100 million--
     making the narrowness of his interests clear to everyone. Or 
     he could give in--looking not only venal but also foolish.
       How did Nelson gain such leverage in the legislative 
     process in the first place? Because many assumed that his 
     objections to abortion coverage in the health bill were 
     serious--not a cover, but a conviction. Even though Nelson, a 
     rare pro-life Democrat, joked in an interview that he might 
     be considered a ``cheap date,'' Republican leadership 
     staffers in the Senate thought he might insist on language in 
     the health-care bill preventing public funds from going to 
     insurance plans that cover abortion on demand, as Democratic 
     Rep. Bart Stupak had done in the House.
       Instead, Nelson caved. The ``compromise'' he accepted 
     allows states to prohibit the coverage of elective abortions 
     in their insurance exchanges. Which means that Nebraska 
     taxpayers may not be forced to subsidize insurance plans that 
     cover abortions in Nebraska. But they will certainly be 
     required to subsidize such plans in California, New York and 
     many other states.
       In the end, Nelson not only surrendered his beliefs, he 
     also betrayed the principle of the Hyde Amendment, which 
     since 1976 has prevented the coverage of elective abortion in 
     federally funded insurance. Nelson not only violated his pro-
     life convictions, he also may force millions of Americans to 
     violate theirs as well.

[[Page S13828]]

       I can respect those who are pro-life out of conviction and 
     those who are pro-choice out of conviction. It is more 
     difficult to respect politicians willing to use their deepest 
     beliefs--and the deepest beliefs of others--as bargaining 
     chips.
       In a single evening, Nelson managed to undermine the logic 
     of Medicaid, abandon three decades of protections under the 
     Hyde Amendment and increase the public stock of cynicism. For 
     what? For the sake of legislation that greatly expands a 
     health entitlement without reforming the health system; that 
     siphons hundreds of billions of dollars out of Medicare 
     instead of using that money to reform Medicare; that imposes 
     seven taxes on Americans making less than $250,000 a year, in 
     direct violation of a presidential pledge; that employs 
     Enron-style accounting methods to inflate future cost 
     savings; that pretends to tame the insurance companies while 
     making insurance companies the largest beneficiaries of 
     reform.
       And, yes, for $100 million. It is the cheap date equivalent 
     of Taco Bell.

  Mr. SESSIONS. The leader's time is up at 6 minutes after the hour; is 
that correct?
  The PRESIDING OFFICER. The Republican leader has 6\1/2\ minutes 
reserved.
  Mr. SESSIONS. I ask Senator Kyl this: The CBO report this morning 
essentially says you cannot count the same money twice; correct?
  Mr. KYL. Madam President, it doesn't say you cannot. It just says 
that is what would happen if you attempted to apply the money both to 
the trust fund and to the additional spending. It says it ``would 
essentially double count and thus overstate.''
  What I am saying is that it doesn't say you can't do it, but they are 
saying you only have one pot of money to pay for two things and, 
obviously, you cannot do that and be honest about the accounting. That 
is my interpretation of what it says.
  Mr. SESSIONS. I think that is correct. The Senator may not know this. 
I understand that at the request of our Democratic colleagues, they 
have returned to CBO and gotten another statement this morning, perhaps 
so they can continue to make the argument that somehow this creates a 
surplus. But staff having examined that, I am informed that it in no 
way refutes this morning's statement that this cannot simultaneously 
fund a new program and strengthen Medicare at the same time.
  I think it is a matter, will Senator Kyl not agree--I am not afraid 
to talk about it--if we need to slow down before we vote, so be it. 
First of all, is the Senator convinced, as Senator Gregg indicated this 
morning and CBO does, that we are, in fact, passing a bill that would, 
if it passes, add to the debt approximately $170 billion, as staff has 
calculated based on this letter, and would not reduce the debt by $132 
billion?
  Mr. KYL. Mr. President, I am absolutely convinced of that, yes.
  Mr. SESSIONS. I do not think there is any dispute about it. I think 
that is the fact. It has been exposed. The President looked us in the 
eye in a joint session of Congress, did he not, and said this 
legislation would not add one dime or one dollar to the debt of the 
United States?
  Mr. KYL. Mr. President, it is my recollection that is pretty close to 
what the President said. I guess maybe this would not be such a big 
deal unless you are trying to do two things with the same pot of money. 
As long as the other side is also claiming we are actually extending 
the life of Medicare, which I heard one of my colleagues do on 
television this morning, then you cannot make this other claim. You can 
claim one or the other but you cannot claim both. That is precisely 
what the head of CBO said:

       To describe the full amount of HI trust fund savings as 
     both improving the government's ability to pay future 
     Medicare benefits and financing new spending outside of 
     Medicare would essentially double-count a large share of 
     those savings and thus overstate the improvement in the 
     government's fiscal position.

  Mr. SESSIONS. To follow up on that, is it not true--and President 
Obama Monday flatly stated in one press conference that it would reduce 
our deficit over 10 years by $130 billion and extend the Medicare 
Program by 9 years, which is patently false, it would appear. I am not 
sure he understood the complexities of all this accounting, but, in 
fact, I think he misspoke at that point. Would the Senator from Arizona 
not agree?
  Mr. KYL. Mr. President, I obviously cannot get into the President's 
mind, but I must say that all of us had missed this point. I said 
before I ascribe no ill will to anybody on the other side. This is hard 
to understand. Accounting can be arcane. That is why this statement 
from the CMS was a little troubling to us when we first read it. They 
said:

       Despite the appearance of this result from the respective 
     accounting conventions--

  Which is a fancy way of saying accountants have their way of showing 
things and that might have confused you--

     in practice, improved party financing cannot be 
     simultaneously used to finance other Federal outlays.

  You cannot use the same pot of money of $10 to buy two different $10 
benefits. You can buy one or the other or half of each, but you cannot 
buy both. As the old saying goes, you cannot sell the same pony twice.
  Mr. SESSIONS. It said, did it not, in that CMS letter that was a fact 
``despite the appearance of this result from the respective accounting 
conventions''? Were they not warning us that it might appear this way 
but it cannot be that way?
  Mr. KYL. Mr. President, our colleague Senator Gregg, a respected 
member of the Budget Committee, pointed out this morning why that is 
so, and my colleague from Alabama can do that as well.
  There are two different systems of accounting by two different parts 
of the government. The only way they can do this is by sending an IOU 
back to the Social Security trust fund, but, of course, the IOU comes 
out of the pocket of the taxpayers where we have to borrow it and it is 
still an obligation even though it shows up on accounting books as 
obligation satisfied.
  Mr. BAUCUS. Will the Senator yield for a simple question?
  Mr. KYL. Sure.
  Mr. BAUCUS. I wonder if the Senator is aware that CBO this morning at 
9:57 sent an e-mail to all relevant staff that its estimates with 
regard to budget deficit reduction still stand, still hold. CBO still 
estimates this legislation results in a $132 billion deficit reduction. 
That was an e-mail sent today. Is the Senator aware of that e-mail?
  Mr. KYL. I did not see that e-mail. I assume that is the same 
communique about which the Senator from Alabama is talking. It shows 
you exactly why this is so confusing and why I am a little bit 
concerned about the politicization of the CBO.
  Last night and again this morning, we have a memo that says you 
cannot pay twice. If after that he says I still show that as a surplus, 
then what he has to also be saying is, and therefore it does not extend 
the life of the Social Security trust fund. As I said, you can do one 
or the other, or roughly half of each, but you cannot do both. If he is 
choosing to say it is applied to one, then our colleagues cannot 
continue to say that it applies to the other.
  Mr. President, Americans' biggest complaint about the current 
healthcare system is the increasing cost of health insurance premiums.
  President Obama promised that his healthcare reform bill would 
address this problem. As he said during his campaign, ``I have made a 
solemn pledge that I will sign a universal healthcare bill into law . . 
. that will . . . cut the cost of a typical family's premium by up to 
$2,500 a year.''
  By the President's own yardstick, this bill is a failure, since it 
actually increases premiums for many Americans and fails to restrain 
growths for the rest.''
  Recently, the nonpartisan Congressional Budget Office (CBO) concluded 
that, under this bill, those in the individual market--that is, those 
without employer-sponsored insurance--will face premium increases 
between 10 and 13 percent. That's approximately $2,100 per family by 
2016.
  A second study, from the actuarial firm Oliver Wyman, also concluded 
premiums will rise under this legislation, thanks to burdensome new 
Federal mandates and requirements and several new taxes.
  In the individual market, this study predicts, premiums will rise by 
$3,300 per year for family coverage and $1,500 for individuals. In my 
home State of Arizona premiums could rise by as much as 72 percent in 
the individual market.
  This study also tells us that the small group market would see 
premium

[[Page S13829]]

increases. Small employers purchasing new policies in the reformed 
market would experience premiums up to 20 percent higher in 2019 than 
they would under current law.
  Oliver Wyman also estimates that, if this bill is enacted, 2.9 
million fewer Americans would have insurance through small-employer 
policies.
  So what this bill does is raise the cost of insurance for many 
Americans and then force everyone to buy a policy--and not just any 
policy, one that is been approved by Washington!
  Our friends on the other side of the aisle argue that many families 
will receive government subsidies to help with the increased cost of 
insurance brought on by new mandates, taxes, and Federal requirements.
  There are a few problems with this argument.
  First, not every family will qualify for such subsidies. Indeed, 14 
million Americans who buy their own coverage would earn too much to get 
a subsidy, according to the Congressional Budget Office.
  So 14 million Americans will be required, by Washington, to purchase 
unsubsidized insurance that is more expensive than they could get under 
current law. And this is being called reform?
  Second, those who do receive a subsidy may find the subsidy does not 
begin to cover the total cost of the increase. So, those families, too, 
will actually be worse off.
  And, finally, the heart of this debate is a basic question: What is 
the point of raising the price of insurance and then subsidizing a 
portion of the increase? You are still raising premiums and someone has 
to pay for subsidies.
  Americans have asked us to lower healthcare costs, not raise them and 
then provide subsidies to those who qualify. And they certainly don't 
want to pay more in taxes to subsidize their own insurance--but that is 
what the Democrats' bill would have them do.
  As the Wall Street Journal recently editorialized, ``The [Reid] bill 
will increase costs, but it will then disguise those costs by 
transferring them to taxpayers from individuals:''
  Not surprisingly, small business associations, whose members would be 
overwhelmingly impacted by this legislation, are disappointed.
  The Small Business Coalition for Affordable Healthcare, for one, 
opposes this bill.
  Their name says it all. This organization believes, as all of us do 
here in the Senate, that the status quo is not acceptable and not 
sustainable. But they disapprove of this legislation because, as they 
wrote in a letter to Congress, ``it costs too much and delivers too 
little.''
  Here are just a few of the dozens of businesses represented by this 
organization: The Americans Hotel and Lodging Association; American 
Bakers Association; the Independent Electrical Contractors; the 
National Association of Convenience Stores; the National Automobile 
Dealers Association; Printing Industries of America; the Society of 
American Florists. The list goes on and on.
  These businesses wrote a letter to Congress expressing disapproval of 
the bill's huge costs and failure to bring down premiums, among other 
provisions that hurt small businesses. They believe that increased 
premiums have a domino effect, hurting both the employer and the 
employee, resulting in fewer jobs, depressed wages, and fewer choices.

  I will share some excerpts from their letter, with regard to 
increased premiums and costs:
  They write:

       The bill does little to make insurance more affordable and 
     the [small business] tax credit is so limited, few will be 
     able to obtain affordable insurance.

  They go on:

       The impact on non-group premiums is . . . devastating, as 
     they are expected to increase an average of 10-13 percent per 
     person. Those estimates, in addition to the financing 
     provisions in the bill, slam the ``savings'' door shut.

  Another organization, the National Federation of Independent 
Business, has also raised major objections to this bill with regard to 
increased premiums.
  Here is a telling excerpt from a letter they wrote to the two Senate 
party leaders:

       H.R. 3590 fails the small business test, and, therefore, 
     fails small business. The most recent CBO study detailing the 
     effect [this bill] will have on insurance premiums reinforces 
     that, despite claims by its supporters, the bill will not 
     deliver the widely-promised help to the small business 
     community.

  Bruce Josten of the U.S. Chamber of Commerce concurs. He recently 
said:

       The fundamental failure of the Senate bill is its failure 
     to address cost containment. We have a bill that raises taxes 
     on pretty much everything that moves in the healthcare space. 
     And successful cost containment practices that are in the 
     marketplace, like health savings accounts or flexible 
     spending accounts, are dramatically weakened in this . . . 
     Healthcare cost increases are going to crowd out the 
     compensation pool.

  The majority leader recently disagreed with the notion that this bill 
increases costs, citing a prediction by the President's Council of 
Economic Advisers that the bill before us would bring down costs.
  This is the same council that told us unemployment would peak at 8 
percent if only Congress would pass the stimulus. As Americans know, 
Congress passed the stimulus, and we are now at 10 percent 
unemployment.
  Moreover, if the Council of Economic Advisors is supposed to be the 
Bible of economic analysis and administration officials know best, why 
is it that on the same day the President's top economic advisor Larry 
Summers declared on This Week, ``the recession is over,'' the Council's 
chair, Christina Romer, told Meet the Press viewers that ``of course'' 
the recession is not over? So, who should we believe on costs?
  I submit that small business owners and their representatives have 
the most intimate knowledge of which policies will benefit them and 
which stand to hurt them. They are telling us this bill will hurt them.
  Finally, I would like to point out that this bill does not even 
guarantee that all Americans have insurance. This bill leaves 24 
million Americans uninsured.
  We are going to spend $2.5 trillion to raise the price of insurance 
for millions of Americans and keep affordable insurance out of reach 
for millions more.
  There are much better ways to give access to affordable healthcare to 
all Americans.
  We should start with serious medical liability reform, which has been 
proven in Texas, Arizona, and Missouri to bring down costs for patients 
and doctors.
  We need to allow Americans to buy insurance across State lines. This 
is one of the most commonsense reforms out there. Why should Americans 
be denied access to lower-cost policies just because they are being 
sold in other states?
  We should also allow small businesses to band together to pool their 
risk and purchase insurance at the same rates large corporations get.
  Enacting these simple reforms would cost little, if anything, and 
would be sure to bring down costs. That is the kind of reform Americans 
would be sure to support.
  The ACTING PRESIDENT pro tempore. The Senator's time has expired.
  The majority leader is recognized.
  Mr. REID. Mr. President, I ask unanimous consent that the Baucus 
motion to waive be set aside.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. REID. Mr. President, I want to take a moment to talk about the 
motion to table the appeal by Senator Cornyn and the ruling of the 
Chair that no point of order lies under rule XLIV.
  Senator Cornyn's appeal is not about transparency and certainly not 
about disclosure. It is about delay and obstruction. That is what the 
whole tenor of all the Republican statements has been regarding this 
legislation.
  The vote is whether we create a whole new point of order even though 
Senate rules at this stage do not allow a point of order. They want to 
rewrite the rules at a whim, not for purpose of disclosure and 
transparency but for the purpose of delay and obstruction.
  The legislative history of the Honest Leadership and Government Act 
specifically addresses the issue of whether a point of order lies in 
this instance:

       If rule XLIV does not expressly provide for a point of 
     order with respect to a provision, then no point of order 
     shall lie under the provision.

  We open a Pandora's box if we reverse the ruling of the Chair on 
appeal. What would be the new rule? How

[[Page S13830]]

would the new rules be implemented? What happens to the health care 
bill? Who decides the answers to these questions?
  Moreover, if we overrule the Chair, we would be setting a dangerous 
precedent that points of order lie even if not provided for in Senate 
rules, standing orders, or procedures.
  It is clear the purpose of this is to obstruct and delay. I urge my 
colleagues to vote to table the Cornyn appeal of the ruling of the 
Chair when that comes.
  Mr. CORNYN. Will the Senator yield for a question?
  Mr. REID. No, I will not. The health care votes we have held this 
week have been procedural in nature. Each has been a party-line vote 
and much of this debate is focused on politics. But health reform is 
not about procedure or partisanship or politics. It is about people--
people like the thousands who write us every day.
  At my desk, we have a few of the letters we have picked up in the 
last day or so. Sorry, staff has had to lift that and I didn't. This is 
a few we have gotten. Look at this. They are all basically the same. 
Each of these letters right here represents a story, a tragedy, a life, 
a death, but most of all, a person--a person, people who wake up every 
morning and struggle to get health care or struggle to hold on to what 
they have, people who lie awake every night second-guessing the 
agonizing decisions they have to make about what to sacrifice just to 
stay healthy.
  Here is a letter that was written to Senator Bob Casey of 
Pennsylvania. Listen to what this woman said:

       Dear Senator Casey. In a country like the United States, we 
     shouldn't need a tip jar in an ice cream shop to raise money 
     for a kid with leukemia. Jennifer Wood.

  Here is another one of those letters. This one is from a father in 
North Las Vegas, NV:

       Can you imagine what it is like to have a doctor look you 
     in your eye when you hold your 1-year-old child and be told 
     that you will likely outlive your son?

  He goes on to say:

       I am certain my story is not unique, but it is real. Stop 
     forcing Americans to use the most expensive point of service, 
     the emergency room, to get what the system won't give them. 
     Let's make all Americans equal in the eyes of health care, 
     please.

  This legislation is not about the number of pages of this bill. It is 
about the number of people--people such as the man whose letter I just 
read who was told by a doctor that he would likely outlive his son. It 
is about the number of people whom this bill will help. That is what 
this is all about. It is about fairness. So when people are hurt or 
sick, they can go see somebody who can help them and not lie awake at 
night wondering if they will outlive their 1-year-old son.
  Mr. President, how much time remains?
  The ACTING PRESIDENT pro tempore. There is 1\1/2\ minutes remaining.
  Mr. REID. I yield back that time and ask the vote start earlier.
  I withdraw that request.
  I ask unanimous consent that prior to each vote today there be 2 
minutes of debate equally divided and controlled in the usual form.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  There is now 2 minutes equally divided.
  The majority leader.
  Mr. REID. Mr. President, stop the 2 minutes from running. I do want 
to explain. We will shortly have a series of up to seven votes. As we 
noted in the last few days, if Members remain at their desks, the votes 
can be concluded much earlier.


                         Ensign Point of Order

  The ACTING PRESIDENT pro tempore. There is now 2 minutes of debate 
equally divided prior to a vote on the constitutional point of order 
offered by the Senator from Nevada, Mr. Ensign.
  Who yields time?
  The majority leader.
  Mr. REID. Mr. President, the vote sequence will be as follows: Ensign 
constitutional point of order; Corker unfunded mandates point of order; 
Baucus motion to table the Cornyn appeal ruling of the Chair; Hutchison 
constitutional point of order. I have been advised that a Republican 
Member will move to suspend the rules so he can offer his amendment 
under rule XXII. He is going to be allowed 10 minutes. This will 
require 67 votes because it is an effort to change the rules. Following 
that we will have adoption of the substitute amendment and cloture on 
H.R. 3590. So there is a series of seven votes.
  The ACTING PRESIDENT pro tempore. Who yields time?
  The Senator from Nevada is recognized.
  Mr. ENSIGN. Mr. President, I raise a constitutional point of order 
because I am concerned that the health reform bill violate's Congress's 
enumerated powers under article I, section 8 and the fifth amendment 
takings clause of the Constitution.
  Each one of us takes an oath to defend the Constitution of the United 
States. We do not take an oath to reform health care. We do not take an 
oath to do anything else here but to defend the Constitution of these 
United States.
  Health care reform needs to fit within the Constitution. The 
Constitution limits the powers we have. The Congress, the U.S. 
Government has never enacted anything that would regulate someone's 
inactivity in the way the individual mandate in this health care bill 
would. Anything we have ever done, somebody actually had to have an 
action before we could tax or regulate it. In this case, if you choose 
to not do something--in other words, if you do not choose health 
insurance--this bill will actually tax you. It will act as an onerous 
tax. So for the first time in the history of the United States this 
bill will do something the Federal Government has never done before. 
This bill would do something that is beyond Congress's powers to 
authorize. This bill is unconstitutional and I urge all Members to vote 
in support of the constitutional point of order.
  The ACTING PRESIDENT pro tempore. The Senator's time has expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, our committee and the HELP Committee have 
given a lot of thought to the provisions in this legislation. We also 
gave a lot of thought to the constitutionality of the provisions--how 
they work and the interrelationship between the power of Congress and 
the States and what States will be doing, particularly under the 
commerce clause and the tax-and-spending powers of the Constitution.
  It is very strongly our considered judgment, and that of many 
constitutional scholars who have looked at these provisions--and many 
articles have been put in the Record--that clearly these provisions are 
constitutional. The commerce clause is constitutional, the tax-and-
spending clause, and the provisions clearly are constitutional.
  I yield back my time.
  The ACTING PRESIDENT pro tempore. The question is on agreeing to the 
constitutional point of order made by the Senator from Nevada, Mr. 
Ensign, that the amendment violates article I, section 8 of the 
Constitution, and the fifth amendment.
  The question is, Is the point of order well taken?
  The yeas and nays have been ordered.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Kentucky (Mr. Bunning).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``yea.''
  The ACTING PRESIDENT pro tempore. Are there any other Senators in the 
Chamber desiring to vote?
  The yeas and nays resulted--yeas 39, nays 60, as follows:

                      [Rollcall Vote No. 389 Leg.]

                                YEAS--39

     Alexander
     Barrasso
     Bennett
     Bond
     Brownback
     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
     Voinovich
     Wicker

                                NAYS--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

[[Page S13831]]


     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

                             NOT VOTING--1

       
     Bunning
       
  The ACTING PRESIDENT pro tempore. The point of order is not well-
taken.


                         Corker Point of Order

  The ACTING PRESIDENT pro tempore. There is now 2 minutes equally 
divided prior to the vote on the motion to waive the point of order 
raised by the Senator from Tennessee, Mr. Corker.
  Who yields time?
  The Senator from Tennessee is recognized.
  Mr. CORKER. Mr. President, thank you so much.
  There is almost nothing held in lower esteem than for the Senate to 
pass laws in this body that cause mayors and Governors to have 
budgetary problems because we create unfunded mandates.
  Many of you have been mayors and Governors, and for that reason, in 
1995, in a bipartisan way, a law was created--15 Senators on the other 
side of the aisle who are now serving supported this law--to keep us 
from passing unfunded mandates. CBO has stated without a doubt that 
this bill violates that.
  I urge Members to vote against this motion to waive that. It is 
important. It says everything about the way we do business here in 
Washington. Please, let's not pass another huge unfunded mandate to the 
States at a time when they all are having budgetary problems. This 
speaks to the essence of who we are and the arrogance many people 
perceive us to have here in Washington.
  The ACTING PRESIDENT pro tempore. The Senator from Montana is 
recognized.
  Mr. BAUCUS. This point of order calls for legislation to impose an 
obligation on States to extend their coverage on Medicaid. Under 
existing law, on average, the Federal Government pays about 57 cents on 
the dollar for every dollar spent under Medicaid. Under this 
legislation, the Federal Government will pay 100 percent of that 
obligation for newly enrolled beneficiaries up through the year 2016. 
Afterward, the Federal Government will pay on average 90 percent of the 
cost of new enrollees. Therefore, I think this is a very fair deal for 
States, and I urge my colleagues to waive the point of order.
  Mr. President, I also ask consent that this vote and all subsequent 
votes in this sequence be 10-minute votes.
  The PRESIDING OFFICER (Mr. Sanders). The question is on agreeing to 
the motion to waive the Budget Act point of order raised under section 
425(a)(2).
  The yeas and nays were previously ordered.
  The clerk will call the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Kentucky (Mr. Bunning).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``nay.''
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 55, nays 44, as follows:

                      [Rollcall Vote No. 390 Leg.]

                                YEAS--55

     Akaka
     Baucus
     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 (FL)
     Pryor
     Reed
     Reid
     Rockefeller
     Sanders
     Schumer
     Specter
     Stabenow
     Tester
     Udall (CO)
     Udall (NM)
     Whitehouse
     Wyden

                                NAYS--44

     Alexander
     Barrasso
     Bayh
     Bennett
     Bond
     Brownback
     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
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shaheen
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Warner
     Webb
     Wicker

                             NOT VOTING--1

       
     Bunning
       
  The PRESIDING OFFICER. The motion to waive section 425(a)(2)requiring 
a simple majority is agreed to.
  The point of order falls.
  The majority leader is recognized.
  Mr. REID. Mr. President, I have spoken to the Republican leader. 
Senators on both sides feel that it would be to their advantage if we 
had the vote on Christmas Eve at 7 a.m. rather than 8 a.m. That being 
the case, I ask unanimous consent that the vote start at 7 a.m. on 
Christmas Eve.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. LEAHY. May I address a question to the distinguished majority 
leader.
  The PRESIDING OFFICER. The Senator from Vermont.
  Mr. LEAHY. Mr. President, it will not affect my travel plans because 
I long ago decided----
  Mr. REID. If I could interrupt my friend, quit while you are ahead.
  Mr. LEAHY. You have your agreement on this. But is there any 
possibility that our friends on the other side, knowing that those who 
are traveling to the Midwest are going to face horrendous problems, 
that we could have that vote this evening? It will not affect the 
Senator from Vermont one way or the other, but it will affect a lot of 
Senators, Republicans and Democrats alike, who have to fly through the 
Midwest to get where they are going.
  Mr. McCONNELL. Regular order.


                CORNYN APPEAL OF THE RULING OF THE CHAIR

  The PRESIDING OFFICER. Regular order has been called for.
  There is now 2 minutes equally divided prior to a vote on the motion 
to table the appeal of the ruling of the Chair.
  The Senator from Texas.
  Mr. CORNYN. Mr. President, upon passage of the Honest Leadership and 
Open Government Act, the majority leader said:

       I believe last November Americans . . . asked us to make 
     Government honest. We have done that . . . This is the 
     toughest reform bill in the history of this body as it 
     relates to ethics and lawmaking.

  This is an appeal to the ruling of the Chair that that provision of 
rule XLIV is unenforceable. Why would anybody who voted overwhelmingly 
to make this the toughest reform bill in the history of the body render 
this rule toothless by agreeing with the attempt to set this aside and 
to waive its effect?
  I ask my colleagues to make sure we vote for transparency, for 
honesty, for open government. Vote no on this motion to waive.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, the plain text of the language in rule 
XLIV provides that no point of order lies against amendments. That is 
the way the draftees intended it. That is the way they wrote rule XLIV. 
That is why the Presiding Officer ruled that way on the advice of the 
Parliamentarian. We should support the Chair and the Parliamentarian 
and vote for the motion to table the appeal of the ruling of the Chair.
  I yield back the remainder of my time.
  Mr. CORNYN. Do I have time remaining?
  The PRESIDING OFFICER. One second.
  Mr. CORNYN. I ask my colleagues to vote no on the motion to waive.
  The PRESIDING OFFICER. The question is on agreeing to the motion to 
table the appeal of the ruling of the Chair that there is no point of 
order under rule XLIV, paragraph 4(a).
  The yeas and nays were previously ordered.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Kentucky (Mr. Bunning).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``nay.''
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?

[[Page S13832]]

  The result was announced--yeas 57, nays 42, as follows:

                      [Rollcall Vote No. 391 Leg.]

                                YEAS--57

     Akaka
     Baucus
     Begich
     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
     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--42

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

                             NOT VOTING--1

       
     Bunning
       
  The motion was agreed to.
  Mr. REID. I move to reconsider the vote.
  Mr. DURBIN. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                        HUTCHISON POINT OF ORDER

  The PRESIDING OFFICER. There is now 2 minutes, equally divided, prior 
to a vote on the constitutional point of order made by the Senator from 
Texas, Mrs. Hutchison.
  The Senator from Texas.
  Mrs. HUTCHISON. Mr. President, the 10th amendment says:

       The powers not delegated to the United States by the 
     Constitution . . . are reserved to the States. . . .

  In this bill, a State such as Texas and many other States that have 
taken full responsibility for insurance plans for their employees and 
teachers will have to justify any change in those terms to the Federal 
Government.
  The majority claims the commerce clause gives them the power to do 
what is in this bill. But what they fail to mention is the power to 
regulate interstate commerce has not been the basis for a robust role 
in insurance regulation.
  This is an encroachment of the Federal Government into a role left to 
the States in the Constitution. The 10th amendment is being eroded by 
an activist Congress, and it is time to stop it now.
  I urge a vote to uphold this point of order.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, the bill before us is clearly an 
appropriate exercise of the commerce clause. We further believe 
Congress has power to enact this legislation pursuant to the taxing and 
spending powers. This bill does not violate the 10th amendment because 
it is an appropriate exercise of powers delegated to the United States, 
and because our bill fundamentally gives States the choice to 
participate in the exchanges themselves or, if they do not choose to do 
so, to allow the Federal Government to set up the exchanges fully 
within the provisions as interpreted by the Supreme Court of the 10th 
amendment.
  I urge my colleagues to vote against the point of order.
  The PRESIDING OFFICER. The question is on the constitutional point of 
order made by the Senator from Texas, Mrs. Hutchison, that the 
amendment violates the 10th amendment.
  The question is, Is the point of order well taken?
  The yeas and nays have been ordered.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Kentucky (Mr. Bunning).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``yea.''
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 39, nays 60, as follows:

                      [Rollcall Vote No. 392 Leg.]

                                YEAS--39

     Alexander
     Barrasso
     Bennett
     Bond
     Brownback
     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
     Voinovich
     Wicker

                                NAYS--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

                             NOT VOTING--1

       
     Bunning
       
  The PRESIDING OFFICER. The point of order is not agreed to.
  The Senator from South Carolina.
  Mr. DeMINT. Mr. President, since I have not used or yielded 10 
minutes, I ask to be recognized for up to 10 minutes under rule XXII, 
paragraph 2.
  The PRESIDING OFFICER. The Senator has that right.
  The Senator from South Carolina.


                        DeMINT MOTION TO SUSPEND

  Mr. DeMINT. Mr. President, in just a moment I will move to suspend 
the rules for the purpose of offering an amendment that would ban the 
practice of trading earmarks for votes.
  While I want to be careful not to suggest wrongdoing by any Member, 
there has been growing public concern that earmarks were used to buy 
votes for this legislation. It has been argued by some that this 
practice is acceptable because it is necessary to get things done in 
the Senate. I reject that argument, and I urge my colleagues to put an 
end to business as usual here in the Senate.
  The House of Representatives has a rule prohibiting the use of 
earmarks to buy votes for legislation. If we were in the House 
considering this bill, vote trading would be a direct violation of the 
ethics rules. Unfortunately, a vote-trading rule does not exist in the 
Senate.
  During the debate on the lobbying and ethics reform bill in the 110th 
Congress, the senior Senator from Illinois, Mr. Durbin, and I offered 
an earmark reform amendment which contained the following language:

       A Member may not condition the inclusion of language to 
     provide funding for a congressional earmark . . . on any vote 
     cast by another Member.

  The Durbin-DeMint amendment was written to mirror Speaker Pelosi's 
earmark reforms in the House. The Durbin-DeMint amendment passed the 
Senate by a vote of 98 to 0 and was included in S. 1, the Honest 
Leadership and Open Government Act, which passed the Senate by a vote 
of 96 to 2.
  The rule against trading votes for earmarks was in the bill when it 
left the Senate, but then the bill moved to a closed-door negotiation. 
Somehow, at some point in those closed-door negotiations, someone 
dropped the earmark-for-vote language. I have no idea who it was, and 
we may never know. Remember, this bill was called the Honest Leadership 
and Open Government Act. In any case, the vote-trading rule was dropped 
from the bill, which then passed the Senate and was signed by the 
President.
  Just to confirm all of this, I wish to make a parliamentary inquiry 
to the Chair. Is the Chair aware of any prohibition in the Standing 
Rules of the Senate such as the previously referenced rule contained in 
the Durbin-DeMint amendment or in the Rules of the House of 
Representatives?
  The PRESIDING OFFICER. No such rule exists in the Senate.
  Mr. DeMINT. No such rule exists.
  I have an amendment which would correct this error. It mirrors the 
Durbin-DeMint language which passed the Senate 98 to 0, and I will read 
the relevant parts. I quote:

       It shall not be in order in the Senate to consider a 
     congressionally directed spending

[[Page S13833]]

     item . . . if a Senator . . . has conditioned the inclusion 
     of the language . . . on any vote cast by any Senator.

  This language had unanimous bipartisan support in 2007, and it should 
be part of the rules today. This rule would provide needed 
accountability and allow any Senator to raise a point of order to 
strike any earmark that has been used to buy votes. This point of order 
could be waived and the ruling of the Chair could be appealed with the 
support of two-thirds of Senators present and voting.
  Before I make this motion and we vote on this amendment, I wish to 
make a few things absolutely clear. First, this rule already won a 
unanimous vote in the Senate in 2007, so it is not controversial. 
Second, this rule only applies to earmarks used to buy votes in the 
future. It will not, unfortunately, apply to the earmarks in this bill. 
Third, this vote is not a trick. The amendment is written as a 
``standing order,'' so it will not increase the number of votes 
required to pass this legislation. It will not slow down the health 
care bill in any way.
  The only reason for Senators to oppose this amendment is if they want 
to use earmarks to buy votes for legislation. It is that simple. If you 
support business as usual, then oppose this motion. But if you want to 
start to clean this place up and bring some integrity back to the 
legislative process, then please support the motion.
  Mr. President, I move to suspend the provisions of rule XXII, 
including germaneness requirements, for the purpose of proposing and 
considering my amendment No. 3297, and I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  It appears there is a sufficient second.
  The yeas and nays were ordered.
  The Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, this proposed new point of order may sound 
good in theory, but it has many flaws, in fact, when you stop and think 
about it. If you think the Senate is tied up in knots now, if this were 
in effect, the current situation would pale in comparison to what the 
effect of this amendment would be.
  The amendment is written in a way to become an endless source of 
delay. Senators could make one point of order after another under this 
provision, pointing to different provisions or indicting the integrity 
of different Senators.
  The amendment provides no way for determining how to rule on a point 
of order raised under it. A point of order cannot be decided without 
solid guidance. Points of order make the most sense when they are based 
on objective criteria.
  The proposed amendment to rule XXII would ask the Chair and the 
Parliamentarian to sort through purely subjective concepts such as the 
basis for a Senator's vote or the intent behind inclusion of a 
provision. How would the Chair be able to rule on such a point of 
order? Would the Parliamentarian have to question the chairman of a 
committee or a Senator who offers the amendment, under oath? Would the 
Parliamentarian have to question every Senator who requested a directed 
spending item, under oath, to ensure they did not condition their 
support on inclusion of the item?
  The rule may sound good in theory, but it is totally unworkable as a 
practical matter.
  I move to table the DeMint motion and ask for the yeas and nays.
  The PRESIDING OFFICER. There is 1 minute left for those who favor the 
motion. Who yields time?
  The Senator from South Carolina, 1 minute.
  Mr. DeMINT. Mr. President, I would answer the questions of the 
Senator by suggesting that Senator Durbin, who wrote the amendment, 
perhaps may wish to make a couple of comments about it because this is 
the mirror--
  Mr. DURBIN. Are you yielding time?
  Mr. DeMINT. Yes, I sure will.
  Mr. DURBIN. I don't understand how this amendment would work. If the 
Senator happens to have a hurricane in his State and needs disaster aid 
and we put money in the bill, then would we have to question the 
Senator's motive for voting for the bill? I think it goes entirely too 
far, and I support this effort to table.
  Mr. DeMINT. This a DeMint-Durbin amendment. It is mirrored after 
Speaker Pelosi's bill. They have this rule in the House. They can make 
it workable. Certainly, the integrity of this body is worth 
considering.
  I would encourage my colleagues, at this point, when the public is 
looking at us, asking for some trust and integrity, we can make this 
bill work. I ask my colleagues to support my amendment and oppose the 
tabling motion.
  Mr. BAUCUS. I move to table the motion and ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The question is on agreeing to the motion to table the motion to 
suspend the rules.
  The clerk will call the roll.
  The PRESIDING OFFICER (Mr. Akaka). Are there any other Senators in 
the Chamber desiring to vote?
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Kentucky (Mr. Bunning).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``nay.''
  The result was announced--yeas 53, nays 46, as follows:

                      [Rollcall Vote No. 393 Leg.]

                                YEAS--53

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

                                NAYS--46

     Alexander
     Barrasso
     Bayh
     Bennett
     Bond
     Brownback
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Feingold
     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Isakson
     Johanns
     Kyl
     LeMieux
     Lugar
     McCain
     McCaskill
     McConnell
     Merkley
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Warner
     Webb
     Wicker

                             NOT VOTING--1

       
     Bunning
       
  The motion was agreed to.
  Mr. REID. I move to reconsider the vote, and I move to lay that 
motion on the table.
  The motion to table was agreed to.


                      Amendment No. 2878 Withdrawn

  Mr. REID. Mr. President, I ask unanimous consent that amendment No. 
2878 be withdrawn.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                     Amendment No. 2786, as Amended

  Mr. REID. Mr. President, what then is the pending business?
  The PRESIDING OFFICER. There is now 2 minutes of debate prior to a 
vote on amendment No. 2786, as amended.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, this is a vote to adopt the substitute. 
This is another vote on whether we wish to reform health care.
  I urge my colleagues to vote aye and move this process forward.
  I yield back my the time.
  Mr. REID. I ask for the yeas and nays.
  The PRESIDING OFFICER. The yeas and nays have been ordered.
  Who yields time in opposition?
  Mr. REID. I yield back the time on behalf of my Republican colleague.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The question is on agreeing to amendment No. 2786, as amended.
  The yeas and nays have been ordered.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Kentucky (Mr. Bunning).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``no.''
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 60, nays 39, as follows:

[[Page S13834]]

                      [Rollcall Vote No. 394 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
     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
     Voinovich
     Wicker

                             NOT VOTING--1

       
     Bunning
       
  The amendment (No. 2786), as amended, was agreed to.
  Mr. REID. Mr. President, I move to reconsider the vote, and I move to 
lay that motion on the table.
  The motion to lay on the table was agreed to.


                             Cloture Motion

  The PRESIDING OFFICER. Under the previous order and pursuant to rule 
XXII, the Chair lays before the Senate the pending cloture motion, 
which the clerk will report.
  The 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 H.R. 3590, the 
     Service Members Home Ownership Tax Act of 2009.
         Christopher Dodd, Richard Durbin, Mark Begich, Paul G. 
           Kirk, Sheldon Whitehouse, Roland W. Burris, Max Baucus, 
           Sherrod Brown, Claire McCaskill, Jon Tester, Barbara A. 
           Mikulski, Bill Nelson, Maria Cantwell, Mark Udall, 
           Arlen Specter, Kirsten E. Gillibrand, and Ron Wyden.

  The PRESIDING OFFICER. By unanimous consent, the mandatory quorum 
call has been waived.
  The question is, Is it the sense of the Senate that debate on 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 assistant legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Kentucky (Mr. Bunning).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``nay.''
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 60, nays 39, as follows:

                      [Rollcall Vote No. 395 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
     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
     Voinovich
     Wicker

                             NOT VOTING--1

       
     Bunning
       
  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 to invoke cloture on the underlying bill is 
agreed to.
  Mr. REID. Mr. President, I think we all recognize that things have 
gotten pretty tense around the Senate as we have worked three weekends 
in a row, long hours, and approach the Christmas holiday. Sometimes the 
tension has boiled over into what has been said on and off the floor, 
and the way we treat each other, and that is very regrettable.
  Two nights ago there was an unfortunate incident that deserves 
special mention, though. One of our colleagues, the Senator from South 
Carolina, attacked the office of the Senate Parliamentarian. We all 
know that the Senate Parliamentarian is a non-partisan referee. The 
Office of the Parliamentarian does their best to enforce the rules and 
procedures of the Senate in an impartial manner.
  We have all come across situations when we were frustrated by the 
Parliamentarian's ruling because we were hoping that a given amendment 
was or was not germane, or that a given point of order was or was not 
well taken. But, we have all taken comfort in the fact that whatever 
the ruling in the instant case, the Parliamentarian was calling it 
straight and the same ruling would apply to similar amendments by other 
Senators and similar facts in the future.
  So, it is simply not right and not fair to attack the 
Parliamentarians for doing their job. This is especially so when the 
issue is not a close call. Our colleague from South Carolina attacked 
the Parliamentarian over a ruling relating to the difference between 
amendments to the Standing Rules of the Senate and procedural changes 
adopted in less formal ways. The former requires a 2/3rds vote to 
achieve cloture; the latter is treated like any other piece of 
legislation. The distinction is an interesting quirk of Senate rules. 
But it is a venerable and well-established distinction. The Senate 
Manual includes 70 pages of Standing Orders. The Budget Act process--
which the minority used to make a point of order just today--is almost 
entirely dependent on procedures that are not part of the Standing 
Rules of the Senate. In fact, in the last two Congresses, the Senator 
from South Carolina has authored or co-sponsored at least 17 bills or 
amendments that implicate the distinction. For the Parliamentarian to 
be accused of ``redefin[ing] words,'' ``ignoring a rule'' of the 
Senate, and a ``truly historic'' and unconstitutional ``subvert[sion 
of] the principle we have operated under'' for re-stating this 
longstanding distinction is completely unwarranted.
  As I noted, tensions are running high and Senators are tired and, 
according to one recent article, cranky. But I hope that the body will 
do its best to ensure proper decorum as we proceed for the remainder of 
the year and the remainder of the Congress. We need to treat each other 
with respect. And we certainly need to treat the institution of the 
Senate and its hard-working employees with respect.
  Mr. President, I ask unanimous consent there now be alternating 
blocks of time as follows: The first hour under the control of the 
Republicans; further, that after the first 2 hours, then there be 
alternating blocks of 30 minutes, with the Republicans controlling the 
first 30 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. HARKIN. Mr. President, there have been a lot of conversations on 
this floor in the last couple hours. There are a lot of people who are 
facing tough timetables tomorrow. I know of one Senator----
  Mr. VITTER. Mr. President, regular order. Regular order, Mr. 
President.
  Mr. HARKIN. Mr. President, I ask consent I be given 2 minutes.
  The PRESIDING OFFICER. Is there objection?
  Mr. VITTER. Mr. President, reserving the right to object. I would be 
happy for those 2 minutes to come out of the Democrats' 1 hour without 
asking for regular order.
  Mr. HARKIN. That is fine.
  The PRESIDING OFFICER. Without objection.
  Mr. HARKIN. Mr. President, I know one Senator whose family is with 
their in-laws. The husband is from England

[[Page S13835]]

and the kids are over there and cannot make it for Christmas dinner 
tomorrow night. I know another person who has to get out to the West 
and there are a lot of storms out there. If they can get that early 
flight, they can make two legs and get home. If they have to go later 
in the day, they have to do three legs and they may not make it. There 
are a lot of people around here who are having a lot of problems that 
we are all here. There is no reason to hold over the vote so I am going 
to ask unanimous consent that the vote on the passage of the bill and 
the vote on the debt limit bill occur at 6 p.m. this evening.
  The PRESIDING OFFICER. Is there objection?
  Mr. VITTER. Addressed the Chair.
  The PRESIDING OFFICER. The Senator from Louisiana.
  Mr. VITTER. Mr. President, that request has not been cleared on this 
side. On behalf of my colleagues, I object. If the Senator would like 
to talk to all his colleagues about it, that would be fine, but in the 
meantime, I would object.
  Mr. HARKIN. Mr. President, then I would further ask unanimous consent 
that the votes that are going to occur at 7 a.m. tomorrow occur at 
12:15 a.m., in the morning.
  The PRESIDING OFFICER. Is there objection?
  Mr. VITTER. Mr. President, my response would be the same and I would 
object in the same vein.
  The PRESIDING OFFICER. The objection is heard.
  Mr. HARKIN. I want Members to know who is keeping us here.
  Mr. RISCH. Mr. President?
  The PRESIDING OFFICER. The Senator from Idaho.
  Mr. RISCH. Mr. President, I ask unanimous consent that the vote 
referred to by Senator Harkin take place at 2 p.m. on January 20, 2010, 
when we return.
  The PRESIDING OFFICER. Is there objection?
  Mr. HARKIN. I object.
  The PRESIDING OFFICER. There are objections.
  The Senator from Louisiana is recognized.
  Mr. VITTER. Mr. President, I ask unanimous consent that this first 
block of time on the minority side be divided equally between the 
following Senators: myself, Senators Coburn, Thune, Sessions, Kyl, and 
Ensign.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. VITTER. I thank the Chair. Mr. President, I ask for order on the 
floor.
  The PRESIDING OFFICER. The Senate will be in order.
  Mr. VITTER. Mr. President, I ask that time not be counted against me 
until the floor is in order.
  The PRESIDING OFFICER. The Senator will not be charged. The Senator 
from Louisiana is recognized.
  Mr. VITTER. Mr. President, I rise to talk about this important health 
care issue but also to talk about another vitally important issue 
directly connected, which is spending and debt because we will also 
have an enormously important vote tomorrow morning on increasing the 
debt limit. It is already over $12 trillion, but the proposal is to 
increase it further.
  In starting, let me refer back to a couple comments and parts of the 
debate yesterday because I think it will provide a good segue into this 
important debate. First, yesterday, as we were debating health care, my 
colleague from Louisiana, the distinguished senior Senator, Ms. 
Landrieu, was on C-SPAN's ``Washington Journal.'' In discussing the 
health care bill, my participation came up. She said: ``Senator Vitter 
has not lifted a finger to pass this bill.''
  I wish to say that is a very kind and positive and generous comment 
of the Senator and I take it as a nice Christmas overture and I accept 
it in that vein. I wish her all the best this Christmas season as well. 
It is obviously very true, and I take it as a very positive comment.
  I would go further. I fought hard against this bill. I fought hard 
for alternative reforms, focused reforms, reforms focused like a laser 
beam on real solutions in health care to real problems such as 
preexisting conditions. I would simply add, I don't think this fight is 
over by a long shot. I will continue fighting and I will continue 
offering those alternatives.
  With regard to the bill and this enormously important issue of 
spending and debt, as I was leaving the floor to go to meetings in my 
office after speaking yesterday, Senator Baucus took issue, apparently, 
with some of my comments--specifically, my comments about Medicare. I 
had suggested that this bill cuts Medicare by $467 billion, almost $\1/
2\ trillion. Although I needed to go to meetings, I think Senator 
Baucus took issue with that and characterized that as actually 
extending the life of Medicare.
  The Congressional Budget Office answered that debate far better than 
I could have. They answered that debate in the last 24 hours with their 
report. They outline very clearly and we have been talking about it 
earlier today that, in fact, Medicare money and other pools of money 
are double counted in this analysis about the health care bill. ``The 
key point is that the savings to the HI trust fund under the health 
care bill would be received by the government only once so they cannot 
be set aside to pay for future Medicare spending and, at the same time, 
pay for current spending on other parts of the legislation or on other 
programs.''
  The same Congressional Budget Office report says ``to describe the 
full amount of HI trust fund savings and both improving the 
Government's ability to pay future Medicare benefits and financing new 
spending outside of Medicare would essentially double count a large 
share of those savings.''
  So this answers the Senator's comments directly. You can't have it 
both ways. You can't say we have a bill that is paid for and also a 
bill that strengthens Medicare and extends solvency for additional 
years. That is double counting. That is exactly what the CBO is saying. 
The American people, in a much more basic, commonsense way, know 
better. They know this bill isn't paid for. They know this bill is 
going to expand the deficit and put us on an even worse fiscal road. 
They know that in their gut. They know that with their common sense. Of 
course, that gets us to the other big vote tomorrow extending the debt 
limit, yet again, well beyond $12 trillion.

  These issues are connected. They are connected in the technical way I 
just suggested, and these issues are certainly connected in the hearts 
and minds of the American people. The American people have responded to 
this debate because health care is so vitally important and the health 
care issue is so personal.
  There is even an overarching, larger reason the American people have 
responded so much to this debate. It is because they are connecting the 
dots. They are putting this as part of a larger pattern, and they are 
connecting the dots between bailing out and taking over insurance 
companies and financial companies and car companies, hiring and firing 
the CEO from the Oval Office to potentially one-sixth of the U.S. 
economy in health care. They are connecting those dots in terms of 
spending and debt, as well, because that has been the dominant trend 
over the last 12 months at least.
  We have a debt limit today. It is over $12 trillion. The motion 
tomorrow suggests that is not enough. We need to go higher. The 
American people are connecting the dots, particularly in the last year, 
and they are scared to death about where it leads. How did we get this 
way? How did we come to this $12 trillion-plus point? Well, in July, 
2008, Fannie Mae and Freddie Mac were given an unlimited line of credit 
from the Treasury that, so far, has been $400 billion, and that bill 
increased the debt limit from $9.8 trillion to $10.6 trillion. But that 
wasn't enough. Only 3 months later, in October, 2008, came the Wall 
Street bailouts, the $700 billion TARP that will raise the debt limit. 
That did raise the debt limit even further, to $11.3 trillion, but we 
weren't done yet. Only a few months after that, in February of this 
year, we passed the so-called stimulus bill. That will cost over $1 
trillion before it is all over, and then the debt limit was raised to 
$12.1 trillion. Then we passed an omnibus spending bill earlier this 
year that increased spending about 8 percent over the previous fiscal 
year.
  This month, we passed another omnibus spending bill that increased 
spending another 12 percent on top of that. That is what is leading to 
tomorrow's debt limit vote. That is what is leading to the statement 
that our debt limit is

[[Page S13836]]

now above $12 trillion. But that is not enough. Apparently, we need to 
go further.
  The American people are connecting the dots. They see this trend, 
which has accelerated dramatically over the last 12 months, and they 
are truly scared for our collective future--for their kids' and their 
grandkids' future. All these things I mentioned plus this health care 
bill are part of that.
  The American people know in their gut--they may not understand all of 
the Congressional Budget Office technicalities, but they know in their 
gut that you cannot have it both ways. You cannot count $467 billion of 
Medicare cuts as both helping pay for the other spending in the bill 
and strengthening Medicare. It is one or the other. It cannot be both. 
It is the same thing in the health care bill with regard to Social 
Security--$52 billion double-counted. But you cannot have that both 
ways. It is the same thing in this health care bill with regard to the 
CLASS Act--$72 billion double-counted. You can't have that both ways. 
Those factors alone put this bill out of balance, adding to the 
deficit, adding to the debt.
  What about the doc fix, the fix of reimbursement rates under Medicare 
to health care professionals such as doctors, which is clearly needed. 
That was taken out of the health care bill. Why? Because that would 
cost money. It was taken out. It was just pushed down the road, the can 
was kicked down the road. That has to be revisited by March 1 of next 
year. If a real 10-year-or-more doc fix is passed, that will be another 
$200 billion unpaid for--more deficit and more debt.
  The American people get it. They know in their hearts, in their gut, 
that we are on an unsustainable course. They know all these bailouts 
and so-called stimulus acts, all these spending bills and now this 
enormous health care bill, are part of that unsustainable course, and 
they are crying out. They are saying we must reverse course, we must 
save our Nation. I hope we do that starting here, starting now.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Oklahoma, Mr. Coburn, is 
recognized.
  Mr. COBURN. Mr. President, I ask consent to have 3 minutes outside of 
the time allotted to make a point of personal privilege, and I ask 
unanimous consent for that. I would say the reason is today is my 41st 
wedding anniversary, and I was going to discuss that.
  The PRESIDING OFFICER. Is there objection? Without objection, it is 
so ordered.


                Honoring My Wife on My 41st Anniversary

  Mr. COBURN. In 1953, I met a young lady--actually, it was 1954--a 
young lady when she was 6 years of age. Her name was Carolyn. I went 
through grade school with this young lady. I went through junior high 
with this young lady. I went through high school with this young lady. 
The only serious dating relationship I ever had in my life was with 
this young girl named Carolyn Denton. She became one of my best friends 
in high school. It just so happened that one weekend I couldn't get a 
date, she didn't have one, and I asked her out. From that point 
forward, I fell in love with somebody I have been married to for 41 
years, my wife Carolyn Coburn.
  On this day of significant votes in the Senate, and tomorrow, I 
wanted to take a moment to say how much I appreciate what she has meant 
to me the past 41 years, how much stronger she has made me as a man, 
how she has completed every aspect of my life being my partner as we 
walk through life, and the gift she gave me of three wonderful 
daughters.
  So to my wife Carolyn, in front of the body, I tell you thank you and 
happy anniversary.
  I would like to go to my prepared remarks.
  The PRESIDING OFFICER. The Senator is recognized.
  Mr. COBURN. Mr. President, I have spent 5 years in the Senate talking 
to my colleagues about spending. We find in front of us another 
opportunity to do the wrong thing. We have a debt limit increase. Yet, 
in those 5 years, after hundreds and hundreds of amendments the body 
has refused to agree to that would cut spending, we are going to 
increase the debt limit but we are not going to make any effort to cut 
the spending.
  I have given seven complete speeches on the floor about the 
significant amount of waste in the Federal Government. I will not 
repeat those now. But that number is now annualized to $380 billion a 
year--every year, $380 billion worth of waste. Part of it is fraud, but 
a large part of it is duplication. Let me give some examples of the 
duplication because I think when Americans hear this they do not 
understand why.
  The Government Accountability Office found that there are 13 Federal 
agencies that spend $3 billion to fund 207 Federal programs, 207 
different programs, to encourage student standards in the fields of 
math and science--13 different agencies, 207 different programs. We 
could have spent one-tenth that amount of money and had exactly the 
same results and saved $2.7 trillion. But we will not do it.
  Another example, according to GAO, to the tune of $30 billion, the 
Federal Government funded more than 44 job-training programs 
administered by 9 different Federal agencies across the Federal 
bureaucracy. According to the Catalog of Federal Domestic Assistance, 
we have 14 departments within the Federal Government and 49 independent 
agencies that operate exchange and study-abroad programs. We have 49 
programs instead of 1. I have tons of other examples just like that.
  We have failed to do our job, and the easiest thing in the world is 
to spend somebody else's money. Increasing the debt limit without 
having a rescission to get rid of programs just like this and have one 
program that is effective and efficient, that has metrics on it, that 
measures its goals and is accountable, instead of 49 or 72 or 64 across 
a large number of different agencies--we can do that, but there is no 
will here to do that. As a consequence, what we do, instead of making 
the Federal Government more efficient, we just raise the debt limit. I 
am not about to be a part of that anymore.
  I know my colleagues get upset with me as I come to the floor year 
after year talking about what we do and the fact that we do not fix the 
real problems. I have been rather hard to get along with, by my 
colleagues, in terms of them advancing new programs when we do not 
eliminate the programs that are already doing the same thing.
  I think at this time of Christmas, one of the things we ought to be 
doing is telling the American public that we will change. Next year, 
instead of creating new programs, we are going to look at all the 
programs and consolidate them and have one that does math and science, 
one that is for work-study programs abroad, not the numerous numbers we 
have for which we have no accountability.
  America recognizes our incompetence, but we are going to spell it 
out. In this new year that comes forward, there is not going to be a 
week that comes by that I do not come to the floor and show another 
example to the American people of how we are not doing our work. It 
grieves me--not for me but for my children and everybody else's 
children, for my grandchildren and everybody else's grandchildren--that 
we fail to treat the real symptoms of our debt; that is, we will not do 
the hard work of oversight. We should be condemned for that. We are 
failing the American people. It ought not to be.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from South Dakota, Mr. Thune, is 
recognized.
  Mr. THUNE. Mr. President, I appreciate the comments of both my 
colleagues from Louisiana and Oklahoma touching on an issue that I 
think is becoming increasingly important to a lot of Americans.
  I was listening this morning to one of my colleagues on the other 
side as he came down here and talked about how all the spending 
problems and all these debt problems were all inherited from the 
previous administration. There is sort of a Bush-phobia or something 
around here among Members on the other side because they do not want to 
own up for the decisions they have made.
  Granted, I would be the first one to admit that when Republicans were 
in control of the Congress, we didn't do it right all the time and we 
lost our way a little bit with regard to spending.
  But having said that, we now have--since 2006--a Democratic Congress. 
I need to remind my colleagues that the President doesn't spend a dime 
under

[[Page S13837]]

our Constitution. Congress has the power of the purse. Congress 
appropriates funds. So if you look at the last several years in terms 
of appropriations, going back to the last couple of years that the 
Republicans were in control of the Congress, the amount of spending in 
the nondefense part of the budget was a negative 1 percent in 2007, 5 
percent in 2006, and 8 percent in 2005. That is nondefense 
discretionary spending in our annual appropriations. If you go to total 
growth, which includes defense, you are talking about 8 percent in 
2005, 5 percent in 2006, and 2 percent in 2007--more than most people 
would argue we needed to be spending in annual appropriations bills.
  But the Democrats took control of the Congress after the 2006 
election, so they started writing the budgets. We have ownership for 
the 2007 budget, but the Democrats have ownership for 2008, 2009, and 
2010. The 2008 budget grew at 9 percent total growth. Nondefense 
discretionary spending grew at 6 percent. If you look at nondefense 
discretionary spending in 2009, the last fiscal year, it was 12 
percent. In this fiscal year, 2010, the estimate is that we will spend 
17 percent over the previous year. So year-over-year spending in 
nondefense discretionary appropriations here in the Congress will have 
grown almost 30 percent in the last 2 years. That is not a problem that 
was created by the Bush administration. That is not a problem, 
obviously, for which the Republican majority was responsible. That is 
the Democrats, when they took control of the Congress after the 2006 
elections, beginning in 2007. They write the budgets, they approve the 
appropriations bills. Obviously, as you can see, the numbers have gone 
up dramatically--12 percent in the 2009 budget year, and the 2010 
estimate for which we are now funding appropriations bills--and we have 
funded most of them now with the omnibus or with the smaller 
appropriations bills, the six bills that were passed just a week or two 
ago--looking at 17 percent year-over-year spending in appropriations. 
So that is almost 30 percent in the last 2 budget years. That is not a 
problem the other side can hold the previous administration responsible 
for or attack them for.
  I will also mention that the $1 trillion approved earlier this year 
in the stimulus funding was approved on almost party lines. There were 
a couple of Republicans who supported that, but for the most part that 
was something approved by the Democratic majority. It was proposed by 
the President of the United States. That is not spending for which the 
former President is responsible.
  At some point around here, people have to own up and take 
responsibility for their own decisions. You cannot blame the past 
administration. You cannot blame inherited problems for all the 
spending that is going on right here, right now. The last year, as I 
said, appropriations spending--and this year again--was by any stretch 
way above anything we have seen or should see at a time when we have an 
economy in recession and most Americans are having to tighten their 
budgets--12 percent nondiscretionary increase in 2009 and 17 percent 
increase in spending in 2010.
  With that and the stimulus spending, it brings us to where we are 
today, which is this massive expansion of the Federal Government--$2.5 
trillion in new spending for a new entitlement program. That, too, is 
not something for which the previous administration is responsible. 
That is something this administration, the majority here in the 
Congress, has decided they want to push through. They want to finish it 
before the Christmas holiday. They want to get this in the rearview 
mirror before the American people have an opportunity to see what is in 
it, particularly in the last hurried rush here over the weekend where 
we got the 400-page amendment that included all the special last-minute 
deals that were made to try to get that elusive 60th vote. What we have 
seen is now the $2.5 trillion in new spending is filled with all kinds 
of goodies that are going to favor individual Senators and individual 
States.
  The American people are starting to react.
  The point I want to make about this is, the one thing that the 
President and a lot of our colleagues on the other side have been 
talking about is how this reduces the deficit. This saves $132 billion 
over the next 10 years. Just remember that is $132 billion over 10 
years. If you look at what the deficit was for the month of October, if 
any of my colleagues know what the deficit was for the month of 
October, 1 month alone, this last October, it was $176 billion--in 1 
month. They are crowing about $132 billion in savings over a 10-year 
period.
  What is interesting about that $132 billion, if you take away all the 
gimmicks and you look at all the phony accounting that has been done to 
get to that number, it goes down in a real hurry.
  For example, the SGR fix, the physician reimbursement issue is a $200 
billion-plus item. Let's say they are saying they got $132 billion in 
savings over the next 10 years. But at some point you have to deal with 
that $200 billion SGR. If you take that away, you end up with a 
negative $68 billion already. Then you add in this CLASS Act, which 
everybody who has any sense, any actuary has absolutely denounced, 
including even the Washington Post. But if you look at what the CLASS 
Act does, they are using the revenues in the first early years that 
come from the premiums paid in. That money will be spent.
  So when it comes time to pay out benefits, there isn't going to be 
any money there. But they are showing a $72 billion savings or addition 
to their so-called savings in that first 10 years from the CLASS Act. 
The chairman of the Budget Committee has called the CLASS Act a Ponzi 
scheme of the first order, something that Bernie Madoff would be proud 
of.
  You take that $72 billion out, which the Congressional Budget Office 
says is going to add huge deficits in the outyears, you take out that 
$72 billion, and you are already at a $130 billion deficit. We haven't 
even dealt with the fact that because of the way they have set this up, 
by front end loading the tax increases and back end loading spending, 
that understates the total cost.
  In the first 10 years, if you take those first 4 years when you have 
$56 billion of revenue coming in and only $9 billion of spending going 
out, that is another $47 billion that you could add to the deficit. So 
you have gone from $132 billion in savings to a $177 billion deficit. 
That is before you even get to the more important issue, which is what 
the CBO came out with today in response to a question by the Senator 
from Alabama asking: How can you count money that is going to come from 
these Medicare cuts, count that as revenue that will save and extend 
the life of Medicare, and still spend it for a new entitlement program 
on health care?
  The CBO basically said that is double counting. In fact, I want to 
read what they said:

       To describe the full amount of HI trust fund savings as 
     both improving the government's ability to pay future 
     Medicare benefits and financing new spending outside of 
     Medicare would essentially double-count a share of those 
     savings and thus overstate the improvement in the 
     government's fiscal position.

  Every American knows you can't spend the same money twice. That is 
what this does. They are going to cut $1 trillion over 10 years, when 
fully implemented, out of Medicare, but they will spend that money on a 
new entitlement program and still count the savings in Medicare. You 
can't have it both ways. The American people have figured out this 
shell game.
  When you take a $177 billion deficit after you take out all these 
accounting gimmicks, you are already running a significant deficit. 
Then when you add in the fact that what the CBO now says, what most of 
us have believed to be true and have been arguing, that you can't spend 
the same money twice, you cannot double-count that revenue, the 
Medicare trust fund is going to take a significantly big hit. I know 
the Senator from Alabama is going to talk more extensively about that. 
I want to point that out because we are going into a big debate about 
raising the debt limit. Everybody, now that the horse is out of the 
barn, wants to shut the gate. But you can't spend $2.5 trillion on a 
new entitlement program and then claim to be fiscally responsible or 
say that you are doing something to reduce the deficit.
  Interestingly enough, the CMS Actuary said these Medicare cuts are 
unlikely to be sustainable on a permanent basis. We all know we are not

[[Page S13838]]

going to cut $1 trillion out of Medicare over the first 10 years. That 
just doesn't happen here. All that money is going to get borrowed and 
put on the debt or they will have to raise taxes to pay for it. You 
can't have it both ways.
  As we get into the debate about the debt limit, it is important to 
put things into context. I want to say again that $132 billion in 
savings, which is what they are saying they get by this health care 
reform bill with all the tax increases and the Medicare cuts, is 
suspicious in the first place, given the fact that the SGR, the $200 
billion is not included, the $72 billion CLASS Act, and the $47 billion 
that they achieve by front end loading tax increases and back end 
loading spending brings you to a $177 billion deficit in the first 10 
years. That does not even include the funky accounting being used with 
regard to the Medicare trust fund. We will get into this debate about 
the debt limit, but nothing bears on that more heavily than what we do 
with health care.
  We need to defeat this. I hope we will still see some courage by a 
few of my colleagues to help us take this health care bill down, to go 
back to the drawing board, to do it right and to actually put in place 
solutions that will meaningfully reduce the cost of health care for 
people in this country, not increase their premiums, and not add to the 
deficit and saddle future generations with an enormous debt they don't 
deserve. Remember, $176 billion was the deficit in the month of October 
alone. We are talking about, under their numbers, $132 billion in 
savings over 10 years which, when you sit down and figure it out, it 
just doesn't add up.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Nelson of Florida). The Senator from 
Arizona.
  Mr. KYL. Mr. President, when the recession hit last fall, many 
Americans had been living beyond their means and had to quickly scale 
back. Families all across America have been tightening their belts. 
They have been forgoing vacations, meals in restaurants, extra 
Christmas presents, cutting back wherever they can. The government 
needs to take a lesson from those families. It is time that Congress 
and the administration get serious about cutting spending in a 
meaningful way. Spending during President Obama's first year in office, 
to put it charitably, has not been what most would describe as 
responsible. Government spending grew by $705 billion in fiscal year 
2009, an increase of 24 percent. Appropriations legislation enacted 
this year will increase spending by another 8 percent in the year 2010. 
All of this spending, of course, has an impact on both the Federal 
deficit and the Federal debt.
  Let me clarify the difference between those two numbers. The deficit 
is the amount of total spending not covered by revenues in a given 
year. The debt is the sum of all of the Nation's yearly deficits. The 
2009 deficit made history and not in a good way. It exceeded $1.4 
trillion in the last fiscal year. That is the highest amount in history 
and more than three times as much as the highest deficit during the 
last administration. The budget President Obama submitted to Congress 
doubles the deficit in 5 years and triples it in 10. It also creates 
more debt than the combined debt under every President since George 
Washington. That seems almost impossible, but it is true.
  The President's budget creates more debt than all of the debt ever 
combined throughout the history of the country, from George Washington 
all the way up through George Bush, more debt under President Obama's 
budget than all of that combined.
  Even Management and Budget Director Peter Orszag has said that is not 
sustainable. The debt has reached an almost unimaginable sum of $12 
trillion. To pay the Federal Government's bills for the next 2 months, 
tomorrow we are going to consider passing a roughly $300 billion 
increase in the allowable U.S. national debt known as the debt ceiling. 
That means our debt ceiling, now $12.1 trillion, will be $12.4 
trillion. After those 2 months, we will need to add another $1.5 
trillion to the debt ceiling to pay for the remaining spending in the 
year 2010.
  Early next year our debt ceiling will be a whopping $13.9 trillion. 
Of the massive national debt, a paper by the Heritage Foundation tells 
us:

       The recession and excessive spending have caused the debt 
     held by the public to grow sharply to 56 percent of the 
     economy, topping the historic average of 36 percent. To make 
     matters worse, entitlement programs will double in size over 
     the next few decades and cause the national debt to reach 320 
     percent of the economy.

  That is so obviously unsustainable that it has to be of great concern 
to us. It is like the size of a credit card being several times more 
than our income, such that we can never pay the debt on the credit 
card. That is even to ignore the interest payments. Let's not forget 
about that. That is another tab we have to pick up. I have only been 
talking about the principle. But in 2009 alone, interest payments were 
$209 billion. By the year 2019, interest payments are expected to reach 
$800 billion a year. That is just the interest on the debt.
  How are we going to afford that? By the way, who do we pay that to? 
We pay it to all the people we borrow money from, one of which is the 
nation of China. Chinese officials have indicated that they are very 
nervous about the amount of debt the United States is taking on.
  In mid-March, Chinese Premier Wen Jiabao voiced concerns about U.S. 
Government bond holdings:

       We have lent huge amounts of money to the United States. Of 
     course we are concerned about the safety of our assets. To be 
     honest, I am a little bit worried, and I would like to . . . 
     call on the United States to honor its word and remain a 
     credible nation and ensure the safety of Chinese assets.

  What can a lender do when he or a nation becomes concerned that the 
borrower is going to have trouble paying back, when the borrower keeps 
coming back for more and more lending? What you do is you raise the 
interest rate to reflect the greater risk in the lending of the money. 
That is what is going to happen to us. That greater interest rate is 
going to be manifest in payments that we have to make by our 
productivity and the taxes we pay. That will decrease our standard of 
living and create an additional obligation on the American people.
  President Obama has acknowledged the problem. He said:

       We can't keep on just borrowing from China. We have to pay 
     interest on that debt, and that means we are mortgaging our 
     children's future with more and more debt.

  He is right. So why does he propose more spending and more borrowing 
and more than any other President in the history of the world?
  It is time for words and actions to match. It is time for Congress 
and the President to start reining in this out-of-control spending and 
debt. I stand with my colleague from Alabama in support of his 
amendment to reinstate statutory spending caps. While this is not a 
panacea for solving the fiscal problems the Nation faces, it is a good 
way to start on the path to responsibility. I will bet that most of our 
colleagues on the other side of the aisle will vote against it. It is 
wrong for them to expect Republicans to extend the debt ceiling as long 
as they are unwilling to do anything to get spending under control.
  Americans expect us to get this spending and debt under control. When 
we return to the Senate in January, our first item of business will be 
a long-term debt ceiling extension, including consideration of the 
Sessions amendment and others. After pushing the stimulus, the auto 
bailout, cash for clunkers, the massive $2.5 trillion health care bill, 
and others, I would hope our Democratic colleagues are ready to take a 
breather from their big spending and support a more reasonable course 
so that we don't have to continue to extend the Nation's debt ceiling.
  The PRESIDING OFFICER. The Senator from Alabama.
  Mr. SESSIONS. Mr. President, I thank Senator Kyl for his consistent 
performance over his entire career in the Senate of trying to maintain 
financial responsibility in this body, and I respect him highly on that 
and many other issues.
  There is so much we could say at this point on the debt limit, on 
which we expect the vote tomorrow. I am not going to vote on a debt 
limit increase until we accompany it with some action that will 
actually reduce the incredibly irresponsible path we are on. That is 
going to be one of my positions, and I think others will take the same 
view.
  Saying we have to increase the debt--well, we have to do something

[[Page S13839]]

about reckless government spending. We really do. We have to do 
something about it. They always say: Next year. So I say: When? I 
believe we should condition any increase in the debt limit on the 
passage of legislation that would renew what has expired, spending caps 
on the discretionary spending accounts. I thank Senator Kyl for 
supporting the legislation.
  In other words, we can do that. We did it in 1990. You can see, as 
shown on this chart, the declining expenditures that resulted in those 
numbers. We passed it in 1990. As shown on this chart, those yellow 
lines represent the deficit--up to $300 billion, and it began to 
shrink. In late 2000, 2001, we had surpluses in our accounts. It is odd 
to show a surplus, shown below the line on this chart, but we 
accomplished that.
  President Clinton liked to claim credit for it. I have a vague memory 
that Republicans shut the government down to contain President 
Clinton's spending. But there were battles over containing spending, 
and it worked. A big key to it was the spending limits, the spending 
caps. Those expired in 2002, and, look, we began to show the increases 
in deficits again. So I think as a condition of voting for a debt 
increase we should have a fix of the restoring of the caps.
  Senator Kyl made reference to the fact that under President Obama's 
10-year budget he submitted earlier this year, which was scored by the 
Congressional Budget Office, a nonpartisan group, but the leaders were 
picked by the Democratic majority. What would it do to our deficit, I 
ask? He has a budget for 10 years. He shows what he expects to have in 
revenues during those 10 years and what he expects to spend. He does 
not show, however, what is spent in the health care legislation because 
that was not in law at the time the budget was submitted. So in truth 
it will be worse than this.
  But let's look at this. In 2008, the debt was $5.8 trillion; in 2013 
it doubles to $11.8 trillion; and by 2019, it triples to $17.3 
trillion. That is a stunning tripling of the public debt of the United 
States of America. It is an unsustainable path. One of the most grim 
parts of the scoring of this deficit expansion is it is not getting 
better. In years 8, 9, 10, the deficit is going up to almost $1 
trillion a year; in 2019--the 10th year--going up. They are not 
projecting during that 10 years any recession. In fact, they projected 
that we would come out of the recession we are in now faster than we 
are coming out of it. So the numbers probably will be worse there.
  This is not made up. This is the President's budget. It is scored by 
this Congress's CBO, and it is the best numbers we have. It is a 
stunning development. We cannot continue. That is why people say it is 
unsustainable.
  Senator Kyl made reference to this. I made a chart on it some time 
ago. I just could not believe it. In 2009, the total interest this 
government paid on the debt we owe was $170 billion. You can see, this 
chart shows the annual interest payments we make that are surging year 
after year. It is the result of several things.
  CBO is cautious, but they are acknowledging that interest rates are 
going to go up. We have virtually zero interest rates in short-term 
Treasuries today. That is not going to continue. So you have more debt 
and higher interest rates. You get surging interest payments.
  In 2017, we have interest payments over $600 billion. It goes over, 
in 2019--1 year's interest--$799 billion. As I recall, the 
supplementals we have used to fund the war in Iraq represented about 
$70 billion a year. A couple years ago, our highway spending was about 
$40 billion a year. Aid to education is about $100 billion a year. In 
2019, in 1 year, we will pay $799 billion, I think, at a minimum, just 
in interest. You see how huge those numbers are? It is unsustainable. 
We cannot continue to do this.
  The American people understand it. CNN did a poll last month. They 
asked this question of the American people:

       Which of the following comes closer to your view of the 
     budget deficit--the government should run a deficit if 
     necessary when the country is in a recession and at war or 
     the government should balance the budget even when the 
     country is in a recession and is at war?

  What do you favor? Sixty-seven percent say: ``Balance the budget.''
  Well, what is Congress doing? Running the most incredible series of 
deficits we have ever seen, tripling the national debt in 10 years--all 
in furtherance, basically, of President Obama's budget, which calls for 
this.
  Sure, President Bush was not as frugal and fiscally responsible as he 
should have been. Most, however, of his debt was driven by war costs. 
But regardless, he could have been more frugal and spent less. But the 
deficits he had would come in at half or less than half of the deficits 
we are going to see on average over the next 10 years. So I have to 
say, we are losing our perspective.
  This health care reform bill is a serious matter. We have a report 
this morning from the Congressional Budget Office that clarifies what 
has been pretty obvious to us for some time, but it was difficult to 
get an official accounting of how these numbers are scored or added up 
by the Congressional Budget Office.
  But, basically, what they say is pretty simple. They are saying that 
proposals in this bill that raise the payroll tax on Medicare and 
reduce expenditures within Medicare--cutting Medicare--saves money. It 
puts more money in the pot. But it is part of the Medicare trust fund 
pot. As to that savings, it is said: Well, we will just spend it over 
here and pay for this new health care program that was just voted on 
earlier today.
  So we are going to take this savings and increased revenue to 
Medicare, and we are going to spend it over here. This is a chart I 
just put together to try to show that. As shown on this chart, here is 
Medicare. You raise Medicare income and you cut their costs and you 
create an extra surplus. We have some surplus still in Medicare. If we 
do not do something about it, Medicare will be in deficit in 2017--8 
years. So this transfer of money then goes to the U.S. Treasury, and: 
Oh, we have extra money, let's spend it on a new health care reform 
that has never before been passed, creating benefits for people who 
have never received these kinds of benefits before because we want to 
be helpful to those people, create more insured people in America.
  But as the CBO said, you cannot count this money twice. What about 
the people who are paying into Medicare, who have been paying into it 
for 40 years? They have not received a dime of benefit--until they get 
to age 65--and it is their money they are putting into Medicare. They 
are not just giving it over here to the U.S. Treasury.
  As one of them wrote me: You are taking my money. I am 67. I am just 
now beginning to draw Medicare. You are taking my money and giving it 
to somebody else. I have never received any benefits from Medicare 
until now, and you are taking it from me.
  So as a matter of the way our accounting occurs, the U.S. Treasury 
cannot take that money just free and clear. It is not extra, free 
money.
  I see my colleague. I want Senator Baucus to recognize that according 
to the CBO Director--he told me last night, there are bonds issued. 
Treasury has to give a bond to Medicare, a Treasury note, an IOU. So 
when Medicare starts running in default--as it will within the next 15 
years if this bill were to pass--when Medicare starts running 
into default, they are going to have the Treasury pay for it. So, in 
effect, this bond causes the U.S. Treasury to pay interest to Medicare.

  During this first 10 years, the U.S. Treasury will pay interest to 
Medicare of $69 billion on the money they borrowed--this IOU here. 
Then, when it goes into default--as it is inevitably heading into 
default--the Treasury will have to pay those bonds. So it increases the 
debt.
  What CBO says, without any equivocation, is--it is not disputable--
the debt of the United States will be increased by this bill, not 
decreased. It will not be a $132 billion surplus in reality but will be 
a $170 billion deficit, just on that. Then, when you get to what 
Senator Thune talked about, other gimmicks in the bill, it makes that 
even worse.
  You say, well, the CBO has a score that says it is a $132 billion 
surplus. It reduces our debt $132 billion. Well, the way they are doing 
this, and the way that accounting is done, with trust funds and 
nontrust funds in a unified

[[Page S13840]]

government budget, they do not score this IOU because they seem to 
think it is all one government, and so what is one is not the other, 
and it is not debt. But it is a debt, and they said it explicitly. You 
cannot count the money over here as adding to the life of Medicare and 
at the same time score this as free money to be spent over here on this 
program.
  President Obama, Monday, at a press conference, said it is going to 
reduce our deficit $132 billion, and it is going to extend the life of 
Medicare by 9 years. Well, you cannot do both, as they have explicitly 
stated in the letter we got from CBO, and it is just a matter of 
absolute fact.
  They say:

       To describe the full amount of HI trust fund savings--

  Over here in Medicare--

     as both improving the government's ability to pay future 
     Medicare benefits and financing new spending outside of 
     Medicare would essentially double-count a large share of 
     those savings. . . .

  Well, these kinds of gimmicks and manipulations have been done 
before, but it is time to end it. I think the American people have 
said: In a time of war, in a time of recession, we need to get busy 
about the budget--by a two-thirds vote.
  They are right. We are going to work our way out of this recession. 
This American economy will respond sooner or later and, hopefully, 
sooner for the people of the United States.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. SESSIONS. Mr. President, is that the 10 minutes on this side? And 
is there time left on this side? I ask unanimous consent to have 3 
additional minutes.
  Mr. THUNE. Mr. President, I think our side has another 10 minutes or 
so, with which I would perhaps enter into a colloquy with the Senator 
from Alabama.
  I would ask the Senator, on the point he made--and I give the Senator 
great credit for raising that question to the CBO--because I think it 
is intuitive to most people that you cannot spend money twice; that you 
cannot somehow double-count it. That is essentially what the CBO said 
in their letter. I think the Senator quoted from it.
  They went on to say--CBO has written ``that the savings to the HI 
trust fund . . . would be received by the government only once, so they 
cannot be set aside to pay for future Medicare spending and, at the 
same time, pay for current spending on other parts of the legislation 
or on other programs.'' That is the argument we have been making all 
along. I guess finally it dawned on the CBO, evidently, and it took the 
Senator's question, I think, to get them to respond this way.

  But the way the Senator explained the interaction between government 
trust funds, the unified budget, and the IOUs the government writes to 
itself, perhaps gives some explanation to how they came up with this 
actually achieving a savings. But the Senator made it very clear: $170 
billion actually to the deficit. As I mentioned earlier, the accounting 
gimmicks that have been used have understated the 10-year cost of this. 
By the way, my staff corrected me. The off-the-top-of-my-head 
calculation was $177 billion in deficit; it is actually $187 billion. 
So you add that to what you mentioned, pretty soon you have what they 
are claiming is a $170 billion savings turns into a very sizable 
deficit.
  So I would ask the Senator from Alabama--again, I give him great 
credit for bringing this to light, raising this issue with the CBO--
what does that mean for this piece of legislation we are going to be 
voting on tomorrow, a $2\1/2\ trillion expansion of the government 
financed through tax increases and Medicare cuts. Yet even with all 
that, the assumption is, this is not going to meet the requirement the 
President set out; that is, that it doesn't add a single dime to the 
deficit.
  What does that mean to that commitment made by the President and to 
this legislation's sort of fiscal situation as we move forward and to 
these negotiations or discussions, if this passes tomorrow, with the 
House of Representatives?
  Mr. SESSIONS. This is a huge issue. I remember a few months ago, in a 
joint session of Congress, President Obama spoke to us. He looked out 
at the crowd and said: This bill will not add one dollar--or one dime--
to the national debt. It was a firm commitment to all the American 
people who were listening, all the Congressmen and Senators in that 
room--it will not add to the debt. So what we now know is that this 
bill is going to add to the debt. There is no doubt about it. The debt 
of the United States will increase. It is a dangerous trend that 
happens in a lot of different ways that has put us onto this course.
  I think he recognized you shouldn't increase the debt. He recognized, 
if he is going to create an entirely new health care program over here, 
it ought to be paid for, and he promised to do that. We have Members of 
this body, Members of the House who supported the bill, based on the 
promise it would not increase the debt. But we have now, conclusive 
proof, in any number of different ways but particularly with the CBO 
score, that it will increase the debt. It is a decisive issue as far as 
I can see.
  Mr. THUNE. If the Senator will further yield, in addition to this 
revelation from the CBO, which I think does change the game and the 
whole debate about whether this is a budget buster, which it has been 
described as, in spite of the fact that our colleagues on the other 
side have been arguing it extends the life of Medicare, I think this 
statement by the CBO certainly shreds the notion that you can have it 
both ways; that you can double count this money; that you can spend it 
twice. You can't do that. I think the American people get that, which 
is why they believe it will add to the deficit as well.
  But there are other things in this bill----
  Mr. SESSIONS. I would just say my understanding, having looked at 
this at some length and given it thought, is the legislation will 
extend Medicare because it increases the Medicare tax, and that will 
bring in more money. It pretends we will slash provider payments on 
health care and others and save money that way. So, on paper, it 
definitely should extend the life of Medicare.
  What do we do with the money? Well, the money that is saved is not 
staying in Medicare. It is being borrowed by the U.S. Treasury to spend 
on a new program, and the U.S. Treasury owes it to Medicare. We can see 
in the trends in Medicare it will not be too many years before Medicare 
is going to want that money. That is going to leave us over here, and 
that is why we have a debt. It increases our debt, and we are going to 
have to pay that back--our children, our grandchildren--sooner than 
that. Hopefully, we will be around to pay some of that back.
  So that is the problem we have. It is a misrepresentation to say this 
creates money that can fund a program on a permanent basis. It does 
not. It is just an internal debt situation.
  Mr. THUNE. If the Senator will further yield, a couple other items 
that are being used to get us to where this argument can be made, which 
is that there are savings from this, this $132 billion savings and 
deficit reduction the majority has talked about also includes the 
creation of an entirely new program called this CLASS Act.
  There were eight Democratic Senators who wrote a letter, basically, 
asking that the CLASS Act not be included in this bill, recognizing 
what many have; that is, that the CBO has recognized that while it may 
show some savings in the early years, when people are paying premiums, 
it is similar to everything else. That money, when it gets spent on 
other things, isn't there to pay out benefits when the time comes to 
pay out benefits. So we get this artificial $72 billion infusion of 
cash in the early years, which is being used to, again, understate the 
cost of this and to demonstrate--or to make the argument that there is, 
in fact, $132 billion in savings here or deficit reduction.
  There is $72 billion that this CLASS Act represents in that first 10-
year window which, as I described earlier, our colleague on the other 
side has described it as a Ponzi scheme. But it does create an entirely 
new program, not unlike some of the entitlement programs that already 
exist, where payments are coming in now that are being used to spend 
for other purposes that someday, when the chickens come home to roost, 
there is going to be another reckoning. Again, I think it is another 
example of a program of a way

[[Page S13841]]

in which this financial picture, with regard to this health care bill, 
is understating its true costs and its impact on deficits in the long 
run.
  I would ask my colleague from Alabama, having looked at that 
particular program, if he would agree that too is something that is 
going to cost us significantly in the outyears and whether that is 
something that ought to be included as counted toward the whole 
calculation on deficit reduction in this legislation.
  Mr. SESSIONS. I thank Senator Thune for his leadership in exposing 
this. The way I believe this operates--and you correct me if I am 
wrong--but the way I believe it operates is it requires a certain 
number of premiums now, and the actuaries who score these things say 
that in the years to come, there will be claims on those policies and 
people will claim more and more as they get older and the years go by 
and it becomes actuarially unsound. But in the first few years, on 
paper--on paper--for the first 2 years, it looks good because you have 
more coming in than going out. So they are scoring this short-term 
surplus--correct me if I am wrong--they are scoring this as an asset, 
as income to the Treasury, when the contracts people have when they 
start paying this money in protects them for years and years to come, 
and in the future they will be making more claims than are paid out.
  That is why it is actuarially unsound and will increase the debt in 
the long run. Would the Senator describe it that way?
  Mr. THUNE. Well, I think that is exactly how it would work. Again, it 
is another gimmick, if you will; another accounting tool.
  Mr. SESSIONS. So it is dishonest. When you know a program is not 
actuarially sound and it is going to take additional Federal Government 
revenue to honor the contracts in the years to come, to count that 
today as an asset is wrong. It is improper to do that. We ought not to 
propose a plan that has a Ponzi scheme-type nature to it.
  Mr. THUNE. Well, I don't disagree, and I think the American people 
agree with that.
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. SESSIONS. I thank the Chair and yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, this has been an interesting discussion we 
have heard in the last 15, 20 minutes. One can do anything with 
figures, numbers. I am not going to cite the often-used phrase that 
some category of people can figure, another category of people can do 
something else. But anyway, one can do anything with numbers, anything 
whatsoever. Frankly, this is an effort to confuse by pulling different 
figures out from one document and then another and concocting--they can 
put a board up here. It is just an effort to confuse. One can do 
anything with numbers.
  The real question is, What are the facts?
  Mr. SESSIONS. Will the Senator yield?
  Mr. BAUCUS. I wish to first make a point, and I will yield later to 
the Senator.
  The Congressional Budget Office stands by its analysis. I have before 
me an e-mail sent today, dated today's date, 2:56 p.m., and let me read 
it, from the Congressional Budget Office:

       The Congressional Budget Office has been asked whether our 
     memo this morning discussing the effect of [this legislation] 
     incorporating the manager's amendment, on the federal budget 
     and on the balance in the Hospital Insurance trust fund 
     alters CBO's earlier findings about the budgetary impact of 
     the legislation. It does not. In particular, as described in 
     our December 19 and December 20 letters to Senator Reid--

  Let me continue reading and, hopefully, Senators are listening to 
this because this is a letter today, actually it is an e-mail today, at 
2:56 p.m. CBO says:

       CBO and the staff of the Joint Committee on Taxation 
     estimate that the legislation would reduce federal budget 
     deficits by $132 billion during the 2010-2019 period.

  Next:

       CBO expects that the legislation would reduce federal 
     budget deficits during the decade beyond 2019 relative to 
     those projected under current law--with a total effect during 
     that decade that is in a broad range between one-quarter 
     percent and one-half percent of GDP.

  Of course, we know that is about $650 billion to $1.3 trillion. That 
is CBO today.
  Third:

       CBO expects that the legislation would generate a reduction 
     in the federal budgetary commitment to health care during the 
     decade beyond 2019.

  So what everyone says--and I might say to my good friend from 
Alabama, part of that chart he had before us today is accurate, I mean 
the flow of Medicare and the IOUs and so forth. The part that is 
inaccurate is the increasing debt and the double accounting part. There 
is no double accounting here. There are separate accounting regimes and 
procedures that are used for all trust funds, including Medicare. The 
Medicare trust fund issues dollars that are in surplus in the outyears, 
as the Senator said, that have been held by the trust fund--by the 
trustees--and dollars that are used in any way the Federal Government 
decides to spend dollars, either pursuant to legislation or maybe the 
administration on its own may be spending some dollars in one place or 
another.
  This is not double accounting. Nobody has claimed there is double 
accounting. There are two different regimes and that is how--the 
Senator accurately described how the Medicare trust fund is accounted 
for. But it is also true that under our budget rules, we have a unified 
budget, there is one government--U.S. Government--there is Medicare and 
the rest of the government, and under that unified budget regime, the 
CBO still reaches the same conclusion it has always reached. I would 
like that to be on the Record.
  The Senator has a question.
  Mr. SESSIONS. Mr. Chairman, I would agree that--
  The PRESIDING OFFICER. The Senator will address the other Senator 
through the Chair.
  Mr. SESSIONS. Mr. President, will the Senator yield for a question?
  Mr. BAUCUS. Mr. President, I yield for a question.
  Mr. SESSIONS. I think that CBO's second statement is correct. I think 
the statement they did earlier about the $132 billion surplus reducing 
the debt over 10 years is technically accurate. But I think the 
statement they issued early this morning that this is--to count it in 
both places is a double count of the money, in effect.
  My question to the Senator is, we are going to be talking about 
voting on the debt limit tomorrow.
  Mr. BAUCUS. That is correct.
  Mr. SESSIONS. The debt limit is the gross debt of the country.
  Isn't it true the passage of this health care bill will increase the 
gross debt of the country, the gross debt being both the public debt 
and the intergovernmental debt?
  Mr. BAUCUS. No, that is not----
  Mr. SESSIONS. Will not the bill increase the gross debt of the United 
States?
  Mr. BAUCUS. If I might respond and answer the question--no; the exact 
opposite. CBO says so. CBO says it actually reduces the debt by $1 
billion.
  Mr. SESSIONS. I am asking the difference. The question is gross debt. 
Does it reduce or increase the gross debt?
  Mr. BAUCUS. If I might, Mr. President, as the Senator knows, the debt 
is the accumulation of deficits, and by definition, if a deficit is 
reduced, therefore, the national debt is also reduced. That is a 
mathematical truism. If the deficit is reduced, automatically the debt 
is reduced. That is mathematics.
  The next point I want to make, there was substantial debate today 
about the constitutionality of this bill. As I have discussed before, 
we have confidence that the health care plan we have crafted is an 
appropriate exercise of the commerce clause and does not violate the 
10th amendment. We further believe that ample power is available under 
the takings and spending power, as well.
  I ask unanimous consent to have printed in the Record two articles by 
Prof. Erwin Chemerinsky and Prof. Michael Dorf.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                     [From Politico, Oct. 23, 2009]

                  Health Care Reform is Constitutional

                         (By Erwin Chemerinsky)

       Those opposing health care reform are increasingly relying 
     on an argument that has

[[Page S13842]]

     no legal merit: that the health care reform legislation would 
     be unconstitutional. There is, of course, much to debate 
     about how to best reform America's health care system. But 
     there is no doubt that bills passed by House and Senate 
     committees are constitutional.
       Some who object to the health care proposals claim that 
     they are beyond the scope of congressional powers. 
     Specifically, they argue that Congress lacks the authority to 
     compel people to purchase health insurance or pay a tax or a 
     fine.
       Congress clearly could do this under its power pursuant to 
     Article I, Section 8 of the Constitution to regulate commerce 
     among the states. The Supreme Court has held that this 
     includes authority to regulate activities that have a 
     substantial effect on interstate commerce. In the area of 
     economic activities, ``substantial effect'' can be found 
     based on the cumulative impact of the activity across the 
     country. For example, a few years ago, the Supreme Court held 
     that Congress could use its commerce clause authority to 
     prohibit individuals from cultivating and possessing small 
     amounts of marijuana for personal medicinal use because 
     marijuana is bought and sold in interstate commerce.
       The relationship between health care coverage and the 
     national economy is even stronger and more readily apparent. 
     In 2007, health care expenditures amounted to $2.2 trillion, 
     or $7,421 per person, and accounted for 16.2 percent of the 
     gross domestic product.
       Ken Klukowski, writing in POLITICO, argued that ``people 
     who declined to purchase government-mandated insurance would 
     not be engaging in commercial activity, so there's no 
     interstate commerce.'' Klukowski's argument is flawed because 
     the Supreme Court never has said that the commerce power is 
     limited to regulating those who are engaged in commercial 
     activity.
       Quite the contrary: The court has said that Congress can 
     use its commerce power to forbid hotels and restaurants from 
     discriminating based on race, even though their conduct was 
     refusing to engage in commercial activity. Likewise, the 
     court has said that Congress can regulate the growing of 
     marijuana for personal medicinal use, even if the person 
     being punished never engaged in any commercial activity.
       Under an unbroken line of precedents stretching back 70 
     years, Congress has the power to regulate activities that, 
     taken cumulatively, have a substantial effect on interstate 
     commerce. People not purchasing health insurance 
     unquestionably has this effect.
       There is a substantial likelihood that everyone will need 
     medical care at some point. A person with a communicable 
     disease will be treated whether or not he or she is insured. 
     A person in an automobile accident will be rushed to the 
     hospital for treatment, whether or not he or she is insured. 
     Congress would simply be requiring everyone to be insured to 
     cover their potential costs to the system.
       Congress also could justify this as an exercise of its 
     taxing and spending power. Congress can require the purchase 
     of health insurance and then tax those who do not do so in 
     order to pay their costs to the system. This is similar to 
     Social Security taxes, which everyone pays to cover the costs 
     of the Social Security system. Since the 1930s, the Supreme 
     Court has accorded Congress broad powers to tax and spend for 
     the general welfare and has left it to Congress to determine 
     this.
       Nor is there any basis for arguing that an insurance 
     requirement violates individual liberties. No 
     constitutionally protected freedom is infringed. There is no 
     right to not have insurance. Most states now require 
     automobile insurance as a condition for driving.
       Since the 19th century, the Supreme Court has consistently 
     held that a tax cannot be challenged as an impermissible take 
     of private property for public use without just compensation. 
     All taxes are a taking of private property for public use, 
     but no tax has ever been invalidated on that basis.
       Since the late 1930s, the Supreme Court has ruled that 
     government economic regulations, including taxes, are to be 
     upheld as long as they are reasonable. Virtually all economic 
     regulations and taxes have been found to meet this standard 
     for more than 70 years. There is thus no realistic chance 
     that the mandate for health insurance would be invalidated 
     for denying due process or equal protection.
       Those who object to the health care proposals on 
     constitutional grounds are making an argument that has no 
     basis in the law. They are invoking the rhetorical power of 
     the Constitution to support their opposition to health care 
     reform, but the law is clear that Congress constitutionally 
     has the power to do so. There is much to argue about in the 
     debate over health care reform, but constitutionality is not 
     among the hard questions to consider.
                                  ____


                [From FindLaw Legal News, Nov. 2, 2009]

      The Constitutionality of Health Insurance Reform, Part II: 
                          Congressional Power

                          (By Michael C. Dorf)

       Although many key details remain to be negotiated, Congress 
     appears poised to enact some substantial reform of American 
     health care that will build on, rather than replace, our 
     patchwork of government, private, and non-profit insurance. 
     The bill that the President signs will likely contain, among 
     other things, an ``individual mandate'' requiring that 
     everyone obtain health insurance or face a financial penalty. 
     Would such a mandate be constitutional?
       In my last column and an accompanying blog entry, I 
     considered and rejected the objection that an individual 
     mandate would be an unprecedented burden on liberty because 
     it would affirmatively direct conduct, rather than either 
     forbidding conduct or imposing affirmative obligations on 
     only those who engage in conduct that the government has the 
     power to forbid. As I explained, there are substantial 
     precedents for such affirmative obligations and even if there 
     were not, there is no reason in principle why an affirmative 
     duty is a greater restriction on liberty than a prohibition 
     or condition.
       In this column, I consider a different objection to the 
     individual mandate: the claim that the federal government 
     lacks the authority under the Constitution to impose the 
     mandate or to penalize those who do not comply. As I explain, 
     this objection is also unsound as a matter of constitutional 
     law. I conclude, however, that individual members of Congress 
     ought to decide for themselves whether regulating health care 
     in the manner of the proposed bills is an appropriate job for 
     the federal government, or instead should be left to state 
     regulation or the market.


  Is a Regulation of Health Care a Regulation of Interstate Commerce?

       Under the Tenth Amendment, Congress may only enact 
     legislation that falls within one or more of its enumerated 
     powers. Most of those powers--and all of the powers that are 
     potentially relevant in the health insurance reform debate--
     are found in Article I, Section 8. From the very earliest 
     days of the Republic, there has been controversy about the 
     scope of those powers.
       Consider, for instance, that the Constitution does not 
     expressly grant Congress the power to charter a bank. 
     Accordingly, President George Washington asked two of his 
     Cabinet members to prepare memoranda on whether that power 
     could nonetheless be inferred from the powers that are 
     enumerated in the Constitution--including the powers to 
     regulate interstate and foreign commerce, to coin money, to 
     lay and collect taxes, to spend money for the general 
     welfare, and to enact such laws as are ``necessary and proper 
     for carrying into execution the'' specifically enumerated 
     powers.
       Arguing for a position that would today be called ``states' 
     rights,'' Thomas Jefferson said no. The enumerated powers had 
     to be construed narrowly, he said, or else the federal 
     government would completely overshadow the states. Alexander 
     Hamilton disagreed, however. He explained that in order to 
     carry out the powers it was expressly granted, Congress must 
     have implied powers. Washington sided with Hamilton and, 
     years later, in the landmark 1819 case of McCulloch v. 
     Maryland, so did the Supreme Court.
       At various points in American history, politicians and 
     judges have flirted with the Jeffersonian view, but for the 
     most part, the Hamiltonian position has prevailed, especially 
     with respect to laws purporting to regulate interstate 
     commerce. Thus, under the Supreme Court's 1942 decision in 
     Wickard v. Filburn, Congress can forbid a farmer from growing 
     more wheat than his federal quota allows on the theory that 
     if he does not grow wheat, he will purchase it, which will 
     affect the interstate market.
       Likewise, in the 2005 case of Gonzales v. Raich, the Court 
     said that in the course of regulating the national illegal 
     market in marijuana, Congress could forbid the intrastate, 
     noncommercial production and consumption of medical 
     marijuana, even if it is legal under state law. The Court 
     explained that Congress legitimately worried that making an 
     exception to the general prohibition on marijuana use for 
     medical marijuana use that is authorized by state law could 
     substantially undermine the government's ability to police 
     other marijuana production, distribution, and possession.
       That same logic applies to the individual mandate in the 
     health insurance context. As I explained in my last column, 
     the main point of the individual mandate is to ensure that 
     insurance companies cover people even though they have pre-
     existing conditions. Without the individual mandate, however, 
     many young, healthy people would decline insurance until they 
     got sick, creating a severe adverse selection problem. Thus, 
     the individual mandate is closely connected with the 
     regulation of health insurance, just as the Court said in 
     Raich that the regulation of marijuana that is used for 
     medical purposes is closely related to the regulation of the 
     broader market for marijuana.
       Health care is an enormous interstate business. It 
     therefore counts as interstate commerce, regulable by 
     Congress. Just as, in Raich, Congress acted constitutionally 
     by declining to exempt individual acts of noncommercial 
     intrastate marijuana possession from the Controlled 
     Substances Act, so too Congress would act constitutionally by 
     including an individual mandate within the ambit of its 
     regulation of health care.


    Is Existence an ``Economic Activity''? That's the Wrong Question

       Skeptics nonetheless point to two Supreme Court cases--the 
     1995 ruling in United States v. Lopez and the 2000 decision 
     in United States v. Morrison--as grounds for the conclusion 
     that the individual mandate would be beyond the power of 
     Congress under the Commerce Clause. In Lopez, the Court 
     invalidated a federal criminal law forbidding

[[Page S13843]]

     possession of a firearm near a schoolyard. In Morrison, the 
     Court rejected a federal law providing victims of gender-
     motivated violence with a right to sue their attackers. Both 
     decisions reasoned that Congress typically cannot regulate 
     ``noneconomic'' intrastate activities on the ground that they 
     affect interstate commerce.
       Accordingly, lawyers David Casey and Lee Rivkin, writing in 
     The Washington Post in August, concluded that Lopez and 
     Morrison make the Commerce Clause unavailable as a source of 
     congressional power for the individual mandate because a 
     human being's mere existence is not a form of economic 
     activity. Indeed, they might have added, existence is not an 
     activity at all.
       Although the issue is not entirely free from doubt, I do 
     not think that Casey and Rivkin have correctly read the 
     precedents. In Lopez and Morrison, Congress sought to 
     prohibit activities--firearms possession near schools and 
     gender-motivated violence, respectively--that were not, 
     according to the Court, ``economic.'' In those two cases, it 
     was only by several logical inferences of the handbone-
     connected-to-the-wristbone-wrist-
     bone-connected-to-the-elbow-bone sort that one could move 
     from the regulated activity to an effect on commerce. For 
     example, in Lopez, the theory went as follows: Guns near 
     schools intimidate children; intimidated children have a 
     hard time concentrating on their studies; they learn less; 
     they then grow up to be less productive members of 
     society; and thus the national economy suffers. Even 
     though each link in this chain is plausible, the Lopez 
     majority reasoned that if the Court were to allow this 
     sort of inferential process, then virtually anything would 
     count as a regulation of interstate commerce. 
     Acknowledging that congressional power under the Commerce 
     Clause is very broad, the Court in Lopez and Morrison 
     nonetheless insisted that it is not infinitely broad.
       By contrast with the laws that were invalidated in Lopez 
     and Morrison, the individual mandate is quite close to the 
     core of the Commerce Clause. Treating the mere existence of a 
     human being as the predicate of regulation in the health care 
     bills would miss the point. Whereas the Gun Free School Zones 
     Act in Lopez and the civil remedy provision of the Violence 
     Against Women Act in Morrison sought to discourage certain 
     conduct, the point of the individual mandate is to encourage 
     certain conduct. And crucially, the conduct the individual 
     mandate seeks to encourage is quintessentially economic: It 
     is the purchase of a service, namely health insurance.
       Does Congress have the power to encourage people to engage 
     in market transactions? Of course it does. That, after all, 
     was the whole point of the law upheld in Filburn: By limiting 
     the amount of wheat that farmer Filburn could grow, the 
     government sought to encourage him to buy compensating 
     amounts on the market. As the unanimous Court explained in a 
     ruling that the more recent cases expressly reaffirm: ``The 
     stimulation of commerce is a use of the regulatory function 
     quite as definitely as prohibitions or restrictions 
     thereon.''
       In the end, then, the argument of Casey, Rivkin, and others 
     who oppose the individual mandate on Article I grounds 
     amounts to no more than the assertion that the Constitution 
     forbids Congress from using the most direct means of 
     encouraging market activity: a mandate that individuals do 
     so. But there is nothing in the text or history of the 
     Constitution to support that conclusion.
       Indeed, the Ur-decision about Article I power, McCulloch, 
     says the exact opposite: ``Let the end be legitimate, let it 
     be within the scope of the constitution, and all means which 
     are appropriate, which are plainly adapted to that end, which 
     are not prohibited, but consist with the letter and spirit of 
     the constitution, are constitutional.''
       As we have seen, the individual mandate is ``plainly 
     adapted'' to the undoubtedly legitimate end of regulating the 
     enormous and enormously important health-care sector of the 
     national economy. It is therefore constitutional.


                           The Taxation Power

       In light of the broad interpretation the Supreme Court has 
     given to the enumerated powers of Congress, an Act may be 
     justified on more than one constitutional ground. Thus, the 
     individual mandate could alternatively be upheld as a valid 
     exercise of the Article I power to ``lay and collect taxes, 
     duties, imposts and excises,'' as bolstered by the Sixteenth 
     Amendment's authorization of an income tax. After all, in 
     most versions of the individual mandate, Americans are not 
     literally required to purchase health insurance: Instead, 
     they are told to pay a tax from which they can be exempted if 
     they have health insurance.
       To be sure, as Casey and Rivkin observe, a 1922 case, 
     Bailey v. Drexel Furniture Co., holds that Congress may not 
     use taxation as a pretext for accomplishing a regulatory 
     objective that it could not accomplish directly. But 
     subsequent cases upholding ``occupational taxes'' on 
     businesses that Congress clearly intended to discourage, have 
     made clear that a tax that serves a revenue-raising purpose 
     is not invalid simply because it also serves a regulatory 
     purpose. And there is no doubt that the tax on uninsured 
     income earners would serve a valid revenue-raising purpose--
     namely, to defray the costs of subsidizing health insurance 
     for those who could not otherwise afford it.
       Thus, even if Congress lacked the power to adopt the 
     individual mandate under the Commerce Clause, the taxing 
     power would separately authorize a properly-worded tax on the 
     uninsured, despite its regulatory impact.


      Federalism in Congress: Its Members, Too, Can Consider the 
                Constitutional Dimensions of Legislation

       The foregoing analysis shows why an individual mandate 
     would be upheld against a court challenge, so long as the 
     courts faithfully apply the current Supreme Court precedents. 
     Nonetheless, members of Congress are entitled--indeed, some 
     might say they are obligated--to reach their own 
     constitutional judgment about any bill that comes before 
     them. And that is especially true when there is a question 
     about the proper role of the federal government and the 
     states.
       In its cases involving challenges to congressional power, 
     the Supreme Court has sometimes said that the broad deference 
     given to Congress arises out of institutional concerns: 
     Except in extreme cases, the Justices lack the fact-finding 
     capacity and democratic legitimacy to make all of the fine-
     grained judgments about what matters should be federalized 
     and what matters should be best left to the states. In the 
     words of the late constitutional law scholar Herbert 
     Wechsler, the Court relies on ``the political safeguards of 
     federalism'' to do most of the work of ensuring a 
     constitutional balance between national and state regulation.
       Wechsler pointed to a variety of ways in which the 
     interests of the states are represented in Congress itself. 
     Chief among these are the facts that each state has two 
     Senators, and that electoral districts respect state lines. 
     In addition, as Stanford Law School Dean Larry Kramer has 
     noted in more recent scholarship, the national political 
     parties tie members of a state's congressional delegation to 
     state politicians. Taken together, these and other mechanisms 
     ensure that Congress will not simply federalize everything, 
     leaving no area of regulatory discretion to the states.
       Wechsler's point was mostly descriptive: Congress, he said, 
     would in fact take account of state interests. But we might 
     add a normative dimension: Congress should take its 
     constitutional role seriously in matters of federalism, 
     because judges are going to be highly deferential in such 
     matters if and when federal statutes are constitutionality 
     tested.
       Accordingly, it would be perfectly appropriate for one or 
     more members of Congress to vote against the individual 
     mandate or health care reform more broadly on the ground that 
     they think such matters should be left to state regulation or 
     to private decision makers. But it would be equally 
     appropriate for Congress to conclude otherwise and thereby 
     join the ranks of the other industrialized countries--
     including those, like Canada and Germany, with robust 
     commitments to federalism--that have comprehensive national 
     health care systems. Properly understood, the constitutional 
     case law is no obstacle.


                               Debt Limit

  Mr. BAUCUS. Mr. President, tomorrow morning, the Senate will have to 
vote on legislation to increase the statutory limit on the United 
States debt. The measure that will be before us will increase the limit 
by $290 billion.
  The debt limit sets a ceiling on the amount of money the U.S. 
Treasury can borrow. If we pass this bill, then the Treasury can 
continue to borrow money until about February 11 of next year. If we do 
not pass this bill, then at least two very bad things will happen:
  First, the United States would default on the interest payments on 
this debt for the first time in the history of this country. Second, 
the Federal Government would be unable to borrow the money it will need 
to pay Social Security benefits that beneficiaries are entitled to 
receive.
  The bottom line is we have no choice. We have to approve it. The law 
limits how much money the Treasury can borrow. One might ask: How did 
we reach the current limit? The answer is simple and it is, frankly--I 
am trying to give a very fair answer, fair to both sides of the aisle 
and not be political about this but just be fair and explain how we got 
to where we are.
  The financial crisis and the deep recession the new administration 
inherited has resulted in record borrowing this year. Let me be 
specific.
  First, the Bush administration asked for and then used authority to 
spend unprecedented sums of money to help banks, auto companies, 
insurance firms, Fannie Mae, and Freddie Mac to weather the financial 
crisis. The prior administration enacted and used these authorities 
before the current administration even took office. That ran up a huge 
number, a huge addition to our deficits and debt.
  Second, the new administration inherited the great recession. The 
recession has lowered revenues. To compensate for reduced revenues, the 
Treasury has had to borrow more.
  In addition, the recession has increased the need for Federal 
spending

[[Page S13844]]

on things such as unemployment insurance and Medicaid costs for folks 
who can no longer afford health care. To compensate for these increased 
outlays, Treasury has had to borrow more as well.
  Finally, to keep the recession from becoming a lot worse than it has, 
the Obama administration had no choice but to enact a vigorous stimulus 
package, and the Treasury had to borrow the money to make up for this 
shortfall as well.
  Without enactment of this stimulus, the economy could have well 
descended into a depression. We would have been in far worse economic 
shape had we not passed the stimulus legislation.
  To cover the costs of all these measures--that is those in the Bush 
administration and those in the Obama administration--the Treasury 
Department has had to borrow record amounts of money. Unfortunate as it 
is, we had to do it. Had we not, we would be in much worse shape today.
  As a result of this unprecedented borrowing, the Treasury is about to 
reach the current limit. It is clear that we have no choice but to 
raise the ceiling on the debt the Treasury can borrow.
  We have spent the money. We have to raise the debt limit so bills can 
be paid. If we do not, the United States will default on its interest 
payments for the first time in its 220-year history. We cannot let that 
happen. We will not be able to pay all the monthly Social Security 
benefits to which people are entitled. That would be unthinkable.
  It is true we have to work harder to reduce these deficits--we have 
no choice--also, therefore, to reduce our national debt, certainly as a 
percent of gross domestic product. We have no choice. The point is we 
are beginning to reach a crisis in the accumulation of deficits and 
therefore debt. That is clear. We must as a country, as a Congress, 
working with the President, reduce those deficits in national debt. 
However, we have to pay our bills. If we do not pay our bills, we 
default. That would cause catastrophic consequences.
  To prevent those catastrophic consequences--that is, other countries 
having less confidence in the government, less confidence in the 
ability of the United States to pay its debt, less confidence in the 
U.S. dollar--we must increase the Treasury's borrowing limit and, for a 
short period of time, I think it is appropriate and prudent.
  I urge my colleagues to vote for this legislation. There is no way 
around it. It is a necessity. We simply have no choice. We have to pay 
our debts, but in the future, let's work harder to get our deficits 
under control.
  The PRESIDING OFFICER. The Senator from Connecticut.
  Mr. DODD. Mr. President, I am not a member of the Finance Committee 
and do not have the responsibility Senator Baucus does in dealing with 
these debt ceiling issues. But let me corroborate what he has been 
saying. Someone once drew the analogy that this is like going out to 
dinner, ordering a good meal, and then refusing to pay the bill at the 
end of it. We have a meal in front of us--tragically a meal that got 
too large because, frankly, the previous administration accumulated a 
debt without ever asking the American people to pay for it, including 
the war in Iraq and other items that left us in a hole larger than 
created by all administrations combined over 225 years of our history--
a remarkable achievement. It is not just the deficit of one 
administration but all 43 Presidents combined had never accumulated 
what one administration did in 8 years.
  I commend my colleague from Montana. This is no easy task. It is a 
painful vote for anyone to cast, but it is obviously critical. This is 
more than just a vote in this Chamber. It goes to the very stability of 
the global economy.
  We have to meet our obligations. I, for one, am certainly glad to 
cast a vote. I do not think it is a difficult vote. It is a hard vote 
considering what is at stake. But the implications of refusing to 
support this would be catastrophic to our country.
  I thank my colleague.
  Mr. President, 10 minutes short of 12 hours from now, we are going to 
cast our final vote on the national health care proposal. I have some 
closing remarks on this historic debate.
  Before I do so, I wish to thank once again our staffs who have been 
involved in all of this. I know my dear friend and colleague from Iowa 
will talk about this more specifically. I have already announced the 
names of the majority staff who have made a contribution to this 
effort.
  I think it is fairly clear that tomorrow morning at 7 a.m., when we 
cast our votes on this proposal, this is going to be a very divided 
Chamber. Sadly, we are going to end up on a very partisan vote. I 
suspect something along the lines of 60-40, although obviously we need 
less than 60 votes to pass the bill at this point. But I suspect the 
vote will be something like that. I regret that deeply. It saddens me 
we have come to that moment. But it is what it is.
  While last evening I mentioned the members of the staff who are part 
of the majority staff who made such a contribution--and I thank them 
once again for their efforts--I want to also mention the minority staff 
who served their Members well and admirably in this effort, certainly 
during the markup of our bill in the Health, Education, Labor, and 
Pensions Committee that Senator Kennedy chaired for so many years, that 
I had the honor of taking over for him during his period of illness, 
and is now chaired by my friend from Iowa, Senator Harkin.
  The Senator from Wyoming, Mike Enzi, is the ranking minority member 
of that committee. We ultimately had a divided, partisan vote in that 
committee. But as my colleagues have heard me say over and over again 
during these days and weeks of debate, a good part of our bill, even 
though it ended up with a partisan vote, included 161 amendments 
offered by the minority in that markup session. More than half of all 
the amendments considered were offered by the Republicans on that 
committee, on my committee at the time that were adopted almost 
unanimously in most cases.

  I wish to mention the minority staff tonight who made that possible. 
They strengthened our bill and made it a stronger one. Beginning with 
Frank Macchiarola, Chuck Clapton, Katy Barr, Todd Spangler, Hayden 
Rhudy, Keith Flanagan, Amy Muhlberg. They work for Senator Enzi.
  Liz Wroe and Jeff Gonzales work for Judd Gregg of New Hampshire.
  Jay Khosla, Patty DeLoatsche--I may have mispronounced that last 
name; I apologize if I did--along with Paul Williams of Senator Hatch's 
staff made a significant contribution to the bill.
  While, again, there was division on a partisan basis, I thank them 
for their efforts. They put in long hours as well.
  On that note, let me say before getting to the substance of my 
remarks, I chair the Senate Banking, Housing, and Urban Affairs 
Committee. We have been working diligently. In fact, today my good 
friend and colleague from Alabama, Richard Shelby, and I spent about an 
hour or so together and then about five or six members, Republicans and 
Democrats on that committee, spent another hour together, as we have 
every day almost over the last several weeks trying to fashion a bill 
on financial services reform that we hope to present to our colleagues 
on our return in January and February that will deal with the 
catastrophe that has occurred economically in our Nation.
  My hope is as a Chamber--I know my colleagues have heard me say 
this--I arrived in this Chamber as an employee of the Senate about 50 
years ago. I sat on these steps right over here. Lyndon Johnson sat in 
the Presiding Officer chair. John Kennedy was the President of the 
United States. I was a Senate page and listened to the all-night 
debates in the early 1960s on civil rights and got to witness history. 
I got to watch the Members of this Chamber, some of the historic 
figures--Hubert Humphrey, Lyndon Johnson, Everett Dirksen--remarkable 
people who served here. Barry Goldwater, of course. We served together 
in this Chamber for a period of time when I arrived in the Senate.
  Thirty-five years ago on January 3 of next month, I arrived as a 30-
year-old Member of the House of Representatives, and 6 years later I 
arrived here as a freshman Senator 30 years ago. Going back to the 
sixties, I had a lot to do with this Chamber and watched it over the 
years.
  The best moments occur when we work together. This has been a bitter 
and difficult battle over the last number of months. But as someone who

[[Page S13845]]

takes great pride in having been part of this Chamber, as my father was 
before me, for more than a quarter of the life of our country, I want 
to see us once again return to the days when we have our partisan 
debates, which we should because it has built the country.
  Partisanship--there is nothing wrong with that. It is our ability to 
act civilly with each other. I have been deeply disturbed by some of 
the debate I have heard, usually from newer Members, usually those who 
have been here 1, 2, 3 years, who do not have an appreciation of what 
this Chamber means and how we work together.
  While we have our differences, the ability to walk away from 
differences and forge those relationships over the next day is 
critically important. It is always the newest Members who fail to 
understand how the Senate has worked for more than two centuries. We 
need to get back to that sense of civility once again.
  I hope when we return in January to deal with new issues that we will 
get back to that comity that is important. Not the disagreements. The 
disagreements are important, but the ability to deal with each other 
and forge the kind of proposals that serve all of our constituents and 
serve all of our country is going to be critically important.
  I wanted to share that thought with my colleagues this evening as 
someone who now at the ripe old age of 65 has spent well more than half 
of my life deeply involved in this institution. It saddens me when we 
end up being divided and engaged in the ad hominem arguments that I 
think ridicule the institution, belittle and demean the contributions 
that each and every Member wants to make.
  Even though we have had very strong disagreements, I never once in my 
life in this Chamber ever questioned the patriotic intentions of any 
Member. We may have strong disagreements on how to best achieve that 
more perfect Union, but the idea you challenge another's patriotism, 
honesty, their integrity, does a great disservice to this institution, 
in my view.
  Again, I regret sometimes the newer Members who fail to understand 
the importance of maintaining that which our Founders envisioned when 
they created this institution.
  This evening I rise to express once and for all and lastly in this 
debate my strong support for this bill, our Patient Protection and 
Affordable Care Act of 2009. In a little over a week, this decade, the 
first decade of the 21st century will come to a close, and it has been 
a turbulent one for our country. We have been tested by the acts of God 
and the acts of evil men in this decade. We have entered two wars and 
have been through a profound recession, almost a depression. Our 
financial markets have failed. Middle-class families have lost their 
footing. The American dream is fading for far too many of our families 
in this Nation.
  We wear these 10 years heavily. We have seen deep division in our 
country, bitter debates within the walls of this Chamber in which all 
of us are so proud to serve.
  We do not have the luxury of tackling only those challenges that can 
be solved easily. But as Thomas Paine wrote:

       The harder the conflict, the more glorious the triumph.


  Those words come from a pamphlet called ``The American Crisis.'' It 
was published 233 years ago this very week at another very uncertain 
moment in American history. That pamphlet begins with these words:

       These are times that try men's souls; the summer soldier 
     and the sunshine patriot will, in this crisis, shrink from 
     the service of his country; but he that stands it now, 
     deserves the love and thanks of man and woman.

  GEN George Washington, outmanned, outgunned, and sensing that morale 
was flagging in light of recent setbacks, ordered that this pamphlet 
and these words be read to his deeply troubled and impoverished troops. 
And on Christmas Eve, 1776, he gathered his officers at McKonkey's 
Ferry to plan the crossing of the Delaware.
  This body has been in session on Christmas Eve only once since 1963--
and we will tomorrow--when in the wake of President Kennedy's 
assassination, the Senate met to consider a bill to fund our operations 
in Vietnam. We will be in session tomorrow morning, embroiled again in 
times that certainly try men's souls. Like GEN George Washington, we 
have an opportunity to meet history's gaze, to steel ourselves to the 
difficult work of making our Union more perfect.
  The journey we complete tomorrow has been a long and difficult one. 
But I, for one, would not trade it for anything. We who will have the 
privilege to cast our votes at 7 a.m. tomorrow morning for health care 
reform will never cast a more important vote in our Senate careers. 
History will judge harshly those who have chosen to shrink from this 
moment, but those of us who stand up to make this country more secure, 
to make our Union more perfect, we will never forget this Christmas 
Eve. For this Christmas Eve, we have given an incredible gift. We have 
been granted a rare opportunity to deliver an enormous victory for the 
American people for generations to come. We have a chance to alleviate 
tremendous burdens of anxiety and fear and suffering, to make our 
country stronger and healthier, to deliver the leadership our 
constituents have demanded--and rightfully so--and the real and 
meaningful change they voted for 13 months ago. So in the last week of 
a decade in which so much has been asked of the American people, that 
is what history now asks of us in this Chamber.
  Over the past weeks and months, I have come to this floor to talk 
about what this bill will do for the citizens of my State and my 
country. I have talked about how reform will guarantee every American 
will have access to quality, affordable care when they need it, from 
the doctor they choose. I have talked about how reform will reduce our 
national deficit by finally getting health care costs under control. I 
have talked, as others have, about what reform will do for small 
businesses--giving them access to health insurance exchanges where they 
can find the best deals for their workers and a tax credit to help them 
pay for it. And I have talked, as others have, about how reform will 
help our older citizens, our seniors, by strengthening Medicare and 
closing the so-called doughnut hole for prescription drugs and creating 
a new, voluntary program to pay for long-term care. I, along with 
others, have talked about how reform will help doctors and health care 
providers spend more time caring for their patients, which they want to 
do, and less time fighting with insurance company bureaucrats. I and so 
many others have talked about how reform will finally make insurance 
accessible and affordable for the 350,000 residents of my State and the 
31 million people across our Nation who today don't have it, whether it 
is because they can't afford it or because they have been denied 
coverage due to a preexisting condition. I have also talked, along with 
my colleagues, about how reform will finally make insurance a buyer's 
market, ending a wide variety of abusive insurance industry practices 
and empowering consumers to make smart decisions.
  As has been said so many times, this bill is far from perfect, and we 
all know that. It represents not the end but, as my friend and 
colleague from Iowa has said so many times, the beginning of our work. 
Long after all of us have left this Chamber, however we depart, those 
who come after us will work on our product. They will make it better, 
they will make it stronger, they will find our shortcomings in this 
bill, they will add to it, and they will subtract from it. But they can 
never engage in those efforts if we do not do the job I am confident we 
will do tomorrow morning at 7 a.m. on Christmas Eve, and that is to 
renew the American dream, revive our middle class, and rebuild the 
foundation upon which future generations will stand.
  I am very proud of this legislation, with all its shortcomings. I am 
proud to have had a role in bringing it to a vote--an accidental role, 
as all of us know. I wouldn't be standing here talking about it in this 
context, other than as a Member of this Chamber, were it not for the 
tragic death of my great friend and colleague from Massachusetts.
  President Teddy Roosevelt famously said:

       It is not the critic who counts; not the man [or woman] who 
     points out how the strong man stumbles, or whether the doer 
     of deeds could have done them better. The credit belongs to 
     the man who [or woman] is actually in the arena, whose face 
     is marred by dust

[[Page S13846]]

     and sweat and blood; who strives valiantly; who errs; who 
     comes short again and again, because there is no effort 
     without error and shortcoming; but who does actually strive 
     to do the deeds; who knows great enthusiasms, the great 
     devotions; who spends himself [or herself] in a worthy cause; 
     who at the best knows in the end the triumph of high 
     achievement, and who at the worst, if he [or she] fails, at 
     least fails while daring greatly, so that his [or her] place 
     shall never be with those cold and timid souls who neither 
     know victory nor defeat.

  So we happy few, the 60 of us who stand in the arena today, who have 
fought and argued and compromised and organized so that we might cast 
this historic vote at 7 a.m. on Christmas Eve, we would not trade this 
opportunity for anything.
  This last year has proven that progress is not easy. Tomorrow, we 
will prove that it is not impossible. May the next decade in our 
country's history be shaped by that spirit--by the promise of a 
brighter tomorrow, by the unshakable desire to rise to the challenges 
that fate places in our path, by the quest to make our great Nation a 
more perfect one.
  I yield the floor.
  The PRESIDING OFFICER (Ms. Cantwell). The Senator from Iowa is 
recognized.
  Mr. HARKIN. Madam President, I ask unanimous consent that the 
remainder of the time used on the bill today be for debate only.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. HARKIN. Madam President, first of all, before he leaves the 
floor, I want to thank my dear friend, my colleague, my classmate from 
1975, for all his great leadership on this bill. We were all saddened 
by the fact that our leader, Senator Kennedy, could not be with us over 
the last year to guide and direct and to see the fulfillment of his 
lifetime dream of health care reform. It fell upon Chris Dodd's 
shoulders to take it through. Madam President, he did it superbly. He 
kept our committee together.
  Again, I just want to say that Senator Dodd bent over backward, 
extended every consideration to the other side to amend and to be 
involved in the shaping of this bill. As my friend said, we adopted 161 
of their amendments out of 220 or so they offered. Not all of them were 
accepted. Not all of the Democratic amendments were accepted, by the 
way, in the committee. So I thought Senator Dodd went the extra mile to 
accommodate the other side. He did. I am just sorry that not one 
Republican saw fit to support the bill when it came out of the 
committee, but so be it. Because of Senator Dodd's dedication and his 
leadership, we have a great bill here today.
  I have been watching the debate, and most of the things people are 
talking about are items that were in the bill Senator Dodd crafted, 
things that are going to make a big difference in people's lives. I 
will talk about a few of those in my formal remarks--things such as 
doing away with preexisting conditions; stopping rescissions, where 
they cut off your policy when you get sick; keeping kids on their 
parents' policies longer, and all of the things we fought so hard for 
regarding prevention and wellness. All of that is in our bill. It is in 
the bill Senator Dodd brought forward out of our committee. So I am 
proud to have him not only as a friend but as our great leader on this 
health care bill. Tomorrow morning, when we finally pass it, it will be 
in no small part because of the great leadership of Senator Dodd. So I 
wanted to thank him on the floor before he leaves to go home to be with 
his two great kids and his wonderful wife.

  Appreciate it very much, Chris.
  Mr. DODD. I thank my colleague from Iowa, and we couldn't have done 
it without him as well. I appreciate it.
  Mr. HARKIN. I thank the Senator very much.
  Madam President, I also want to thank my good friend from Illinois, 
Senator Burris, for allowing me to go first here, in front of him.
  You know, I was kind of feeling bad for myself because I didn't know 
if I was going to make Christmas Eve with my wife and family for the 
first time in 41 years. But I think, because of moving up the vote to 7 
a.m., I might be able to do that.
  But I just found out that today is Senator Burris's 48th wedding 
anniversary. Congratulations, Senator Burris. So he is here today and 
his lovely wife is out in Illinois, but he sent her flowers today. I am 
sure she appreciated that, but she would much rather be with Roland on 
this day. My goodness, 48 years--in this day and age, it is hard to 
find people married that long. So I congratulate Senator Burris, who is 
a great friend of mine personally and a valuable Member of the Senate. 
I think it shows what people are giving up here to make sure they are 
here to get health reform passed. Senator Burris gave up being with his 
spouse of 48 years. That is quite a sacrifice.
  Thank you very much, Senator Burris.
  Madam President, as we approach the final vote, again I wish to thank 
both Senator Dodd and Senator Baucus for a masterful job of shepherding 
this legislation through the Finance and HELP Committees.
  There is no way we would be here today without the great work of our 
majority leader. To put it in Biblical terms, Leader Reid has the 
patience of Job, the wisdom of Solomon, and the stamina of Sampson. 
Senator Reid is on the verge of achieving what majority leaders going 
back nearly a century have failed to accomplish. Make no mistake about 
it, when this final vote is cast tomorrow morning, Majority Leader Reid 
will have earned his place in the Senate's history.
  As we approach the final vote, we have reached a momentous crossroad, 
just as Senators did in 1935 when they passed the Social Security Act 
and in 1965 when they created Medicare. Each of those bills marked a 
giant step forward for the American people. Each was stridently opposed 
by defenders of the status quo. But in the end, a critical mass of 
Senators rose to the historic occasion. They voted their hopes, not 
their fears. As we know now, in retrospect, they passed laws that 
transformed America in profoundly positive ways.
  The Senate has now arrived at another one of those rare historic 
crossroads. This time, we are going to pass comprehensive health 
reform--a great goal that has eluded Congresses and Presidents going 
back to Theodore Roosevelt.
  I make no bones about my enthusiasm for the reforms in this great 
bill. Is it perfect? Is it what I would write if I could dictate 
everything? No. There have been genuine compromises made, and that is 
the art of legislating.
  There are a lot of things not in this bill for which I fought very 
hard, such as a public option or getting a Medicare buy-in at age 55. 
But I understand the art of compromise. Beyond that, this bill will be 
the biggest expansion of health coverage since the creation of 
Medicare.
  It cracks down on abusive practices by health insurance companies, 
abuses that currently leave most Americans one serious illness away 
from bankruptcy. It includes an array of provisions, including wellness 
and prevention and public health. Our aim in this bill is to change our 
current sick care system to a true health care system that keeps people 
out of the hospital in the first place.
  Madam President, I was struck by something that the distinguished 
minority leader, Senator McConnell, said early Monday morning prior to 
the first critical cloture vote. Addressing Democratic Senators, the 
minority leader turned and faced us and said: It's not too late, it's 
not too late. All it takes is one, just one. Gesturing to this side of 
the aisle, he said: One can stop this bill; one can stop it, for every 
single one will own it.
  He was talking about Democrats. I say to the minority leader, we 
Democrats are proud to own this bill. Just as we are proud of our 
ownership of Social Security and Medicare and the Elementary and 
Secondary Education Act and so many other reforms, progressive reforms, 
that have made America the great Nation we are today.
  For the record, let me point out exactly what it is that Democrats 
will ``own'' by passing this bill. We will own the fact that this bill 
is fully paid for. Indeed, this bill will reduce the Federal debt by 
$132 billion in the first decade and by at least $650 billion in the 
second decade. We will own the fact that some 30 million additional 
Americans will in coming years have access to quality, affordable 
health care.
  Let me mention just a few of the things in the bill that Democrats 
will own next year as soon as President

[[Page S13847]]

Obama signs this into law. We will own the fact that next year 
insurance companies will be required to cover the preexisting 
conditions of children. We will own that. Think about that. There will 
be a program to extend coverage to uninsured Americans with preexisting 
conditions later.
  We will own the fact that this bill provides immediate support to 
health coverage for early retirees. We will own the fact that this bill 
will immediately shrink the size of the doughnut hole by raising the 
ceiling on the initial coverage period by $500 next year.
  We will own the immediate guarantee of this bill of 50 percent price 
discounts on brand-name drugs and biologics purchased by low- and 
middle-income Medicare beneficiaries who are in the doughnut hole. We 
will own the fact that this bill will provide tax credits to small 
businesses to make employees' coverage more affordable. Tax credits of 
up to 35 percent of the cost of premiums will be available to small 
businesses next year.
  In addition, we will own the fact that this bill requires health 
insurance companies to allow children to stay on their family's 
policies until age 26. Democrats will own the fact that this bill 
prohibits health insurers from imposing lifetime limits on the benefits 
consumers believe they are paying for and will tightly restrict the use 
of any annual limits.
  Let me mention one other extremely important thing that, in the 
minority leader's word, Democrats will own. Our bill, immediately, will 
stop insurers from the devastating practice of rescinding or cancelling 
health insurance coverage when a policyholder is seriously ill.
  All of those things I mention will happen right away, Madam 
President, as soon as the bill is signed into law. Taken together, this 
is a breathtaking catalog of reforms that will benefit the American 
people immediately. So, we Democrats are very proud, I say to the 
minority leader, to own these reforms.
  We had hoped that our Republican colleagues would also be proud to 
own them. But let's remember William F. Buckley's conservative model. 
He is sort of the father of the conservative movement in America. He 
said the role of conservatives is ``to stand athwart history yelling 
`stop'.'' That is exactly what our Republican colleagues have been 
doing by filibustering and trying to kill health care. They are 
``athwart history, yelling 'stop'.'' My friends on the Republican side 
will be on the wrong side of history, the wrong side of reform, and the 
wrong side of progress.
  I have been saying this bill, the Patient Protection and Affordable 
Care Act, is like a starter home. It is not the mansion of our dreams. 
It doesn't have every bell and whistle we would all like, but it has a 
solid foundation giving every American access to quality, affordable 
coverage. It has an excellent protective roof which will shelter 
Americans from the worst abuses of the health insurance companies, and 
this starter home has plenty of room for additions and improvements.
  We Democratic Senators are proud to own this starter home. We are 
proud of the fact that this starter home is fully paid for. It is a 
starter home without a mortgage.
  Indeed, as I said earlier, this bill will reduce the Federal deficit 
by $132 billion in the first decade and by at least $650 billion in the 
second decade. So, Madam President, even at this late date before the 
vote tomorrow morning, I say to our Republican colleagues, Democrats 
are proud to own this legislation and this starter home. We are proud 
to own the many reforms and benefits in this bill and we would be very 
pleased to share ownership with as many of our Republican colleagues 
who care to join us.
  With all due respect to William F. Buckley, it is not written in 
stone that conservatives have to say no to history. I urge every 
Senator to say yes.
  This bill has many authors. But in a very real sense this is Senator 
Ted Kennedy's bill. Our late beloved colleague would be so proud to see 
the Senate on the cusp of passing landmark health care reform. For 
decades, from his first days in the Senate, this was his highest 
priority and fondest win. As his friends on both sides of the aisle 
know, his great dream was of an America where quality affordable care 
is a right not a privilege for every citizen.
  Today, we are on the verge of making that dream a reality. So often 
Senator Kennedy talked about the moral imperative of health reform. Too 
often in the debates of recent weeks we have lost sense of this moral 
imperative. We have heard speeches. We have had charts, back and forth 
and back and forth on some of the small stuff; who wins, who loses, 
because of this or that minor provision in the bill.
  Today, on the eve of this historic vote, we should refocus on the big 
stuff, the moral imperative that drove Senator Kennedy. With this bill 
we will get rid of the shameful dividing line that has excluded 
millions of Americans for too long. For too long, tens of millions of 
Americans have been on the wrong side of that divide, without health 
insurance, without regular medical care for their children, just one 
serious illness away from bankruptcy. With this landmark legislation we 
erase that shameful divide within our American family. With this bill 
we say for every American, for every member of our American family, 
access to quality affordable care will be a right, not a privilege. It 
is a monumental achievement.
  I urge all of our colleagues to vote yes on this bill.
  Now, Madam President, a lot has been said about those of us who have 
been the leadership on this bill: Senator Reid, Senator Baucus, Senator 
Dodd, myself, and so many others. It is important to etch in history in 
our Congressional Record the names of those individuals on our staffs, 
who have done so much to get us to this point. I said earlier there is 
an old saying that Senators are a constitutional impediment to the 
smooth functioning of staff. We kind of laugh at that, but we know 
there is great truth to that. Were it not for the staff who spent so 
many hours and so much time away from their families that we would not 
be here.
  I was talking with Senator Reid's office. Kate Leone did a 
magnificent job. Carolyn Gluck, Jacqueline Lampert, Bruce King, David 
Krone, Rodell Molineaux, and Randy DeValk.
  Senator Dodd's staff: Jim Fenton, Tamar Magarik Haro, Monica Feit, 
Brian DeAngelis.
  Senator Baucus's staff: Liz Fowler, Bill Dauster, Russ Sullivan, John 
Sullivan, Scott Mulhauser, Kelly Whitener, Cathy Koch, Yvette Fontenot, 
David Schwartz, Neleen Eisinger, Chris Dawe.
  On our HELP committee: Michael Myers, our great staff director, who 
for more than a decade has led this staff and for almost 20 years has 
worked for Senator Kennedy. We are all sorry that Senator Kennedy could 
not be here for this. I can say honestly that Mike Myers carries on the 
torch as his staff director. He did a magnificent job of getting us 
through this. And David Bowen--David Bowen, if there is one person who 
knows more about what is in this bill than anyone else, it is David 
Bowen. I have never asked him about anything in this bill that he 
didn't know where it was and what it does. He has been at every 
meeting, I don't care how early in the morning, how late at night. I 
know he has been apart from his family and his children. I wish David 
the best in terms of being with his family tomorrow and over Christmas. 
David Bowen has done such a magnificent job of guiding and directing 
this bill and making sure it was all put together.
  Connie Garner, who worked so hard, so hard; Portia Wu, John 
McDonough, Topher Spiro, Stacey Sachs, Tom Kraus, Terri Roney, Craig 
Martinez, Taryn Morrissey, Andrea Harris, Sara Selgrade, Dan Stevens, 
Caroline Fichtenberg, Lory Yudin, Evan Griffis.
  Now I want to mention one other person who has been on my staff but 
now is on the HELP Committee staff, Jenelle Krishnamoorthy. I have for 
many years been advocating that we have to change our focus in America 
from a sick care society to a health care society. I mentioned that 
earlier. This bill contains more for wellness and prevention and public 
health than any bill ever passed by Congress--ever passed--and it is 
not talked about much, you don't hear too much debate about it. But it 
is significant that we are going to change this paradigm. We are going 
to start putting more up front, keeping people healthy in the first 
place.
  One person who has done more than anyone else to make this happen is

[[Page S13848]]

Jenelle Krishnamoorthy. I want to thank her for just focusing laser-
like the last couple of years or so on this and making sure it became a 
big part of our health care reform bill.
  On my personal staff, Jim Whitmire, Beth Stein, Jenny Wing, Rosemary 
Gutierrez, and Lee Perselay. Let me mention Lee. Lee does all my work 
on disability issues. As many people know, it is my name on the 
Americans With Disabilities Act. Nineteen years ago we passed that. Lee 
Perselay does all my work on the disability issue.
  There is another part of the bill not too many talk about, but it is 
so profoundly important to people with disabilities. In this bill there 
is a provision that will have the Federal Government give a 6 percent 
increase in the amount of money that the Federal Government gives to a 
State for Medicaid, 6 percent increase for a State that will enact 
legislation to put in place the provisions of the Olmstead decision by 
the Supreme Court over 10 years ago; that is, that every person with a 
disability has a right to a least restrictive environment. That means 
living in their own communities and their own homes with personal 
assistant services, support so they can live at home rather than going 
to a nursing home.
  This has been a dream of the disability community since we passed the 
Americans With Disability Act in 1990. We have never been able to get 
it done. Now we have it in this bill. It is not talked about much, 
didn't hear much about it. But this will have more of a profound effect 
on people with disabilities than any other single thing in this bill or 
anything that we have done, literally, since 1990. Now people with 
disabilities can live at home and live in their own communities and the 
State will get money from the Federal Government to enable them to do 
that. Lee Perselay.
  Lee Perselay; thank you very much, Lee.
  Kate Cyrul of my staff, Dan Goldberg, and the Senate legislative 
counsel. A special thanks to Bill Baird, along with Stacy Kern-Scheerer 
and Ruth Ernst, who was present throughout the entire HELP Committee, 
and they have gone above and beyond.
  To all the floor staff here, too, we forget about all they have 
done--Mike Spahn and Anne Wall and Stacy Rich and Tim Mitchell and 
Tricia Engle and Lula Davis, wonderful floor staff working with us to 
get us to this point, where we have a final vote on this tomorrow 
morning.
  I wished to particularly mention these individuals. In many ways, 
they are the unsung heroes and heroines of what we have done. They can 
be content in knowing, as they go through life, they did a big thing 
here. They did something so important to help transform our society. I, 
personally, thank each and every one of them and wish them the best of 
the holiday season, Christmas, New Year. We will come back next year, 
and we will start implementing this bill. As the chairman of the HELP 
Committee, we will start looking at building those additions and those 
expansions.
  I yield the floor and thank my friend from Illinois for letting me 
go.
  The PRESIDING OFFICER (Mr. Begich). The Senator from Illinois is 
recognized.
  Mr. BURRIS. Mr. President, how much time do I have?
  The PRESIDING OFFICER. The Senator has 6 minutes.
  Mr. BURRIS. Mr. President, the Senate has long been a forum for great 
debate.
  This institution is equipped to handle the most difficult questions 
our Nation faces.
  Since we took up the issue of health care reform, the debate has been 
fierce, and our differences of opinion have played out in dramatic 
fashion on the national stage.
  Over the last several months, I have said time and again that this 
health reform bill must accomplish the three distinct goals of a public 
option in order to win my support:
  It must create real competition in the health care system.
  It must provide significant cost savings to the American people.
  And it must restore accountability to the insurance industry.
  For months I have told my colleagues that I would not be able to 
support a final bill that fails to meet these three goals.
  I believe they are the keys to comprehensive health reform in 
America, and without them, our legislation would be ineffective and 
incomplete.
  I expressed my concerns about the compromise bill, and I asked tough 
questions.
  I have reviewed the CBO score and the final legislative language as 
soon as it became available.
  I believe the way forward is clear.
  This bill is not perfect. It does not include everything I had hoped 
for.
  But I am convinced that it can meet the three goals of a public 
option.
  I believe it represents a monumental step forward--a strong 
foundation we can improve upon in the months and years to come.
  This is not the end of health care reform in America--it is the 
beginning.
  That is why we need to take the next step in this process. Although 
this is not the bill I had hoped I might be voting on, I am confident 
enough to pass this legislation on to the next step.
  Let us send the Patient Protection and Affordable Care Act to a 
conference committee, where it will be merged with the House bill.
  There, I have every hope that the conferees will have the opportunity 
to strengthen some of these provisions and make this legislation 
better.
  We must not let the perfect stand in the way of the good. While it is 
not everything I had hoped it would be, it is far more than we have 
now.
  And while this bill will not satisfy many of us, it would be a 
mistake to overlook all the good it will do for tens of millions of 
Americans.
  So let me explain exactly why I am convinced that this bill will 
satisfy the three goals of a public option:
  According to the nonpartisan Congressional Budget Office, the 
exchanges that will be created under this legislation will dramatically 
enhance competition in the insurance market.
  This will drive premiums down, allowing consumers to shop around for 
the plan that is best for them, their family, or their small business.
  CBO projections show that this would force providers to compete for 
the first time in many years, reducing costs and bringing everyone's 
premiums under control.
  As a result, many more people would be able to get better coverage 
for less money.
  This bill will enhance the choices that are available for individuals 
and small businesses.
  Everyone will have the choice to keep their current insurance 
coverage if they are happy with it, but if they are not, they will have 
real options for the first time in many years.
  This bill will give consumers the tools they need to hold insurance 
companies accountable.
  It includes strong consumer protections--many of which take effect 
immediately--and it contains significant insurance reforms designed to 
put ordinary folks back in the driver's seat.
  This bill will eliminate annual and lifetime caps on coverage, 
prohibit companies from dropping patients who get sick, and prevent 
discrimination against people who have preexisting conditions.
  It will also require insurance providers to cover essential health 
benefits and recommended preventive care, so more people can get the 
treatment they need.
  Based on these provisions, it is quite clear that this measure will 
provide immediate and lasting improvements in the health care system 
for everyone in this country.
  It will extend quality coverage to 31 million Americans who are 
currently uninsured, and increase access to preventive care.
  This will reduce emergency room visits, allow more people to treat 
preventable and chronic diseases, and help to bring health care costs 
under control.
  In fact, the Congressional Budget Office projects that this 
legislation will cut the deficit by more than $130 billion in just the 
first decade, and will save nearly $1 trillion over the next several 
decades.
  That is why I am confident that this bill will meet the three goals 
of a public option: competition, cost savings, and accountability.
  It may not be the legislation I would have written at the beginning 
of this process, but after nearly a century of debate about health care 
reform, under

[[Page S13849]]

the leadership of 11 Presidents and countless Members of Congress, this 
legislation represents a strong consensus.
  So it is time to take the next step in this process--to send this 
bill to conference and keep building upon this foundation.
  This is not a perfect bill, but it contains a number of fundamentally 
good components.
  Most importantly, it will ensure that 94 percent of Americans can get 
the health coverage they need.
  After decades of inaction, the Patient Protection and Affordable Care 
Act is a monumental step in the right direction.
  There were many competing ideas that gave rise to this bill.
  There were many voices, inside this Chamber and outside of it, 
shouting to be heard on these issues.
  There were concessions and compromises.
  But, out of a century of dissent--out of decades of discussion and 
debate--we have arrived at a basis for comprehensive reform.
  It is time to put aside our differences and move forward as one 
Congress, and one Nation.
  There is much work left to do on this and a host of other issues. But 
in the messy process of debate and compromise, along the path that has 
led us to this point, this body has reaffirmed the enduring truth of 
the motto inscribed in this Chamber, just above the Vice President's 
chair: ``E pluribus unum.'' It is there, Madam President, right over 
your head. It means ``Out of many, one.''
  For our entire history, it has been the creed that binds us to one 
another and to our common identity as Americans. It is the principle 
that drives us to assemble in this august Chamber to debate the 
toughest issues we will ever face.
  Although we come from every section of this country, from many 
States, we are one country, and together, we can create a health care 
system that will be worthy of the people we represent.
  It is time to make good on the promise of the last century and move 
forward with the Patient Protection and Affordable Care Act.
  Let's take the next step, and send this bill to conference.
  I yield the floor.


            medicare geographic inequities in reimbursement

  Mr. HARKIN. Mr. President, I am pleased to support the legislation 
pending before the Senate today, which will ensure that 31 million 
Americans will finally have access to affordable, quality health 
coverage, which will crack down on outrageous abuses by the insurance 
industry, and which will, at long last, put prevention and wellness at 
the heart of our health care system. I rise today, however, to signal 
that there is an area of this legislation that remains of concern and 
that I will be working to fix as we head to conference; namely, 
provisions to rectify the geographic inequities in the low Medicare 
reimbursement rates.
  Across the country, Americans pay equal premiums to support Medicare. 
Yet there is a substantial geographic disparity in physician 
reimbursement levels in the Medicare Part B Program. The degree of this 
disparity is unjustified and inherently unfair--and it is having an 
increasingly negative impact on the number of providers that are 
accepting Medicare and magnifying the workforce shortage problem--
especially in rural areas. The unfairness in this disparity in 
reimbursement rates is compounded by the fact that the States with the 
lowest reimbursement rates are often those that deliver the highest 
quality of care. The system must change and reward the quality of 
service delivered instead of the volume of care served.
  I see that my colleague from Oregon, Senator Merkley, is here on the 
floor. He and I have often discussed this issue, as his State is also 
one that provides outstanding care and yet suffers from unduly low 
reimbursement rates. I wonder if my distinguished colleague shares my 
view that this is something we must continue to work on before this 
bill is finalized?
  Mr. MERKLEY. I thank my distinguished colleague for raising this 
issue, which has also been a concern of mine. I agree with him that my 
State consistently lags behind other States on Medicare reimbursement 
and per capita spending. I strongly believe that a fundamental way to 
achieve the goal of more efficiency in Medicare is to realign the 
Medicare payment system to reward health care providers for the quality 
of care they deliver, not simply the quantity of services they provide. 
Medicare is spending over one-third more for each Medicare beneficiary 
in some States compared to Oregon, to Iowa, or to the home State of my 
good friends from Minnesota, Senators Klobuchar and Franken, who are 
also here on the floor with us today.
  The simple fact is, this antiquated payment formula penalizes rural 
providers and penalizes medical efficiency, and I know in Oregon it has 
forced many physicians to stop accepting Medicare patients or limit the 
number of Medicare patients they serve, and that is why I feel so 
strongly that we must fix it once and for all in the final health 
reform bill. I wonder if the Senators from Minnesota have had a similar 
experience in their state.
  Ms. KLOBUCHAR. I want to thank you, Senator Merkley and Senator 
Harkin, for your work on is issue. I have observed the same problems 
with Medicare reimbursement in my home State. We represent States and 
regions that have demonstrated true leadership in lowering costs to 
Medicare while increasing the quality of care patients receive. The 
high-efficiency areas we represent are known for utilizing integrated 
health delivery systems and innovative quality measures to provide 
Medicare beneficiaries with better value. Research shows that these 
efficient delivery practices can save the Medicare Program upwards of 
$100 billion a year while also providing beneficiaries better access to 
the care they need. Unfortunately, the current Medicare payment 
structure penalizes those who provide efficient care while rewarding 
those who order unnecessary tests and services. It is critical that 
this is addressed in conference, and it will be-a-priority as we move 
forward through this process.
  Mr. FRANKEN. Thank you, Senator Harkin, for your leadership, and also 
thanks to my other colleagues for working on this issue. I agree with 
all that has been said, and I would like to reiterate that our States 
have some of the best health care in the country. And it just doesn't 
make sense that under the current Medicare reimbursement system, the 
good care in our States gets punished and the less effective, more 
expensive care gets rewarded. The result is that we are not providing 
health care in this country; we are providing sick care. We need 
incentives for providers for high-value care, and the best way to do 
this is through Medicare payment reform.
  These geographic disparities in Medicare payments are unfair, and 
they are not good for patient care. We are forcing excellent providers 
out of business because reimbursement rates are low and they just can't 
make ends meet. This is counterproductive to the goal that I know we 
all share--to increase access to high-quality health care for all 
Americans. It is a top priority for me that in conference we make some 
changes so high quality care that is provided at a reasonable cost will 
no longer be punished. Instead, we need to make sure that the bill 
rewards providers for being effective partners in their patients' care. 
I appreciate the opportunity to share these concerns and discuss these 
issues with my colleagues.
  Mr. HARKIN. I couldn't agree with my colleagues more. It is long past 
time to take action to fix this system. I appreciate the commitment of 
the Senator from Oregon and the Senators from Minnesota to fixing this 
problem once and for all.


                      definition of full time work

  Mrs. MURRAY. Mr. President, I would like to engage my friends, the 
Senator from Iowa and Chairman of the Health, Education, Labor and 
Pensions Committee, and the Senator from Montana and Chairman of the 
Finance Committee, in a conversation about how ``full time'' is defined 
in the Patient Protection and Affordable Care Act and clarify any 
misunderstandings about how the legislation resolves the potential for 
exclusion of certain work group such as flight crews and rail workers 
due to the definition of ``full time'' work and the unique way their 
work hours are calculated.
  Is it the Senators' understanding that the Patient Protection and 
Affordable Care Act resolves a potential

[[Page S13850]]

problem of excluding from employer incentives to provide coverage for 
employees who work in professions that use unique calculations for 
hours worked, such as flight crews and rail workers? And that it does 
this by indicating that the Secretary of HHS, in consultation with the 
Secretary of Labor, shall prescribe such regulations, rules, and 
guidance as may be necessary to determine the hours of service of an 
employee, including rules for employees who are not compensated on an 
hourly basis?
  Mr. HARKIN. Yes, the Senator is correct. The Patient Protection and 
Affordable Care Act is designed to expand access to high quality and 
affordable health coverage for all workers. Because of the nature of 
work, some industries uniquely calculate total daily and monthly 
working time to determine full-time schedules. That is why this 
legislation gives the Secretaries of Health and Human Services and 
Labor discretion to establish rules and regulations for the hours of 
service for workers outside of standard hours. This provision is meant 
to be construed broadly.
  Mr. BAUCUS. I would concur with my friend, the Senator of Iowa, in 
his understanding of the act. This provision is meant to be construed 
broadly, and to expand access to high quality and affordable health 
coverage for all workers.
  Mrs. MURRAY. Of particular concern to me are groups such as pilots 
and flight attendants, cabin crews who, under ``full time'' contracts, 
``work'' on average only 70 hours per month due to the unique way their 
hours are calculated. For obvious safety reasons, a pilot is limited, 
through Federal regulations, to flying 100 hours per month, or 1,200 
hours annually, even though he or she contributes many more hours of 
service outside of the time spent flying planes. This unusual work 
schedule, however, raises the potential that a pilot might not be 
considered a full-time employee for purposes of this legislation under 
a rule that defined full time status as simply ``working'' upwards of 
30 or 40 hours per week. The same is true of other flight-crew 
employees.
  Additionally, railroad hours-of-service employees, who work by the 
mile or by the day, could also find it difficult to meet the definition 
of full-time employee under a strict ``hours worked'' standard. Many 
train and engine service railroad employees are paid by the mile and or 
by the day or paid for time available to work, and are not paid by the 
hour. Although these workers are undoubtedly full-time employees within 
their profession, the annual or weekly hours they are calculated to 
work might not satisfy a narrow minimum hour component that did not 
take into account a more flexible hours of service concept for certain 
types of jobs.
  Currently all flight and cabin crew members employed by Part 121 
commercial air carriers and train and engine service railroad employees 
paid by the mile or by the day are full-time employees and receive the 
same benefits afforded other full-time workers. Is it the Senators' 
understanding that this bill is intended to allow these working groups 
to be encompassed in the definition of ``full-time employee'' for 
purposes of the employer incentives to provide quality health care 
coverage?
  Mr. HARKIN. Yes, that is my understanding, that the Secretaries of 
Health and Human Services and Labor will establish standards to govern 
workers in these industries so they are fully entitled to the 
protections under this bill. It is not the intent of Congress to 
exclude or prevent workers with unique work schedules from the benefits 
under the Patient Protection and Affordable Care Act or from incentives 
for employers to provide these workers with quality healthcare 
coverage.
  Mr. BAUCUS. Again, I am pleased to concur with the Senator from Iowa 
in his understanding. The Secretaries of Health and Human Services and 
Labor will establish standards to govern workers in these industries so 
they are fully entitled to the protections under this bill.
  Mrs. MURRAY. Mr. President, I would like to thank the Senators from 
Iowa and Montana for their time and clarification on this issue.
  Mr. DURBIN. The Patient Protection and Affordable Care Act offers 
community health workers some overdue recognition, and more 
importantly, authorizes grants to help support and expand their work.
  Community health workers are from the communities they serve. From 
rural small towns to the urban inner city, community health workers 
reach out to underserved communities in ways that the current health 
care system cannot, providing culturally and linguistically appropriate 
health information in a more familiar and welcoming manner. Their work 
helps to bridge the healthcare gap and diminish disparities.
  Nowhere is this more evident than in the community-based doula 
program. Community-based doulas support pregnant women during the 
months of pregnancy, birth, and the immediate post-partum period. They 
provide parent education, logistical and emotional support. They help 
new mothers make better lifestyle choices and deliver healthier babies. 
What makes these programs work is the culturally sensitive mentoring 
within the community.
  In Chicago, the community-doula model has made a big difference in 
the lives of these young moms and their babies. The Chicago Health 
Connection came up with this model. They trained mentors from the 
community to work with at-risk moms, many of whom didn't know where 
else to turn. These mentors spend time in the neighborhood, finding and 
befriending pregnant women who need help.
  With the guidance of the doula, the Chicago Health Connection found 
that more young mothers were going to their prenatal care appointments, 
making better lifestyle choices, and--not surprisingly--delivering 
healthier babies. The doulas stay with the moms through the early 
months, encouraging breastfeeding, cuddling, and interactive play.
  Bina Holland is a community-based doula at the Easter Seals 
Children's Development Center in Rockford, IL. Bina has had a powerful 
impact on one of her clients--a 14 year old girl who was 5 months 
pregnant and severely underweight. Bina taught her about healthy 
nutrition habits to strengthen her body to carry a baby. Bina also 
encouraged the young woman to visit her doctor regularly and to openly 
talk with the doctor about the health status of the baby.
  The girl delivered her baby early at 2.5 lbs, and Bina was there to 
explain the health benefits of breastfeeding. The young mom agreed to 
nurse her child, and each week the mother monitored the baby's growth. 
The child was nursed to health, and the mother successfully graduated 
from the doula program. Thanks to Bina.
  Community-based doulas are a powerful resource for maternal and child 
health, and the model is effective. In communities that have employed 
it, outcomes include better prenatal care, higher birth weight, higher 
breastfeeding rates, better parenting skills, fewer preterm births and 
c-section deliveries, and delays in subsequent pregnancy for teenages.
  With Chicago Health Connection's success, they took on the challenge 
of working with other communities to build their own community-based 
doula program. Today, they have transformed into Health Connect One, a 
training organization for communities nationwide interested in starting 
their own community based doula programs. The need is everywhere, and 
these women are working hard to make these important services available 
everywhere for all moms.
  I am encouraged by the language in Section 5313 of the Patient 
Protection and Affordable Care Act, Grants to Promote the Community 
Health Workforce and want to ensure that the definition of community 
health worker includes community-based doulas. The Federal Government 
currently funds community-based doula programs through the Maternal and 
Child Health Bureau's Special Projects of Regional and National 
Significance. Expanding the definition of community health workers in 
the reform bill will give these evidence-based programs greater support 
to meet the needs of families in underserved communities.
  Community-based doula programs are a proven example of the health 
outcomes that education, prevention and health literacy can bring. With 
grants to promote the community health

[[Page S13851]]

workforce, doulas will continue to promote positive health behaviors in 
pregnant women and improve the lives of families nationwide.
  Mr. FEINGOLD. Mr. President, I will vote for the comprehensive health 
reform bill being considered in the U.S. Senate, but I will also work 
to improve its flaws. There is much that is good about this 
legislation. It will, over the course of 10 years, help ensure that 
nearly every American has access to good and affordable health 
insurance. It will put Medicaid and Medicare spending on a more 
sustainable and stable path. It will increase access to home and 
community-based long term care services, increase our medical 
workforce, and end some of the worst abuses by the private insurance. 
But there are serious deficiencies--like the failure to establish a 
public health insurance option--that we know of, and there will be 
undoubtedly be some gaps in the bill that we will discover during 
implementation. The commitment that is made with this legislation is 
ongoing, and will require diligent oversight and improvements in the 
years to come.
  I am pleased that many of the priorities I laid out at the start of 
this process have been addressed in this bill. The bill includes 
provisions I fought for that help make sure Wisconsin is treated 
fairly. Those provisions include fixes to a flawed Medicare formula 
that denies our state fair reimbursement, financial incentives for the 
kind of low-cost, high-value care practiced in Wisconsin, and hundreds 
of millions of dollars in additional Medicaid assistance for Wisconsin 
to account for the State's leadership in expanding coverage to its 
citizens. But I also recognize that this bill does not do as much as I 
would like to reform our current health care system, and I will work to 
try to make sure the final version fixes these flaws.
  I receive countless letters and emails and phone calls from my 
constituents on health care reform. Some of the most heartbreaking 
letters I receive are from people who are sick or caring for a sick 
loved one and do not have health insurance. Some of these people are 
recently laid off due to the recession, and have lost their health 
insurance. Some people had health insurance, but were dropped from 
their coverage because they became sick and actually needed health 
care. And some people were denied health insurance altogether, either 
because it was priced out of their reach, or because they had a 
preexisting condition. In far too many cases, these people have been 
forced to declare bankruptcy because of their medical bills. Two thirds 
of all personal bankruptcy cases in the United States are due to 
medical debt, and over 80 percent of those individuals had health 
insurance. And in the most egregious cases, sick children in Wisconsin 
and around the country have reached lifetime limits on care that are 
set by an insurance bureaucrat, and are denied coverage for further 
medical treatment.
  Because of this bill, lifetime and annual limits on coverage will be 
prohibited. Premiums cannot increase due to medical needs or illness. 
Insurers cannot charge women more than men for the same insurance 
policy. Restricting or denying coverage based on preexisting conditions 
is prohibited for all Americans, beginning with children effective 6 
months after final passage of this bill. A recent study found that 36 
percent of currently uninsured adults were unable to get health 
insurance because of a preexisting condition. Preexisting conditions 
can be anything from serious, chronic diseases like diabetes or cancer 
to medical episodes like acne or even pregnancy. In nine States, being 
a victim of domestic violence can be a preexisting condition. This bill 
will end these consumer abuses.
  People will be guaranteed the ability to renew their health insurance 
year after year. If a claim is denied, policy holders have a guaranteed 
right to appeal. And group insurers are required to spend at least 85 
percent of every premium dollar on actual health care; if they are 
found to be spending less, they are required to refund the difference 
to the customer. This policy, along with others, will require an 
unprecedented level of transparency in the sale of health insurance 
policies.
  One of the strongest points of this bill for me, and perhaps one of 
the most underappreciated, is the commitment made to realign Medicare 
spending to reward our doctors and hospitals for the quality of care 
they provide to their patients, rather than the quantity of care. 
Moving to a value-based system is one of the single most effective ways 
to reduce health care spending and improve the quality of care. 
Wisconsin is a national leader in value-based delivery of health care. 
If every health care provider operated like those in Wisconsin, over 
$100 billion a year in taxpayer dollars could be saved. Just last year, 
the Congressional Budget Office estimated that nearly 30 percent of 
Medicare spending could be avoided by integrating and coordinating 
care, in the manner of high-value providers.
  As a result of this bill, Medicare reimbursement for certain health 
care providers will be based, in part, on the quality of care they 
deliver to their patients. Health providers will now have the 
opportunity to voluntarily join together as Accountable Care 
Organizations to coordinate the care they deliver to their patients, 
and to share in the savings they generate for Medicare. They will be 
given numerous opportunities and incentives to change the way they 
deliver health care, and will, for the first time, be penalized for 
delivering low-quality care. For example, if a hospital demonstrates 
high rates of readmissions or hospital acquired infections, they will 
receive less reimbursement from Medicare. Not only will patients 
receive smarter care from their physicians, these policies will help 
ensure that taxpayer dollars are going to pay for the value of care 
Medicare patients receive, as opposed to the volume of care.
  In addition to these positive changes to the way Medicare pays for 
health care, there is language to finally address the historic inequity 
in Medicare reimbursement that Wisconsin and other rural States have 
faced. Thanks to the leadership of Senator Chuck Grassley in the Senate 
Finance Committee, this bill includes language that will increase 
Medicare reimbursement for Wisconsin physicians and directs the 
Secretary of Health and Human Services to analyze and adjust the 
current formula to ensure more accurate payments for rural providers in 
the future. Fixing the flawed Medicare formula so that Wisconsin 
receives its fair share of Medicare reimbursements has long been a 
priority of mine.
  I am pleased that this bill more fairly reimburses Wisconsin for the 
leadership my state has demonstrated in extending coverage to low-
income residents through BadgerCare, our State Medicaid program. I was 
concerned that the Senate Finance Committee bill would have denied 
Wisconsin much-deserved Medicaid dollars, and I worked hard to try to 
ensure the bill before the Senate fixed this problem. As a result, 
relative to the bill that the Senate Finance Committee reported, this 
bill will bring hundreds of millions more in Medicaid assistance back 
to Wisconsin. I appreciate the willingness of my fellow Wisconsin 
Senator, Herb Kohl, the Chairman of the Finance Committee, Senator Max 
Baucus, and Senator Reid in working with me to ensure that Wisconsin's 
investment is acknowledged in this legislation.
  I am also pleased by the attention to long-term care reform in this 
bill. Modern medicine has turned fatal diseases into chronic diseases, 
and enabled individuals to live much longer. These are tremendous 
accomplishments. But the reality is that these individuals need even 
more assistance because of medical advancements--from their families, 
communities, and government.
  Long-term care reform is inextricably linked to overall health 
reform, and one cannot truly succeed without the other. While this bill 
does not include a comprehensive strategy to reform our long-term care 
system as I had hoped, it does include a number of critical building 
blocks to assist reform efforts in the future. One of these critical 
pieces is the Community Living Assistance Services and Supports Act, or 
CLASS Act. The CLASS Act would create an optional insurance program to 
help pay for home care and other assistance for adults who become 
disabled. Those choosing to participate would pay monthly premiums into 
an insurance trust, and after 5 years, could access a cash benefit if 
they become disabled and need assistance.
  Another critical component of this bill is the attention paid to 
expanding

[[Page S13852]]

home and community-based care options. Again, Wisconsin has been a 
national leader in increasing access to home and community-based care, 
beginning with the Community Options Program almost 30 years ago. As a 
State Senator, I worked to help expand Wisconsin's Community Options 
Program, known as COP, which provided flexible, consumer-oriented and 
consumer-directed long-term care services in community-based settings, 
enabling thousands of people needing long-term care to remain in their 
own homes rather than going to a nursing home. Over time, the COP 
program turned into Wisconsin's FamilyCare program, which is our newest 
State entitlement program for low-income and disabled adults to receive 
necessary care, supports, and services in their homes and communities.
  The progressive vision that is the driving force behind Family Care 
is also the driving force behind the long-term care provisions in this 
bill. This bill will establish the Community First Choice Option, which 
gives States the option to create a new Medicaid benefit through which 
States could offer community-based attendant services and supports to 
Medicaid beneficiaries with disabilities who would otherwise require 
the level of care offered in a hospital, nursing facility, or 
intermediate care facility.
  This bill also removes barriers to expanding home and community-based 
services; protects recipients of home and community-based services from 
spousal impoverishment; and increases appropriations by $40 million to 
help fund Aging and Disability Resource Centers.
  And finally, as a result of Senator Reid's amendment, the bill 
provides new financial incentives for States to shift Medicaid 
beneficiaries out of nursing homes and into home and community-based 
services.
  Over 10 million Americans are currently in need of long-term care, 
and that number is expected to rise to 15 million in the next 10 years. 
These individuals struggle to remain independent with limited 
assistance. Policies like those included in this bill, which increase 
options for home and community-based care so that nursing homes are not 
the only choice, are smart changes that will benefit consumers of long-
term care and save taxpayers money.
  One of my most important priorities for the bill was that it be 
fiscally responsible. Based on the most current projections, the 
Congressional Budget Office expects this legislation to reduce the 
deficit by $132 billion by 2019 and roughly $1 trillion by 2029. While 
the bill does not go as far as I would like to rein in health care 
spending, the $871 billion price tag on the bill is fully offset and 
will not add a penny to the deficit.
  Deficit reduction is achieved through a number of policies, three of 
which are included in legislation I introduced to bring down the 
deficit, the Control Spending Now Act. These policies, which make 
prescription drugs more affordable and require wealthy individuals to 
pay their fair share of Medicare premiums, generate $24.6 billion in 
savings.
  For all the positive aspects of this bill, I am deeply disappointed 
by the lack of a public option. I have been fighting all year for a 
strong public option to compete with the insurance industry and bring 
health care costs down. I continued that fight during recent 
negotiations, and I refused to sign onto a deal to drop the public 
option from the Senate bill.
  Removing the public option from the Senate bill is the wrong move. I 
am concerned that without a public option, there will be no true 
competition for the insurance industry. We have included mechanisms to 
protect against egregious year-to-year increases in private insurance 
premiums from this point on, but we have no mechanism to force 
insurance companies to decrease premiums as they are set today. A 
strong public health insurance option would provide a powerful 
incentive for less responsible insurers to re-evaluate their own cost-
sharing and benefit plans to ensure they are an attractive option for 
consumers.
  The public option would give consumers a strong voice in the 
marketplace. If the private market was not meeting their needs, they 
would have an alternative. Competition is how we can reduce our health 
care costs, but there is no real competition in the private market. 
Private insurers compete to generate the most profit, and the best 
return on investment for their shareholders. There is at most a 
secondary motivation to compete to give the best value to consumers. A 
public option serves as an outside factor to force private insurers to 
consider more than just shareholder interests.
  The Congressional Budget Office estimated that the public option in 
the bill that was brought to the floor could save up to $25 billion. 
The CBO's analysis of Senator Reid's amendment, which strikes the 
public option and replaces it with multi-state plans, says the 
following about the new policy:

       Whether insurers would be interested in offering such plans 
     is unclear, and establishing a nationwide plan comprising 
     only of nonprofit insurers might be particularly difficult. 
     Even if such plans were arranged, the insurers offering them 
     would probably have participated in the insurance exchanges 
     anyway, so the inclusion of this provision did not have a 
     significant effect on the estimates of federal costs or 
     enrollment in the exchanges.

  Removing the public option gives up a huge opportunity to reduce 
costs for American families and the government, and I will work to try 
to ensure the final bill fixes this serious mistake.
  I also am concerned about the excise tax on high cost health plans. 
Under this bill, health insurers will be taxed on the value of any 
health care plan sold that is valued above $8,500 for an individual and 
$23,000 for a family. Improvements have been made to this policy during 
Senate consideration, and the thresholds for the tax, along with 
exemptions for high-risk professions, have been expanded. But I have 
heard from so many in my State who have traded wage increases for solid 
health insurance benefits in the past years. I have heard from teachers 
and laborers and union members who are worried they may lose the health 
benefits they have fought for, and can't reclaim the wages they have 
already lost. While this policy is often referred to as the 
``Cadillac'' health care tax, they will be the first to tell you that 
they hardly live the Cadillac lifestyle. I urge my colleagues in the 
Senate and the House to consider the real-life impact that this policy 
could have on working Americans and their families.
  I am concerned about the cuts to home health and hospice providers 
under this bill. Home health and hospice providers offer a truly 
valuable service to our communities. But under this bill, their 
reimbursements will be drastically cut and I am concerned that access 
will decrease as a result. Improvements have been made under Senator 
Reid's amendment, but we must do better for home health and hospice 
providers.
  I am disappointed that the bill does not permit the safe importation 
of prescription drugs, which would reduce health care spending for 
consumers and the Federal Government. I will keep fighting to enact 
this common-sense reform.
  Lastly, I oppose the sweetheart deals that some Senators and interest 
groups apparently cut. These deals weaken the bill by subsidizing 
States or interest groups at taxpayer expense. They are unjustified, 
and they should be eliminated.
  Mr. WYDEN. Mr. President, the Patient Protection and Affordable Care 
Act is a fundamental first step toward providing all Americans with 
affordable, quality health care. The health care system is complex, and 
that is why this Senate and two of its committees, including the Senate 
Finance Committee of which I am a member, have taken the better part of 
this past year crafting this legislation. I believe several provisions 
of this bill are transformational for American health care and will 
begin to move America toward more competition, choice, and quality.
  The first provision is in the managers' amendment, and it is called 
free choice vouchers. This section creates something that has never 
existed before in the American health care system: a concrete way for 
middle-income Americans who cannot afford their health care to actually 
push back against the insurance lobby and force insurance companies to 
compete for their business in the insurance exchanges. Unlike today, 
where if a hard-working, middle-class American can't afford just the 
one health insurance policy available to him at his job, with

[[Page S13853]]

this new provision, there will be a different health care marketplace, 
with free enterprise choices that can actually drive down costs for the 
middle class while ensuring those choices are of good quality. And in 
that new marketplace, a worker who cannot afford his employer's health 
plan can get a tax-free voucher for the same amount the employer 
contributes under the health plan and use that voucher to buy a more 
affordable plan in the insurance exchange.
  I have been an advocate for consumer empowerment and choice my entire 
career in public service. Exchanges are a new pathway to creating a 
competitive marketplace for the first time for health care in this 
country. Massachusetts led the way, opening the door to showing Federal 
legislators the potential for insurance exchanges when Massachusetts 
enacted its own health reform law. Many other States lead the way with 
innovation in health care, including States like Oregon and Vermont. 
That is why I have authored and championed in the Senate Finance 
Committee section 1332, the waiver for State innovation. If States 
think they can do health reform better than under this bill, and they 
cover the same number of people with the same comprehensive coverage, 
they can get a waiver exempting them from the legislation and still get 
the Federal money that would have been provided under the bill. To me, 
this provision is a safety valve, if certain provisions in this bill 
will not work as intended in a given State. This provision will give 
States a way to tailor health reform to best meet the needs of their 
citizens. I intend to work with Senator Sanders and other colleagues to 
make sure that State waivers will be available even sooner than they 
are under the current bill.
  The waiver for State innovation and free choice vouchers will improve 
the number of choices in the bill, for states, for employers and for 
employees. The Patient Protection and Affordable Care Act will also 
increase quality of care, particularly in the Medicare Program. I 
worked in the Finance Committee to increase bonus payments to high 
quality plans in the Medicare Advantage Program. In Oregon, Medicare 
Advantage is a lifeline given the low traditional Medicare 
reimbursement rates in the State. This amendment will reward the high 
quality plans that exist in Oregon, but will also encourage other plans 
across the country to increase the quality of the care they provide. By 
boosting payments to the highest quality plans--the four and five star 
plans--the Federal Government will be incentivizing plans that provide 
preventive care, manage chronic diseases well, and have high levels of 
consumer satisfaction.
  Another provision that will add quality to the Medicare Program is 
Independence at Home, IAH, section 3024 of the bill, that I won 
approval for in the Finance Committee. This provision stems from 
legislation that I introduced with 11 other Members on both sides of 
the aisle. As the name indicates, the Independence at Home program will 
provide a way for seniors with chronic medical conditions to get 
medical treatment at home. The IAH program is based on a house call 
team approach that has proven successful in reducing costs and 
improving the quality of care for high cost patients with multiple 
chronic illnesses, patients who account for 66 percent--85 percent of 
Medicare spending. The Independence at Home program requires providers 
to achieve minimum savings on health care provided to the highest cost 
Medicare beneficiaries as a condition of participating in the program.
  Providing care at home makes sense, and is the right direction for 
the future of health care delivery. But there is another aspect of the 
future of health care that I think holds much promise: personalized 
medicine. I won approval in the Finance Committee, along with Senator 
Carper, for including section 3113 in the bill. This provision will 
increase access to innovative molecular diagnostic tests that provide 
the foundation for the application of personalized medicine for 
individuals suffering from life threatening diseases such as cancer and 
heart disease. These tests hold the promise of getting patients the 
right type of chemotherapy for their specific case of cancer. 
Personalized medicine is the future, and I am thrilled that the Patient 
Protection and Affordable Care Act takes steps to move toward 21st 
century medicine.
  I have spent the better part of my career trying to make the health 
care marketplace more competitive and trying to improve the quality of 
care for all Americans. I take many lessons from my home State of 
Oregon, and have tried to apply the innovation that Oregon is known for 
as an example for how other States can provide higher quality care at a 
lower cost. Through free choice vouchers, State waivers, Medicare 
Advantage bonus payments, Independence at Home, and personalized 
medicine, I believe this bill improves competition, choice and quality 
across the entire country.
  Mr. INOUYE. Mr. President, I am pleased that this bill will extend 
basic health care to more than 30 million Americans who were previously 
unable to afford the costs associated with seeing a medical 
professional. Not since former President Harry S. Truman enrolled as 
Medicare's first participant in July of 1965 has our health care system 
undergone such a complete overhaul. The reform brought about by this 
bill is needed and long overdue. For too long millions of Americans 
have struggled to see health professionals while health insurance 
providers have raised premiums and executives have reaped multimillion-
dollar bonuses. That is no longer the case. This bill also ensures that 
Hawaii, a State long ahead of the curve in terms of providing health 
insurance and affordable access to medical professionals, maintains its 
high level of health care while expanding the reach of existing Federal 
programs. The State Prepaid Health Care Act of 1975 ensures that every 
employee in Hawaii working at least 20 hours a week receive health 
insurance from their employer. Hawaii received an exemption to ensure 
Hawaii's employer mandated health care law would not be rolled back. 
The health care reform bill also includes tremendous cost savings and 
subsidy incentives for the State. Hawaii is one of two States in the 
country who are not permanently enrolled in the Federal 
disproportionate share hospital, DSH, program which reimburses 
hospitals that care for the uninsured. Currently Hawaii's temporary 
enrollment expires in 2012 but the new bill will make DSH permanent 
resulting in more than $100 million for Hawaii's health care industry 
over the next 10 years. I am also pleased that we were able to include 
the reauthorization of the Wakefield Pediatric-Emergency Medical 
Services for Children program, at the suggestion of my two colleagues 
from North Dakota, Senator Kent Conrad and Senator Byron Dorgan. This 
program works to ensure that emergency rooms across the country are 
equipped with the resources necessary to treat young children. A 
civilized, democratic society like ours should help maintain the health 
and welfare of all our citizens. No one should be denied medical care 
or lose coverage because they can't afford to pay to see a medical 
professional. Like that July afternoon in 1965 when President Lyndon 
Johnson signed Medicare into law I am especially pleased to see that 
our great Nation once again has recognized and worked to meet the basic 
needs of our citizens.
  Mr. LEVIN. Mr. President, at a handful of moments, Members of the 
U.S. Senate have faced choices that could fairly be described as 
historic. Each of these choices was between progress--sometimes 
incomplete progress--and an intolerable status quo. In our finest 
hours, we have overcome fear and doubt and stood for the principle that 
our Nation, though great, could aspire to do better. When our ambition 
has weakened, we have taken the timid path. That is an easier journey 
and less laden with fear or political peril, but it has not served our 
own time well or passed the test of history.
  We have come to another of those times. We can vote, now, to address 
decades of frustration and anguish over a health care system most 
Americans know is broken. Or we can destroy the hopes of millions of 
Americans whose modest ambition is not a perfect system, but an 
improved one. We cannot vote to end every problem in health care; this 
bill will not do that. But we can make life safer, more secure, less 
costly, for most Americans, because we can give them a better health 
care system.
  Briefly, here is some of what this legislation will accomplish:

[[Page S13854]]

  People with preexisting conditions who are currently left out of the 
system will be able to get access to health care in the future. Within 
6 months of enactment, this legislation will allow those not covered at 
work and who are unable to find insurance in the individual market 
because of preexisting conditions to buy a plan that will remain in 
place if they get sick. And it will offer free preventive services and 
immunizations.
  This bill has provisions to help strengthen Medicare by giving 
seniors access to important preventive services that they may otherwise 
not be able to afford. And also for seniors, this bill reduces the 
Medicare doughnut hole, a gap in prescription drug coverage that I hope 
we are able to eventually close altogether.
  After 2014, new plans will be barred from imposing annual limits on 
coverage, and sliding tax credits will be available to make insurance 
more affordable for those earning below $88,000 for a family of four, 
or earning below $43,000 for an individual. The credits that will be 
offered to make coverage more affordable will bring millions of 
Americans under the umbrella of health insurance, an important 
improvement for those families now without insurance and a step toward 
reducing burdens and inefficiencies that make health care more 
expensive for all of us. State-based exchanges will offer those seeking 
individual coverage both the purchasing power of belonging to a larger 
group, and a transparent marketplace in which benefits are standardized 
and costs are clear.
  The bill also helps small businesses that are struggling to get a 
handle on ever-increasing health care insurance costs. Beginning in 
2010, small businesses will receive a tax credit of up to 35 percent of 
their costs for insuring their employees and their employees' families. 
In 2014 and beyond, the tax credit can be as much as 50 percent of an 
employer's costs for covering employees. These credits will encourage 
these employers, which are the backbone of our economy, to provide 
health care insurance coverage.
  The bill also includes some major insurance company reforms. 
Beginning in 2011, plans that do not spend a high percentage of their 
revenue for patient care--85 percent of revenue for large-group 
programs, and 80 percent in the individual and small-group market--will 
have to provide rebates to their enrollees.
  One of the benefits of this new requirement on insurance companies is 
reversing the troublesome trend that has seen more and more of our 
health care dollars spent on administration. Since 1970, the number of 
administrative positions in our health care system has increased by 
nearly 3,000 percent, far outstripping the growth in the number of 
physicians over the same period. It is long past time to ensure that we 
are spending precious health care dollars on care and not on paperwork 
and bureaucracy. Hospitals will become more transparent as well--every 
hospital in the Nation will publish a list of standard charges for the 
items and services it provides.
  The bill includes incentives to boost the availability of primary 
care, including financial incentives under Medicare to increase the 
number of primary care physicians. And it also promotes standardizing 
health information technology in an effort to reduce costly 
administrative overhead.
  This is not everything I hoped for. But it is what we can get done. 
It is what we should do.
  The minority has offered no alternatives, just apocalyptic rhetoric. 
Some of them stood before rallies, leading chants about socialism. They 
claimed it is a big government takeover. ``Kill the bill'' was their 
slogan. Before television cameras our efforts to produce reform were 
compared to the activities of financial fraudsters like Bernie Madoff.
  For those familiar with the facts, these notions are rightly seen as 
falsehoods. One of these falsehoods--the notion that health care reform 
would mean ``death panels'' voting to end the lives of senior 
citizens--has just been named by an independent fact-checking 
organization its ``Lie of the Year.'' That's quite a distinction. When 
discussing the scare tactics being used by opponents of health reform, 
the policy director of AARP said, ``The opponents of health reform have 
targeted (seniors) and have . . . misrepresented the facts, and have 
consciously tried to scare seniors who depend on health care. So no 
surprise that they feel anxious, because they're hearing messages every 
day designed to scare the bejesus out of them.''
  The extreme rhetoric of the minority is a repeat of similar rhetoric 
which was used when Social Security and Medicare were being considered 
by the Congress.
  In 1935, as Social Security was being debated, one Republican warned 
the program would ``enslave workers,'' and another declared ``the lash 
of the dictator will be felt'' if it passed. Three decades later, as 
the Congress debated the Medicare Program, one Republican Member of 
Congress said, ``Let me tell you here and now, it is socialized 
medicine.'' A future Republican President of the United States warned 
that if Medicare passed, ``you and I are going to spend our sunset 
years telling our children and our children's children what it was like 
in America when men were free.''
  Incredibly, the same Republican Party that once equated Medicare with 
socialism would now have the public believe they are defending Medicare 
from the threat of socialism. The mental gymnastics this requires is 
breathtaking. If this bill is such a threat to seniors, why does AARP 
support its passage? If it will destroy our health care system, why do 
so many of the groups that know health care first-hand, from the 
American Medical Association to the American Heart Association to the 
American Cancer Society, and dozens of others support passage of this 
bill? If this bill will explode the deficit, why does the nonpartisan 
Congressional Budget Office tell us it will reduce the deficit by $132 
billion over the first decade after enactment, and up to $1.3 trillion 
in the second?
  Are all these organizations, the nonpartisan CBO, independent fact-
checkers, scores of economists and health care experts--are they all 
engaged in a conspiracy to engineer a socialist government takeover of 
medicine? I am afraid that some of our Republican colleagues have 
latched onto any argument at hand to justify their opposition to health 
care reform.
  Let me ask one final question: What do opponents say to our 
constituents who speak to us every day of their belief that the time 
for health reform has come? That today is not the time? The man from 
Kalamazoo, MI, who went bankrupt because his health insurance would not 
cover $40,000 in costs for a life-saving heart operation--will they 
tell him this is not the time? The woman from Jackson, Michigan, who 
spent months fighting to get coverage because insurance companies 
considered her pregnancy a preexisting condition--will they tell her 
this is not the time? The worried mother who wrote my office to say, 
``We will lose too many bright young people--if something is not 
done''--will they tell her this is not the time?
  No, this is the time. Now is the time to embrace the same call of 
history that led our predecessors to ignore the apocalyptic rhetoric 
and establish Social Security and Medicare. We must pass this bill, so 
that generations after us do not look back on a broken health care 
system and say, ``Here was another lost moment when it could all have 
changed.'' We must pass this bill. Now is the time. Just as we are 
ploughing the roads of record snow to get to work, our work now is to 
plough through the endless filibusters to get our job done.
  Mr. REID. On behalf of Senator Baucus, Senator Dodd, and myself, I 
submit this statement under the spirit of rule XLIV of the Standing 
Rules of the Senate. We hereby certify that, to the best of our 
knowledge and belief, the managers' amendment to the substitute 
amendment to H.R. 3590 does not contain any congressionally directed 
spending item as defined in rule XLIV.
  Rule XLIV defines a congressionally directed spending item as ``a 
provision or report language included primarily at the request of a 
Senator providing, authorizing, or recommending a specific amount of 
discretionary budget authority, credit authority, or other spending 
authority for a contract, loan, loan guarantee, grant, loan authority, 
or other expenditure with or to an entity, or targeted to a specific 
State, locality or Congressional district, other than through a 
statutory

[[Page S13855]]

or administrative formula-driven or competitive award process.'' To the 
best of our belief, no item meets this definition. There are numerous 
items that affect one or more States or localities differently than 
others, but none of these meet the definition because of one or more of 
the following reasons--(A) no specific amount is associated with the 
provision, (B) the provision involves distribution through ``a 
statutory . . . formula-driven . . . or competitive award process'' or 
(C) the criteria are such that more than one State or locality will or 
may benefit. It is quite common in legislation for formulas and 
programs to make adjustments to affect State- or locality-specific 
needs.
  The rule defines a ``limited tax benefit'' as ``any revenue provision 
that (A) provides a Federal tax deduction, credit, exclusion, or 
preference to a particular beneficiary or limited group of 
beneficiaries under the Internal Revenue Code of 1986; and (B) contains 
eligibility criteria that are not uniform in application with respect 
to potential beneficiaries of such provision.''
  Section 10905 provides exceptions to the annual fee on health 
insurance providers for certain insurers. One of these exceptions is 
provided to any entity that meets the following criteria--a mutual 
insurance company with market share in a State for 2008 between 40 
percent and 60 percent and whose medical loss ratio for all markets--
individual, small group and large group--in 2008 was 90 percent or 
higher. The performance-based exception is available if the entity has 
an average medical loss ratio for years after 2011 for the previous 3 
years for all markets of 89 percent or higher--prior year for 2012 fee 
and prior two years for 2013 fee. It may be argued that this provision 
could be considered a ``limited tax benefit'' as defined in rule XLIV; 
at the same time, the Joint Committee of Taxation has indicated that 
the universe of potential beneficiaries depends in part on how 
``medical loss ratio'' is ultimately determined under the statute. In 
the interest of transparency, the provision was included at the request 
of Senator Ben Nelson so that nonprofit Blue Cross Blue Shield of 
Nebraska would not be excluded from the exemption of nonprofit insurers 
from the fee. In keeping with the spirit of rule XLIV, Senator Nelson 
has provided Senator Baucus with a certification that neither he nor 
his family has a financial interest in the provision.
  Mr. President, I ask unanimous consent to have printed in the Record 
the letter from Senator Nelson of Nebraska dated December 21, 2009.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                                  U.S. Senate,

                                Washington, DC, December 21, 2009.
     Chairman Max Baucus,
     Ranking Member Charles Grassley,
     U.S. Senate Committee on Finance, Dirksen Senate Office 
         Building, Washington, DC.
       Dear Chairman Baucus and Ranking Member Grassley: 
     Consistent with the provisions of Rule XLIV of the Standing 
     Rules of the Senate, I am submitting this letter with regard 
     to Section 10905 of Senate Amendment 3276.
       Section 10905 of the amendment creates a limited exemption 
     from the annual fee on health insurance providers established 
     by Section 9010 of Amendment No. 2786 to H.R. 3590, the 
     Patient Protection and Affordable Care Act of 2009. The 
     exemption from the fee is created for certain non-profit 
     insurers with a high medical loss ratio. Among other 
     exemptions provided for under this section, an exemption from 
     the fee is available to any entity which is a non-profit 
     mutual insurance company with market share in a State for 
     2008 between 40% and 60% and whose medical loss ratio for all 
     markets (individual, small group, and large group) in 2008 
     was 90% or higher. The exception is available only if the 
     entity has an average medical loss ratio for years after 2011 
     for the previous three years for all markets of 89% or higher 
     (prior year for 2012 fee and prior two years for 2013 fee).
       This provision could be considered a ``limited tax 
     benefit'' as defined in Rule XLIV, and I anticipate that Blue 
     Cross Blue Shield of Nebraska may benefit from this 
     provision, provided that that they maintain the high medical 
     loss ratio called for under the provision. My purpose for 
     requesting this provision was so that Nebraska's sole non-
     profit insurer would not be excluded from the exceptions to 
     the insurance fee as set forth in Section 10905.
       Consistent with the requirements of paragraph 9 of Rule 
     XLIV, neither I nor my immediate family have any pecuniary 
     interest in this item.
           Sincerely,
                                               E. Benjamin Nelson.

  Mr. REID. Mr. President, as we finish this session, there are many 
people who have worked to get us to this point. From the staff in the 
Senate to the Capitol Police, many employees have given their time to 
make sure that the Senate could complete its work on health care.
  In particular, I would like to recognize the work of the employees of 
the Government Printing Office, GPO. Each day, the GPO works with the 
Secretary of the Senate to meet the needs of the Senate and we 
appreciate their efforts. Nearly all of the documents we have used for 
the health care debate have been printed and delivered by the employees 
of the GPO.
  This past weekend, when the heavy snow blanketed the city and shut 
down most government agencies and operations, the men and women of the 
GPO came to work and remained at their posts. Some GPO employees spent 
the night to ensure that the Senate was able to get the documents we 
needed. Their performance throughout the health care debate was 
commendable and I would like to ask my colleagues to join me in 
thanking the GPO for a job well done.
  The PRESIDING OFFICER. The Senator from Idaho is recognized.
  Mr. CRAPO. Mr. President, as we approach the vote tomorrow morning, I 
know a lot of people are calling it a historic vote. In some contexts, 
I guess it is. However, many of us are concerned it is a historic 
mistake rather than a history-making opportunity.
  We have had a lot of debate about whether this legislation is the 
right or wrong way to improve health care for all Americans. We have 
had hours and hours, in fact, days and weeks of committee hearings and 
meetings with good bipartisan discussion on options and ways to 
accomplish this. But now, apparently, we have a mandate by the majority 
demanding we have a final vote in the Senate before Christmas.
  While we debate this, let me say I believe we need to hear more from 
the people who are going to be most affected, the American people, 
because the final details of this bill were not crafted in front of the 
American public. I think most people in America know the President 
pledged that this legislation would be crafted around a table that is 
public, where, in fact, he said C-SPAN cameras could be present--in his 
words: So people could see the deals people were making and who was 
working for the American people and who was cutting deals.
  The C-SPAN camera was not present, the table was not open, the room 
was closed, and the bill was negotiated in secret. But we are starting 
to find out what the deals were, and the deals are outraging the 
American people as they see specific exemptions from certain burdens in 
the bill being given to certain States in order to get the votes from 
the Senators for those States.
  We heard about different proposals dealing with the State of 
Louisiana, the State of Florida, the State of Connecticut, the State of 
Nebraska, and the list is growing as we have an opportunity to deeply 
delve into the bill and determine exactly what is in it.
  But we will not have time to know all the details of these deals. We 
will not have time to even know all the details of how the bill works 
because this 2,700-page bill, 400 pages of which were only disclosed 
last Saturday, will be voted on at 7 o'clock in the morning.
  Three days ago, I asked Idahoans who, similar to most Americans--in 
fact, all Americans--want health care reform, to sign a petition on the 
Internet asking the Senate to:

       . . . defeat H.R. 3590 . . . because we need reform that 
     will lower costs while increasing quality . . . and keeping 
     health care decisions between a patient and their doctor.

  The response to this request has been remarkable. In fact, I suspect 
that, as I am speaking, we have already gotten over 20,000 signatures 
on the petition on the Internet. I asked people to go to my Internet 
site, mikecrapo.com, and simply sign the petition. Here is a partial 
stack. We are still printing out the rest of the names of the people 
who signed the petition, but somewhere between 19,000 and 20,000--and 
growing--people signed the petition.
  Here is the remarkable thing about it. When I asked the people of 
Idaho to sign this petition, I asked them to do two things. I asked 
them, first, to go to the Web site and sign the petition. Then, second, 
I asked them to contact everyone within their circle of influence--
people on their Christmas card list, people on their e-mail contacts

[[Page S13856]]

list, people on their Facebook, their Facebook friends, everyone who is 
within their circle of influence--and ask them to also sign the 
petition and, if they didn't live in Idaho, to contact their Senator 
and encourage their Senator to oppose this legislation, if they agreed 
with me that it is not the path our Nation should follow.
  Remarkably, more than half the people who have so far signed the 
petition did not get that information from me. They got the request or 
encouragement to sign the petition from the friend or relative. A huge 
proportion of them do not live in Idaho. In fact, we have had people 
from all over America, in every one of the 50 States, sign this 
petition.
  Why is this happening? By the way, the number is growing. It is 
happening because the more Americans know about this bill, the more 
they know it is not the path they want us to take for health care 
reform. Health care is personal, private, and a sensitive matter among 
individuals and their doctors and their family. This bill makes health 
care a public policy decision controlled by a government bureaucracy. 
Americans don't want that kind of government control over our health 
care economy. Yet instead Americans see an administration and a 
congressional majority forcing this bill down their throats in a rush 
to pass it before public opposition legitimately overwhelms this 
wrongheaded monstrosity. Thousands are signing this petition because 
they desperately want Congress to listen, but they know that their 
collective voice has been ignored. The petition is one way they can 
make themselves heard in hopes that this Congress will pass needed and 
sensible reform but not this bill.
  In fact, another point about this petition is in addition to getting 
on the Web site and signing the petition, I have individuals calling my 
offices and saying: Thank you for giving us an avenue to try to reach 
out to the Senate and tell the Senate to stop. I think thousands of 
Idahoans and people from all over America are eager to have an avenue 
to speak out, and we need to stop and listen. I thank the thousands of 
Idahoans and Americans across the country for being willing to get 
involved as citizens and petition their government to respect our 
rights and to honor our values and to reform health care sensibly. The 
national polls indicate people oppose this bill. They want commonsense, 
lower cost action that will reduce the cost of premiums and doctor 
visits.
  This legislation instead raises taxes on the middle class, increases 
premium costs for many people now carrying insurance, cuts senior 
programs, and fails to lower health care costs. Simply put, there has 
not been a piece of legislation this decade that has come forward to 
meet more opposition than this health care reform bill. The more 
Idahoans and Americans know about the bill, the more they dislike it. 
Health care is a personal, private, and sensitive matter, and this bill 
goes the opposite direction. But the majority is moving full steam 
ahead in hope that they can pass it before the public can understand 
what it is and register their opposition. If we will take the time, we 
can improve the health care system--without the tax increases, without 
the massive increase in the growth of government, without the 
porkbarrel spending and the sweetheart deals, without the Medicare cuts 
and the unconstitutional burdens on State governments this bill 
presents.
  Among the steps many of us are trying to see enacted are things such 
as allowing insurance companies to compete across State lines, allowing 
small businesses to band together to negotiate group rates for 
insurance, requiring pricing disclosures from health care providers to 
promote a competitive, consumer-driven health care market, and offering 
incentives for patients and the private sector to create wellness 
programs and other efficiencies in health care delivery. In fact, when 
a bill similar to this was presented as the Republican alternative in 
the House, with the provisions the House Republicans proposed, it was 
scored, contrary to the bill we will be voting on, by CBO that it would 
actually reduce the cost of health care in America by significant 
percentages. Yet we are now continuing to plow full steam ahead with a 
vote at 7 o'clock in the morning on a bill that will increase the cost 
of health care.
  The petition I brought forward asks Congress to listen. It registers 
the fears of many Americans that they are being ignored by the 
administration and by the majority in Congress. I am going to continue 
to aggressively push for their wishes on the floor of the Senate.
  I wish to take an opportunity now to go ahead and get into a little 
bit more of the detail we do know about this bill. Why do I say it is 
the wrong direction for America? To start, let's ask what Americans 
want in health care reform. If you asked most Americans--and there have 
actually been a number of polls that have shown this--do they want 
health care reform, they say yes. When they are asked what they mean by 
that and what they want, the overwhelming answer is that they want to 
stop the skyrocketing increases in the cost of their health care 
insurance, they want to control the skyrocketing increases in the cost 
of medical care. They also say they want to see increased access for 
those who don't now have access to quality insurance, both because they 
are compassionate and want to see that kind of health care for everyone 
and because they know they are paying for it in their insurance 
premiums, for those who have insurance, and in their taxes, those who 
pay taxes. They want to assure that we continue to have the highest 
quality of health care possible. That is what we are supposed to be 
doing. That is what this bill should be working on. That is the 
objective we should be achieving.
  Yet what are we achieving? In an earlier discussion of the House 
bill, I believe the Wall Street Journal said it was the worst bill 
ever. We now have a different bill in the Senate, but it is still falls 
into the same category. Why? Because it drives up the cost of health 
care. It raises taxes by hundreds of billions of dollars. It cuts 
Medicare by hundreds of billions of dollars. It grows the government by 
$2.5 trillion. It forces the needy uninsured not into a program where 
most of them can get insurance but into a failing and less robust 
medical system, Medicaid. It imposes damaging unfunded mandates on our 
State governments that are already sharing the burden of Medicaid and 
facing difficult troubled economic times. It means increased taxes not 
just at the Federal level but at the State level with unfunded 
mandates. It leaves millions of Americans uninsured, and it establishes 
massive government controls over our health care economy.
  Let me go through a few of those to give more specifics. First, I 
don't think most Americans, when they talk about health care reform, 
think that means we need to grow the size of our government by $2.5 
trillion. Although there is some smoke and mirrors in the way this bill 
is put together, because the first 4 years of its costs are not started 
until 4 years into the bill, so when you try to count the first 10 
years, you only see a smaller number, when you take the first true 10 
years of spending in this bill, it increases the cost of this 
government's health care expenditures by $2.5 trillion. As we can see 
on this chart, look at the first 4 years. The spending is basically 
deferred. Why would that happen? I will explain that when I talk about 
deficit issues. But what it does is hide the true cost of the bill. If 
you measure the true cost of the bill in the first full 10 years of 
spending, it is $2.5 trillion rather than the $1.2 trillion it would be 
if you counted it otherwise.
  What we see is a massive growth of the Federal Government. That is 
not what people were asking for and, frankly, it makes them kind of do 
a doubletake when you explain to them that we are increasing the size 
of our government by such massive amounts with health care reform. 
Those proposing that we adopt this bill often say: Our objective and 
what the American people want is to drive the cost curve down. I often 
ask, what cost curve are they talking about? If they are talking about 
the cost of health care or the cost of health care premiums, they are 
going up. If they are talking about the size of the Federal Government 
and the level of Federal Government spending, that is going up.
  There is one that they talk about. It is called the deficit. That is 
whether we are spending more than we are taxing and cutting. They argue 
that the deficit is going down. There is only one way you can argue 
that this bill does not increase the deficit, and that is if

[[Page S13857]]

you assume that we don't have nearly $\1/2\ trillion of Medicare cuts, 
that we don't have $\1/2\ trillion worth of taxes in the first year and 
$1.28 trillion of taxes in the first full 10 years of implementation 
and that we don't have several budget gimmicks.
  What are the gimmicks? The first and biggest is the one I showed on 
the previous chart. They don't count the first 4 years of spending. 
They stop the spending and don't let it start happening for 4 years so 
that we have 10 years of taxes, 10 years of Medicare cuts, and 6 years 
of spending. When you balance that out, you can claim it doesn't 
increase the deficit because you don't have a full 10 years of 
spending.
  There are other budget gimmicks. We have something called the SGR 
fix, the adjustments in compensation rates for physicians that we all 
know on both sides we must do. We must keep the physician compensation 
comparable and moving up with inflation. That is going to cost $245 
billion, approximately, over the next 10 years. That $245 billion cost 
to reform and adjust the Medicare compensation system is absent from 
the bill. Why? Because they are going to do it in a separate bill and 
probably not pay for it; in other words, not have offsets. We will see 
whether they have offsets, but it is not in this bill. If it were, it 
would drive the deficit numbers by $245 billion in the wrong direction.
  There are other types of gimmicks. For example, there is double 
counting of the Medicare cuts. The CBO came out with a report today 
that said that if you cut Medicare by $465 billion, claiming that you 
are going to use that $465 billion to help make the financial situation 
for Medicare more stable, you can't then take that same $465 billion 
and use it to establish a massive new government program, yet a third 
major government health care entitlement system. You can't spend it on 
a new one and claim you are saving one that is already facing fiscal 
collapse. It is these kinds of budget gimmicks that make many of us 
object to the bill. If you didn't have those budget gimmicks, if you 
didn't have those tax increases, if you didn't have those Medicare 
cuts, there is no way you could say this bill is deficit neutral.
  One of the things CBO does report--I want to move to the question of 
the cost of insurance--is that the premiums in the individual market 
will go up, not down. What does that mean? CBO breaks the insurance 
market into three categories: the individual market, the small group 
market, and the large group market. The individual market is the one 
that is primarily there for small businesses that don't have a large or 
a small group opportunity or individuals who don't get their insurance 
through their employer. It represents about 17 percent or almost 1 in 5 
of all insured people in the country. Their insurance rates under this 
bill--17 percent of all Americans--are going to go up. The amount by 
which they will go up is about 10 to 13 percent, according to CBO.
  The next group is the small group market. They represent about 
another 13 percent. Again, CBO says under this bill their rates are 
going to go up, not quite as badly, between 1 and 3 percent, but up, 
not down.
  That brings us to the large group market. The large group market 
actually fares a little better. This is the remaining 70 percent of 
those insured in the United States. Basically, the CBO report says that 
for them there is a chance theirs may go down by a percent or two, but 
basically, it could be stable, a zero-percent change as well. Because 
individuals in the large group market, those who get their insurance 
from larger employers, have less liability of a harmful impact because 
they have that large group that can continue to negotiate to control 
their health care costs.
  So what do we see? Even under the best scenario--and there have been 
nine or ten studies of this and the CBO report is the one that is the 
most favorable toward the bill; most of the other reports have said 
that the rates are going to go up for everybody--but even if we take 
CBO's numbers, 30 percent of the people will see their insurance rates 
go up, not down. The other 70 percent can expect basically the status 
quo; in other words, not any change at all, maybe a slight decrease.
  Is that what Americans were asking for robust health care reform 
system? No. Americans are asking for true, solid, significant control 
of the cost of their premiums and their health care costs.
  I wish to move next to the question of taxes. This bill increases 
taxes by about $\1/2\ trillion. The President has pledged he wouldn't 
sign a bill that involved tax increases on the middle class. He defined 
the middle class to be people who as individuals make less than 
$200,000 a year or as a family or a couple making less than $250,000 a 
year. Here is the President's pledge:

       I can make a firm pledge. No family making less than 
     $250,000 will see their taxes increase.

  He was pushed on this pledge and he clarified it. He said not your 
income taxes, not your payroll taxes, not your capital gains taxes, not 
any of your taxes. You will not see any of your taxes increase one 
single dime.
  That is the President's pledge. But what do we have? In the first 10 
years, $493 billion in new taxes. The question is: Do those taxes all 
fall on the so-called wealthy, those making more than $250,000? Well, 
CBO and the Joint Tax Committee have analyzed it, and the answer is 
clearly no.
  But before I get to that, let's see what the taxes do in the first 
full 10 years of implementation. Remember, the first 4 years are kind 
of a slow start with the spending, but if you compare the taxes and the 
spending, count the total amount of taxes starting on the day when the 
spending kicks into gear, it is not $493 billion, or whatever the 
number was, it is $1.28 trillion in new taxes. That is not what the 
American people are asking for.
  The next question you might ask yourself is: OK, how much of those 
taxes are going to be paid by people who the President pledged would 
not be hit? Well, the Joint Tax Committee has analyzed the bill, and by 
2019--and the reason they use the year 2019 is that is the end of the 
first full 10 years of implementation--by the year 2019, at least 73 
million American households earning below $200,000 will face a tax 
increase. That is not just people making $200,000, that is everybody 
who pays taxes who makes any kind of income less than $200,000 in 
America. Seventy-three million--not individuals--households will pay 
taxes under this bill.
  One of the things that is interesting, in response to this argument, 
some of my colleagues on the other side have said: Wait a minute. That 
is not true. This bill is actually a tax cut. Wait a minute, you have 
me saying this bill increases taxes and someone on the other side 
saying this bill cuts taxes. How could that be?
  Well, there is a subsidy in this bill for those who are at lower 
income categories and are provided government dollars or subsidies in 
order to purchase insurance--the ones who are fortunate enough not to 
have been pushed into the Medicaid system. That subsidy is about $400 
billion or $500 billion in the bill, and it is administered by the IRS, 
so it is claimed to be a tax cut. If you offset that subsidy against 
tax increases in other parts of the bill, then you can say: Well, there 
is a tax cut in this bill.
  First of all, that is not what the President said. The President did 
not say: I will not increase your taxes more than I will cut somebody 
else's taxes. That is not what he said. What he said was: Your taxes 
will not go up if you are making under $250,000 as a couple or $200,000 
as an individual.
  But even if you accept that argument, 73 percent or $288 billion of 
this tax subsidy goes to taxpayers who do not pay any taxes. Their 
income levels are so low they do not hit the thresholds for incurring a 
tax liability. They get a pure, straightforward subsidy. The 
Congressional Budget Office acknowledges this and scores it as Federal 
spending, not as tax relief.
  But either way you want to look at it, let's say you agree it is tax 
cuts and agree to offset it--which I think is wrong--you still come up 
with 42 million American households earning less than $200,000 a year 
who will face a net tax increase, and the tax increases are not small 
for these families.
  The bill grows the Federal Government. It pushes up every cost curve 
you could think of. It increases taxes. It increases the cost of health 
insurance. It increases the cost of health care.
  What does it do to Medicare? It cuts Medicare by $465 billion in the 
first

[[Page S13858]]

year and, again, if you want to look at the first full 10 years, by 
$953 billion in Medicare cuts. Basically, what we have here in this 
part of the bill is an absolute transfer--an absolute transfer--from 
America's senior citizens right over to the new government entitlement 
program and a redistribution of that wealth to other people.
  Senior citizens who have throughout their life paid the Medicare tax, 
the Medicare payroll tax, will now see the Medicare they thought they 
were going to get cut. What kinds of cuts are we talking about that we 
may be dealing with here? The biggest one is Medicare Advantage--$120 
billion of cuts.
  About one in four American seniors has Medicare Advantage insurance. 
This is insurance that was provided in a contract relationship with the 
private sector. In other words, it was an experiment to see if we could 
let the private sector deliver Medicare and how they would do at it. 
They found they can actually, through the Medicare Advantage Program, 
increase the benefits seniors get.
  This is probably the most popular part of the Medicare Program. It is 
growing rapidly. The reason it is growing rapidly is because it 
provides better coverage. Those in the Medicare Advantage Program are 
going to see their benefits cut.
  Another pledge the President made was: If you like what you have, you 
can keep it. Well, not if you have Medicare Advantage. It is also not 
true about a lot of people who have their insurance through their 
employers these days because that is going to be lost to millions of 
Americans too.
  But in addition to the Medicare Advantage cuts, you are going to see 
hospital reimbursements, skilled nursing facilities, home health 
agencies, hospice, and others cuts to the tune of $465 billion in the 
first 10 years. The experts have all told us, what that is going to do 
is to make impossible for many health care providers in these 
categories to keep their doors open, or it will cause them to reduce 
the amount and quality of services they provide.
  So senior citizens are going to see their Medicare, particularly 
their Medicare Advantage, benefits cut and their access to care 
restricted and reduced under this bill.
  In summary, there has been a lot of talk again about how Americans 
want health care reform. But we need to do it in a smart and sensible 
way. Many have argued there are no alternatives being put forward by 
our side. As I indicated earlier in my remarks, that is simply not 
true. In fact, the alternative that was put forward in the House and 
the alternative many of us have been talking about here have been 
scored to actually achieve the results Americans are asking for.
  We do not need to rush this bill through in a claim that we are 
making history but in a way that will be a huge historical mistake. The 
American people, in huge numbers, are asking us to slow down and stop 
it and start working together in ways that do not create a government 
takeover of health care, that do not drive up the size and reach of the 
Federal Government, that do not drive up taxes but instead provide the 
right kind of approaches to medical savings, that do not slash Medicare 
benefits to our seniors, that do not put massive burdens on our States, 
and that do not force the neediest of our uninsured into a failing 
health care system, Medicaid.
  We are simply going to have to be back at this in the future if we do 
not get it right now. Only then we will be facing much worse fiscal 
circumstances and very difficult problems with sustaining the fiscal 
stability of the two programs we are now dealing with trying to 
sustain: Medicare and Medicaid.
  I urge my colleagues to listen to the people who signed this 
petition--people all across this Nation in every one of the 50 States--
who are saying: Wait. Do not do this now. Do some sensible reform, but 
do not make this mistake.
  I encourage all my colleagues, as we are literally on the eve of the 
vote that will determine whether this bill makes it through the Senate, 
to step back and take a deep breath and evaluate whether it will not be 
better for all of America for us to move a little slower and start 
trying to build a bipartisan solution that can have true benefits for 
the American people.
  With that, Mr. President, I yield the remainder of my time.
  Mr. HATCH. Mr. President, there is a lot of talk from the majority 
about why passing this bill is the right thing to do for the American 
people. It is a decision of conscience for them. Well, let us a take a 
closer look at these decisions of conscience.
  After weeks of closed-door clandestine negotiations, Senator Reid 
finally emerged with a 383-page Christmas list. This bill is a dark 
example of everything that is wrong with Washington today. Despite all 
the promises of accountability and transparency, this bill is a grab 
bag of Chicago-style, backroom buy-offs. It is nothing more than the 
Democratic leadership's own private game of ``Let's Make A Deal'' with 
special interest groups financed by American taxpayers.
  So who won and who lost in this game? Well let us take a closer look.
  AARP issued a strong statement of support for this bill. The Reid 
bill slashes Medicare by almost $\1/2\ trillion to finance additional 
government spending. So, why would the Nation's largest lobbying 
organization, avowed to protect the interests of seniors, support this 
legislation? To find the answer, like anything else in Washington, just 
follow the money.
  AARP takes in more than half of its $1.1 billion budget in royalty 
fees from health insurers and other vendors. The sale of supplementary 
Medicare policies, called Medigap plans, make up a major share of this 
royalty revenue. AARP has a direct interest in selling more Medigap 
plans. However, there is a strong competitor to Medigap policies--
Medicare Advantage plans.
  These private plans provide comprehensive coverage, including vision 
and dental care, at lower premiums for nearly 11 million seniors across 
the country. Seniors enrolled in Medicare Advantage do not need Medigap 
policies. So what happens when the Reid bill slashes this program by 
almost $120 billion? Just look at the Washington Post front-page story 
from October 27 questioning whether AARP has a conflict of interest:

       Democratic proposals to slash reimbursements for . . . 
     Medicare Advantage are widely expected to drive up demand for 
     private Medigap policies like the ones offered by AARP, 
     according to health-care experts, legislative aides and 
     documents.

  One of the most disturbing developments in the Reid bill has been the 
perpetuation and even doubling of the unconstitutional individual 
mandate tax from $8 billion to $15 billion. You heard me right--this 
unconstitutional mandate tax actually doubled behind closed doors. I 
have long argued that forcing Americans to either buy a Washington-
defined level of coverage or face a tax penalty collected through the 
Internal Revenue Service is highly unconstitutional.
  We hear a lot of rhetoric from the other side about Republicans 
defending the big, evil insurance companies while Democrats are the 
defenders of American families. The insurance mandate is a clear 
example of this partisan hypocrisy. Let me ask one simple question: Who 
would benefit the most from this unprecedented mandate to purchase 
insurance or face a stiff penalty enforced by our friends at the 
Internal Revenue Service?
  The answer is simple. There are two clear winners under this 
Draconian policy--and neither is the American family. The first winner 
is the Federal Government, which could easily use this authority to 
increase the penalty, or impose similar ones, to create new streams of 
revenue to fund more out-of-control spending. Second, the insurance 
companies are the most direct winners under this individual insurance 
mandate because it would force millions of Americans who would not 
otherwise do so to become their customers. I cannot think of a bigger 
giveaway for insurance companies than the Federal Government ordering 
Americans to buy their products. If you do not believe me then just 
look at the stock prices of the insurance companies that have recently 
shot to their 52-week highs.
  Jane Hamsher, the publisher of the very liberal blog Firedoglake, 
said the following in a recent posting: ``Having to pay 2 percent of 
their income in annual fines for refusing to comply--with the IRS 
acting as the collection agency--just might wind up being the most 
widely hated legislation of the decade. Barack Obama just might achieve 
the

[[Page S13859]]

bipartisan unity on health care he always wanted--Democrats and 
Republicans are coming together to say kill this bill.' ''
  Now that we clearly understand the huge windfalls the Reid bill 
provides AARP and insurance companies, let me take a moment to talk 
about the winners and losers in the so-called abortion compromise. The 
language to prevent taxpayer dollars from being used to fund elective 
abortions is completely unacceptable. The new abortion provisions are 
significantly weaker than the amendment I introduced with Senator Ben 
Nelson to ensure that the Hyde amendment, which prohibits use of 
federal dollars for elective abortions, applies to any new federal 
health programs created in this bill. The Hyde amendment has been 
public law since 1976.
  The so-called abortion compromise does not stop there. The Reid bill 
creates a State opt-out charade. However, this provision does nothing 
about one state's tax dollars from paying for abortions in other 
states. Tax dollars from Nebraska can pay for abortions in California 
or New York. This bill also creates a new public option run by the 
Office of Personnel Management, OPM, that will, for the first time, 
create a federally funded and managed plan that will cover elective 
abortions.
  When you have Senator Boxer and Speaker Pelosi, two of the largest 
pro-choice advocates in the Congress, supporting this sham so-called 
compromise and everyone from the U.S. Conference of Catholic Bishops to 
the National Right to Life Committee and the Family Research Council 
opposing it, there is only one clear loser--the majority of Americans 
who believe in the sanctity of life and oppose the use of federal 
dollars for elective abortions.
  Last but not least, I would like to spend a couple of minutes to talk 
about the numerous special deals conferred on States in this $2.5 
trillion spending bill. How hefty are the pricetags for decisions of 
conscience? Here are some highlights: $300 million for Louisiana; $600 
million for Vermont; $500 million for Massachusetts; $100 million for 
Nebraska.
  At a recent news conference, when the authors of this legislation 
were asked about the Nebraska earmark for Medicaid funding, the 
majority leader simply replied, ``A number of states are treated 
differently than other states. That's what legislation is all about. 
That's compromise.''
  The next logical question is pretty straightforward--Who will pay for 
these special deals? The answer is simple. Every other State in the 
Union, including Utah, who are collectively facing $200 billion in 
deficits and are cutting jobs and educational services to survive, will 
now pay to support these special deals.
  According to the Congressional Budget Office, the Medicaid expansion 
in the Reid bill creates a $26 billion unfunded mandate on our cash-
strapped States. Coincidentally, only one state avoids this unfunded 
mandate--Nebraska.
  Of course, let us not forget about the biggest loser in this bill--
the hard-working American taxpayer. This bill imposes over a $\1/2\ 
trillion worth of new taxes, fees, and penalties on individuals, 
families, and businesses. The new fees begin in 2010, while the major 
coverage provisions do not start until 2014. Almost $57 billion in new 
taxes are collected before any American sees the major benefits of this 
bill, which are largely delayed until 2014. It is also no coincidence 
that through the use of these budget gimmicks the majority can claim 
this bill reduces our national deficit when we all know these 
reductions will never be realized.
  Based on data from the Joint Committee on Taxation--the nonpartisan 
congressional scorekeeper--this bill would break another one of 
President Obama's campaign promises by increasing taxes on 42 million 
individuals and families making less than $250,000 a year.
  At a time, when we are struggling to fight a double-digit 
unemployment rate, the Reid bill not only increases payroll taxes by 
nearly $87 billion but also imposes $28 billion in new taxes on 
employers that do not provide government-approved health plans. These 
new taxes will ultimately be paid by American workers in the form of 
reduced wages and lost jobs.
  However, it is hard to say we didn't see these new taxes coming. For 
years now, many of us have warned that the out-of-control spending in 
Washington will eventually have to be repaid on the backs of American 
families. In this bill, the repayment comes in the form of stifled 
economic growth, lost jobs, and new and increasing taxes--and they are 
just the first installment of what will be a long and painful extortion 
of taxpayers if Congress doesn't stand up and stop these terrible 
bills.
  According to a recent study of similar proposals by the Heritage 
Foundation, these new job-killing taxes will place approximately 5.2 
million low income workers at risk of losing their jobs or having their 
hours reduced and an additional 10.2 million workers could see lower 
wages and reduced benefits.
  Poll after poll tells us about the growing opposition against this 
tax-and-spend health care bill. The latest Rasmussen poll shows that 55 
percent of Americans are now opposed to this bill. The CNN poll has it 
even higher at 61 percent. Among senior citizens, the group most likely 
to use the health care system, only 33 percent are in favor while 60 
percent are opposed. Independent voters are also opposed almost 2 to 1. 
Opposition in certain state polls, like Nebraska, is even higher at 67 
percent.
  So what is the majority doing to address these concerns? Nothing. In 
fact, despite the efforts by many of us here on this side of the aisle 
to express our substantive policy disagreements for months, one Senator 
recently said the following: ``They are desperate to break this 
president. They have ardent supporters who are nearly hysterical at the 
very election of President Barack Obama. The birthers, the fanatics, 
the people running around in right-wing militia and Aryan support 
groups, it is unbearable to them that President Barack Obama should 
exist.''
  This statement is outrageous. Instead of listening to the policy 
concerns of a majority of Americans, the other side is simply 
dismissing them as rants from the far right. If the majority refuses to 
listen to what Americans are telling them now--I am sure they will have 
a rude wake-up call waiting for them later. It should come as no 
surprise to anyone that this kind of arrogance of power has led to 
congressional approval ratings rivaling the most hated institutions on 
the planet at a dismal 22 percent and falling.
  One of the biggest tragedies of letting this bill move forward is 
that it will do nothing to address the fundamental issue of rising 
health care costs in this country. According to the Congressional 
Budget Office, this bill will actually raise our national health care 
costs by $200 billion. The administration's own actuary at the Centers 
for Medicare and Medicaid Services, CMS, agrees with this assessment. 
When this bill fails to work, Americans will no longer have any faith 
in Congress to effectively address the issue of health care reform. The 
opportunity to save Medicare and Medicaid from their impending 
financial collapse will be lost for another generation.
  The historic blizzard in Washington earlier this month was a perfect 
symbol of the anger and frustration brewing in the hearts of the 
American people against this bill. I urge the majority once again to 
listen to the voices of the American people. Every vote for this bill 
is the 60th vote. Let me repeat that again--every vote for this bill is 
the 60th vote. My Republican colleagues and I are united with the 
American people in our fight against this $2.5 trillion tax-and-spend 
bill. I implore my colleagues not to do this to the American people. 
Don't foreclose on their futures. Don't stick them with even more 
government spending and government intrusion.
  We can fix health care. Many of us have been working to do just that 
for many years. A truly bipartisan bill that would garner 75 to 80 
votes in the Senate, would be fiscally sound and provide the American 
people with the fixes they are asking for in the health care 
marketplace is easily achievable. Many of us are standing at the ready, 
and have been for months, to step forward and pass meaningful health 
care reform that truly would help American families and please American 
taxpayers. To date, we have been rebuffed by an unfailing determination 
by a few to pursue a nearly Socialist agenda. I would ask my colleagues 
on the other

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side of the aisle who do not believe in the Europeanization of America, 
who believe in doing truly bipartisan work here in the Senate, to step 
forward, vote against advancing this bill and work with those of us on 
this side of the aisle who are committed to making a difference to 
craft a health care reform bill they can be proud to support.
  The PRESIDING OFFICER. The Senator from New York.
  Mr. SCHUMER. Mr. President, it is truly my honor to be here on this 
historic evening and speak in support of the bill which we will vote on 
early tomorrow morning, Christmas Eve morning. It is an honor because 
anyone who looks at this country knows the problems we have, and that 
two problems caused by the health care system are at the top of the 
list. One represents a more conservative point of view and one 
represents a more liberal point of view. But I am proud to say the bill 
we will pass tomorrow morning, God willing, deals with both.
  The more conservative issue is controlling costs. The health care 
system costs this country a whole lot of money. By and large, we get 
good health care--not everybody but most people. But it is so 
expensive, and that has been documented.
  What does that mean? It means small businesses cannot grow and 
actually have less money to pay for wages. It means our large 
businesses are less competitive globally. We have seen that in the auto 
industry. It means individuals often have to pay a fortune for health 
care. It means our government runs deficits that are perilous to the 
economy. Health care costs are more the cause of our deficits than 
anything else.
  On the other hand, we run a real problem because many people are not 
covered or covered adequately. The heartwrenching stories told by our 
fine leader--and I cannot give him enough kudos for the job he has done 
here; and I will talk about that in a minute--but the people who are 
not covered or covered poorly suffer in many ways. They become not only 
less happy citizens--that is most important--but less productive 
citizens. The heartwrenching stories of people who do not have coverage 
for them or their children we all know about. It also, by the way, 
increases costs because when people delay coverage, when they are ill, 
it inevitably costs more.
  This bill addresses both. I wish to, in my brief amount of time 
here--and I do not know how much time I have--address both. I wish to 
talk on the cost side first.
  Why do health care costs go up so much more than any other product? 
Two main reasons. First, we do not have perfect knowledge, as the 
economists would say. We basically do not know what we are buying. When 
we go to the doctor, and the doctor says: You need this test, we do not 
know if we need it. Is the doctor genuinely prescribing a test we need 
or is there some element that he makes enough money on this test that 
why not? can't hurt because we do not need it?
  In my family, my relatives have all had prostate cancer, and I watch 
very carefully. But when I go to the doctor and he says I need this 
kind of a test or this kind of a scan, I say: Of course. If it were a 
car or a house, I might investigate to see if I needed it.
  The second reason costs are so expensive is because fundamentally 
health care deals with God's most precious gift to us, which is life. 
Who would not beg, borrow, or steal to find $100,000--who would not 
give their right arm if we were told our husband, our wife, our mother, 
our farther, our son, or our daughter was ill and $100,000 would give 
them a 25-percent greater chance of living better, of healing? We would 
do it. But because most of us do not have that $100,000, we buy 
insurance. That is the reason there is health care insurance. It is not 
because it is health care; it is because it is so vital and so 
expensive. So we are willing to pay $5,000 a year, so that, God forbid, 
if that time comes when we need that $100,000 to cover a loved one, it 
is there because we have insurance.
  So when I go to the doctor and he says I need this special test, 
special scan, special procedure, not only do I not know whether I need 
it--because the training is difficult; and you can go online, but you 
cannot really figure these things out--but, second, I am not paying for 
it. You put those things together, and the costs go through the roof. 
We have tried in this bill to finally get a handle on the costs. Most 
other countries have. In America, we haven't. We must. I believe very 
deeply in covering everybody, but unless we get a handle on the costs, 
we will not be able to afford to cover everybody. Even if we cover them 
today, we will run out of money in 5 years. We do it in four ways, and 
I am going to be very brief about them because my time is somewhat 
limited.

  First, we deal with efficiencies. There is one form. If there is IT, 
as we put in the stimulus bill--information technology--we can save 
hundreds of billions of dollars. Just one form. You go to a doctor's 
office, there is a nurse, a doctor, and there are four people filling 
out forms. If you had one form, you wouldn't need that.
  Second, prevention. Early intervention and prevention saves billions, 
and in this bill that is what we encourage, early intervention and 
prevention. Right now, amazingly enough, if you get diabetes in the 
later stages, Medicare or private insurance will pay for dialysis. God 
forbid someone needs a leg amputation, one of those serious retina 
operations, they pay. They don't pay for the early stages. They don't 
pay for the nutrition therapy, the exercise therapy that could arrest 
diabetes in the early stages. We do that.
  The third thing we try to do in this bill is provide competition in 
the insurance industry, and we do provide competition in the exchanges. 
We do put some limits on the insurance companies with the medical loss 
ratio provisions that Senator Rockefeller, Senator Franken, and Senator 
Nelson helped craft. If we could have had a public option, it would 
have created more competition. That is one of my great regrets, that we 
don't. I worked hard for it, but we don't. Nonetheless, we still get 
some limitation on insurance companies and create more competition.
  The fourth is the hardest: fee for service. The fee-for-service 
system is what drives up the costs. This bill, more than any other 
provision ever passed in America, begins to grapple with that most 
difficult issue.
  You do those four things, and you will bring costs down.
  It is no wonder that CBO has said that in the first 10 years, we save 
$127 billion, even though we are covering 31 million more people, and 
in the second decade, we are going to save over $1 trillion. I forget 
the number. I think it is $1.3 trillion. We are doing whoever becomes 
President in 2020 a huge favor because with the cost-control provisions 
in this bill, should they become law, we will get a great handle on 
costs. It will take a while, but it will do the job. On the other side, 
we don't cover everybody, but 94 percent of all people will be covered, 
so it is an amazing feat to both cover many more people and reduce 
costs, and that is what this bill does.
  I wish to say, for my home State of New York, there are lots of good 
things in this bill. We have 800,000 seniors who would be cut from 
Medicare who will not be because of provisions we were able to get in 
the Finance Committee.
  Graduate medical education, intermediate medical education--a 
lifeblood for jobs in New York because training doctors is probably our 
second biggest industry in New York City--is not cut even though it was 
proposed to be cut. Money for neighborhood national health services and 
community health centers will provide physicians in inner cities and in 
rural areas where they don't have health care. They will get really 
good health care.
  This bill is far from perfect. Had I written it, I would have written 
it a different way. Had Senator Cantwell or Senator Casey or Senator 
Klobuchar written it, they would have written it differently from me. 
But if every one of us in this Senate insisted that the bill had to be 
written exactly our way, we would have 100 bills, each with 1 vote, and 
no progress. So great progress has been made, and this is a proud 
moment.
  There are many people I wish to thank.
  My staff--I do want to mention Meghan Taira, Katie Beirne, and all of 
the others who worked so hard; Jeff Hamond, who worked so hard and so 
diligently on this bill.
  I thank Max Baucus. He soldiered on and on when things looked bleak 
and

[[Page S13861]]

pursued his dream of a bipartisan bill, which would have been a better 
product. It wasn't to be but not because of lack of his efforts.
  Thanks go to Senator Dodd and Senator Harkin on the HELP Committee 
and my colleagues on the Finance Committee, but at the top of the list 
is just one person, and I was proud to be one of his lieutenants on 
this, and that is Harry Reid. I was up close. What an amazing job that 
man did, modestly, without complaining, without looking to what was 
good for him. He had a mission, a job: get us 60 votes on this very 
difficult, complicated proposal. And he did it. He will never get the 
credit he deserves because he is such a modest man, but I wanted to 
share that with my colleagues and with the country as I am sure others 
have done before.
  So this bill is a very good bill on both sides of the ledger. It will 
reduce costs rather significantly and in a smart way, without hurting 
patient care. It gets rid of the fraud and the waste and the abuse and 
duplication. At the same time, it will cover many more people.
  This is a very fine day for this country, this Senate, and Leader 
Reid. Tomorrow morning, I will be very proud to vote for this piece of 
legislation, certainly one of the most important I have ever voted on 
in my 35 years as a legislator.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Washington.
  Ms. CANTWELL. Mr. President, I am proud to be out on the floor 
tonight with my colleagues.
  I thank the Senator from New York for his comments and his work in 
the Finance Committee. He literally did work night and day in that 
committee and then worked with Leader Reid on trying to get consensus 
within our caucus on this legislation. So I appreciate his strong, 
active support in making reform.
  I, too, wish to add my congratulations tonight because we are here to 
talk about controlling health care costs and what we are going to do to 
help the American people. I too wish to thank my colleagues, Senator 
Baucus and Senator Reid, for their active leadership, as well as 
Senator Dodd and Senator Harkin.
  I add my thanks to the whole Finance Committee staff. I don't think 
people realize they have worked from January until December, many 
weekends as well as during the week, many late nights as well as early 
mornings, and they deserve a lot of credit for the details behind this 
legislation and making sure the i's are dotted and the t's are crossed.
  I wish to thank my staff, all of my staff but in particular Mark 
Iozzi, who worked on this legislation, as did the rest of the Finance 
Committee members of the staff, for about the last 11\1/2\ months. I 
was glad to send him off on a plane today to reach his family, and 
hopefully he will be watching the vote tomorrow morning by television. 
It should be a proud moment for him.
  I also wish to add a particular thanks to President Obama. I wish to 
say to the President that he started this year with the dedication that 
this was going to be a year where we got health care reform. He stated 
that at the beginning of his Presidency and held steady to that during 
the very raucous debate that happened in the early months regarding the 
budget and whether we would have the money to do health care reform. He 
remained committed as we went home over the summer and many things 
happened at town meetings. He came back and was determined that we 
would forge ahead. He, as we got legislation out of the Finance 
Committee and had to combine bills, remained active and intent about 
this legislation.
  It reminds me of a saying my father used to make to me because he was 
a Navy man and always came up with nautical terms to kind of describe 
the direction in which he would want his children to go. The 
President's actions on health care policy for this year remind me of 
the saying ``steady as she goes'' because that is what the President 
has done for the last many months--steady as she goes so that we can 
get health care reform.
  So I wish to add my thanks and congratulations to him and to his 
administration and to the many members of that administration who were 
down here on the Hill, including Mr. Messina, who made many frequent 
visits, I think, to Members to talk about some of the details.
  I am glad I am following my colleague from Idaho, from the Northwest, 
who spoke earlier, because I think it shows you can be from the same 
region of the country and have the very same interests but look at this 
legislation differently--not that I don't share some of his concerns, 
and I am going to fight to make changes and add to the legislation as 
it continues to move into conference and in the years after its 
implementation. I think the Senator has brought up some good points 
that we need to follow up on.

  Controlling health care costs in general is what is driving us to 
take action tomorrow morning on Christmas Eve. We know we have already 
seen a 120-percent increase in insurance premiums for the last 10 
years; that is, from 1999 to 2009, we have seen a 120-percent increase 
for Americans and their premium costs. That is something the American 
people can't afford. And when my colleague from Idaho talks about the 
increase we are going to see in the next 10 years, he is right. 
Insurance premiums are going to go up again. This debate is about what 
we are going to do to try to control those costs, whether this 
legislation we are discussing today will have an impact in reducing 
those costs so that maybe premiums aren't going to go up another 120 
percent in the next 10 years and make insurance even more unaffordable 
for the American people.
  We know there are organizations that have done multiple studies. We 
know there is at least $700 billion in waste each year in our health 
care system. That is according to the Robert Wood Johnson Foundation. 
We know that is the kind of money that, if we are smarter about our 
health care choices, we can reduce the costs of health care and improve 
the system.
  Part of this is reforming Medicare and the cost of Medicare because 
Medicare dollars are one in every five health care dollars today. The 
more expensive Medicare is, the end result is the more expensive 
insurance is in general. So it is very important for us to reform the 
Medicare system, to have provider reform, which this legislation has, 
and to change the system.
  But we also have to deal with the cost of the uninsured because we 
know that Americans right now who don't have insurance and who go to 
the emergency room are adding something like $43 billion a year in 
higher premium costs. That is $1,000 for each family in their premium 
increases.
  I know we can do nothing and have these same costs on the backs of 
the American people or we can try to change the system, as we are with 
this legislation, to improve the quality of care and access and to 
lower the costs for Americans. That is why one of the main reforms I 
fought for in this legislation was about paying for value, not for 
volume; that is, to change the fee-for-service system that rewards 
physicians for how many procedures they do or how many patients they 
have seen a day but not for the value of the system. So I know that 
because of the change we have in this legislation, we are going to 
reward physicians, starting several years from now--something that has 
worked in my State and many States in the Pacific Northwest that are 
more efficient at lowering the costs--by increasing efficiency and 
thereby rewarding those States with better Medicare payments.
  What it actually means for individuals is that they are going to get 
shorter waiting times, they are going to get better access to doctors, 
they are going to get more coordinated care, and they are going to get 
better outcomes. Why? Because that is what we are going to incent in 
these reforms. That is the kind of system that is working in many parts 
of the country that are cost-effective, that yield better results for 
individual patients at lower cost.
  I wish to thank my colleague from Minnesota, Senator Klobuchar, 
because it was her legislation that she introduced early this year that 
really catalyzed this effort to focus on many of the things done at the 
Mayo Clinic and things that had been done in Minnesota and things we 
had done in Washington State that said: Let's change this process and 
save dollars for everybody in America by getting off the fee-for-
service systems and going to a system that will be more cost-effective. 
So I wish to thank her and her

[[Page S13862]]

State for that leadership and to thank those in my State who have 
performed the same way on efficiency to deliver this kind of health 
care reform.
  A second cost control of this legislation that I supported that I 
think will do well for many people in this country is in the area of 
long-term care reform.
  Some people may know that my colleague, Senator Harkin, was on the 
floor and was talking about long-term care in the insurance sector, but 
part of what we are doing in this bill is also to incent States to move 
off of nursing home care and on to community-based care.
  Home care juxtaposed to nursing home care is 70 percent cheaper and 
better meets the needs of individuals. I say that because my State 
implemented this policy to focus on long-term, community-based care 
decades ago. The end result is that kind of care has been more cost-
effective, less expensive, personalized care, and individuals get to 
stay in their communities.
  I do not know any senior in America who would choose to go to a 
nursing home over staying in their home or in their community. But they 
have had very little choice up until now on this legislation to be able 
to do that because we continue to incentivize nursing home care.
  There are some who need nursing home care because they need a higher 
level of delivery of care, and those people will still go to those 
facilities. But we will save a lot in our Federal budget, as we look at 
our Medicare and Medicaid budgets, for the future if we simply take 
this one action. This bill alone would be worth passing just for this 
one provision because of how much money it is going to save the Federal 
Government.
  The Basic Health Plan. Many of my colleagues may have heard me talk 
about the Basic Health Plan as a basis of this legislation that we 
added in this country. Many people across the country may not 
understand the Basic Health Plan because they do not have something 
similar to the Basic Health Plan in their States.
  Nearly 20 years ago, the Washington State Legislature passed the 
Basic Health Plan because it allowed States to negotiate for lower 
rates. Essentially, it is a public-private partnership. Some people 
call it a public option. Some people call it a public plan. I call it 
cost-effective health care delivery. It is cost-effective because we 
have proven for 20 years that we get 35 to 40 percent lower rates for 
individuals by grouping into this kind of plan and having the State 
negotiate the rates. We have been able to have that plan now for 20 
years.
  This provision of allowing States to do something similar to the 
Basic Health Plan is a provision we added in the Finance Committee that 
now will allow every State in America to take money they would get 
instead for tax credits and use that money in the delivery of 
negotiated rates for their States. This will allow 70 percent of the 
uninsured to have full coverage.
  What does that mean from a cost-effective perspective? Let's take an 
example. If this legislation is not passed and we have the current 
system in America, an individual in 2016 trying to get access to the 
individual market would have to pay over $5,850, and the individual 
would pay everything. The government would be paying nothing; that is, 
if this bill does not pass. That is what would happen.
  Let's look at what will happen if, in fact, this bill does pass. You 
will have the option of going into the exchange. The estimates are by 
CBO that you will be able to reduce from where we normally would be, 
about 11 percent, the cost of health care. In that exchange, an 
individual who would be covered at 200 percent of poverty would end up 
paying $1,200, and the Federal Government would end up paying $4,000. 
Already somebody is coming out ahead. They say that sounds good. That 
sounds like a better deal than me being able to afford this current 
rate. That would be $5,850. It means I would be uninsured.
  The Basic Health Plan has been in operation for 20 years, driving 
down costs through negotiated rates, as I said, by 35 and 40 percent, 
and it is a far different picture for the individual.
  In our State, the individual only pays $400--$400--versus $1,200. 
Look at the government. The government rate adds to that, $3,700, but 
it is cheaper. Why? Because the State has negotiated with insurers and 
driven down the cost. That is what is missing in the exchange.
  While some of my colleagues, I know, think the exchange is going to 
deliver great clout through the Office of Personnel Management, I hope 
they are right. I am anxious to see the results of that. But I am 
unapologetic about the fact that I know the State of Washington has 
delivered these kinds of savings through negotiated rates and that many 
States in our country have been the most cost-effective tools for 
delivering new and efficient health care models, while we at the 
Federal level still struggle to try to drive those policies.
  I know this legislation has cost controls. I know my colleague from 
Idaho is very concerned about this, and he is right to be concerned. We 
will be judged by how much we are going to drive down the costs. But 
the American people should understand that rates are going to go up 
another 120 percent in the next 10 years if we do nothing. So this 
legislation is about bending the cost curve. It is about looking at the 
projected growth, looking at general inflation, and trying to drive 
health care costs somewhere below what they would be on an annual 
basis. That is our objective.
  We are going to have a challenge in monitoring this legislation, but 
that is why I am going to fight and cheerlead for the Basic Health Plan 
and hope that every State in the country takes the option of delivering 
health care through that kind of negotiated public plan that will allow 
them to drive down insurance costs.
  I hope we can expand the Basic Health Plan in conference to an even 
more robust plan that would cover more people. It does not make sense 
to me to continue to subsidize expensive insurance by giving Federal 
tax credits when I know the bill to the Federal Government and to the 
individual taxpayer can be cheaper by implementing negotiated rates.
  While we have not been able to fully implement that at the Federal 
level, let's not hold States back. Let States do what they have done 
best for the last several decades; that is, innovate--innovate more 
quickly, more effectively, not without a Federal partnership but in a 
partnership with the Federal Government and in a partnership with a 
public-private mechanism that I think has been cost-effective for the 
last 20 years.
  Tomorrow, I will be voting in support of this legislation because I 
believe in the innovation this legislation enables. I know when we 
passed the Basic Health Plan in the mid eighties people said the same 
thing. There were concerns about whether we were going to be able to 
implement the cost-effectiveness. In fact, at that time, it was said 
that some stakeholders believed it would be an entitlement. Others saw 
it as essentially a cost-containment measure that would reduce 
uncompensated care. Some others thought it would demonstrate the 
viability of government-subsidized health care. Advocates wanted to 
implement something quickly so they could develop constituencies.
  All these things are similar arguments to what we are hearing today 
and what this debate has been about. But I know that what happened 
after 20 years of us putting a plan in place is that hundreds of 
thousands of Washingtonians got more affordable health care. It has 
been a plan that has worked effectively. No one has tried to dismantle 
the program from a political perspective. I think working together with 
the Federal Government we can show more cost containment for the 
American public.
  I thank the Chair. I yield the floor.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Ms. KLOBUCHAR. Mr. President, I ask to speak for 12 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Ms. KLOBUCHAR. Mr. President, I come to the floor in support of the 
Patient Protection and Affordable Care Act. It is an honor to follow my 
friend from Washington, Senator Cantwell, who has been such a leader on 
the Finance Committee in focusing on the very issue that is key in my 
State; that is, cost reform, delivery system reform, because for too 
long the people in cost-efficient States, such as Minnesota,

[[Page S13863]]

Washington, and Wisconsin, have been seeing other States not quite 
offering that kind of quality care we would like to see all over the 
country.
  I think it always shocks people. If you go to a hotel and you say you 
want to get a room, usually if you spend more money you have a bigger 
room and you have a better view. That is not true with health care.
  Time and again, we see studies across this country--academic, 
bipartisan studies--showing, in fact, some of the highest quality 
health care comes with some of the lowest costs.
  As the Senator from Washington talked about how we can save that $700 
billion year that is wasted in our system, a lot of it comes not at the 
cost of care but actually at getting better care, because if you reduce 
unnecessary waste, if you stop having people running around to 20 
different specialists who are giving them conflicting advice and not 
conferring and not knowing about the medications they are taking, when 
you have those disorganized systems, they not only cost too much money 
for everyone, they also give worse care. That is why the Mayo model, an 
integrated care model with one primary care doctor working with a team 
of specialists is a model we would like to see all across this country.

  We cannot simply keep pushing our problems to another day. Rising 
health care costs are unsustainable, busting the budget of families and 
businesses alike. If we do not act, these costs are going to break the 
backs of the American people.
  This country spends $2.4 trillion on health care alone. That is $1 
out of every $6 in the American economy. It is projected to be 20 
percent of our whole economy in 2020 if we do not act. Despite spending 
1\1/2\ times more per person on health care than any other country, we 
all know there are many problems in our health care system.
  Wages simply do not keep pace with premiums. Peoples' wages have been 
stagnant or maybe gone up a little, gone down some or they lost their 
jobs, but health care costs continue to skyrocket.
  I always tell the people in my State there are three numbers we need 
to remember--6, 12, and 24. Ten years ago, the average American family 
was spending $6,000 a year on their health care. Now they are spending 
$12,000, with many people spending a lot more. What will they be 
spending in 10 years if we do not act? Mr. President, $24,000, up to 
$36,000 a year on their health care premiums.
  When I go around my State, I hear these stories all the time. Granite 
Gear, a little backpack company up in Two Harbors, MN, makes backpacks 
for our soldiers. They have done well. They built their business. The 
guy in charge of it said he would not have started that business if he 
knew then what he knows now; that is, for his family of four, a small 
little business in Two Harbors, MN, he is spending $24,000 a year on 
his health care.
  I have heard from doctors at Gunderson Lutheran in La Crescent, MN. 
They told me the story of how at one of their hospitals in their region 
they had three patients in a 1-month period come into the emergency 
room with severe stomach problems. They had ruptured appendixes. Do you 
know what they said as to why it got to that point? For two of them, 
they worked at small businesses and they were afraid it was going to 
blow up the premiums for health care coverage for that little company. 
The third one could not afford the copays. They waited and waited and 
waited. They got a doctor and that doctor was the emergency room, some 
of the most expensive care in this country.
  I heard from a mom in Bemidji, MN, who has a daughter named Micki. 
The mom's name is Sheryl. She wrote me a letter. She said:

       I just got off the phone with my daughter Micki. 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 and it was costing them $13,000 a 
     month. For her, this is a matter of life and death. She has 
     cystic fibrosis. Her medications can run anywhere from $7,000 
     to $13,000 a month. Because it is a preexisting condition, 
     the insurance companies won't touch her unless it is under a 
     group plan like the one her husband just lost.

  She went on to say in her letter:

       You need to stand and be my voice, be Micki's voice. Micki 
     is a fighter but she can't keep fighting a system that is so 
     against her. Micki has already lived longer than any of her 
     doctors expected. We need you to be her voice.

  That is why this bill is so important. The status quo is simply not 
sustainable, not for families, not for small businesses, not for big 
businesses that are trying to compete internationally against other 
companies and countries that have more efficient health care systems.
  Despite claims from my friends on the other side of the aisle, we 
have spent months debating this issue. The C-SPAN viewers know what I 
am talking about. If you look at the input the Republicans have had on 
this bill, you can see that over 160 amendments were accepted in the 
HELP Committee. Dozens of bipartisan meetings and roundtable 
discussions were held in the Senate Finance Committee.
  They have engaged across this country--so many people, sadly--in a 
campaign of misinformation. I know a lot of people in Minnesota and 
across the country are left trying to wade through all the ads, 
misinformation, and scare tactics to find out what this bill is about. 
Well, this bill is not perfect, as so many of my colleagues have said. 
We will work to make changes and work forward. I would like to see more 
cost reform in this bill. But what we do with this bill is a beginning 
not an end. We work to reduce cost, we work to expand coverage and 
increase choice and competition for American consumers.
  First, and very important to me and to my mother--who is 82 years 
old--this bill protects Medicare and our seniors. Medicare is one of 
the most valued social programs our country has produced in the last 
half century. Yet it is also a program in dire need of reform if it is 
to survive on sound financial footing and continue to provide the fine 
medical care our seniors have come to expect.
  By 2011, the first baby boomers will enter the Medicare system. 
Without action, if we sit and put our heads in the sand, it will go in 
the red by 2017. So think of people such as my mom--82 years old. She 
wants to live well into her 90s and beyond. Think of people who are 55 
and who want to be on Medicare when they are 65. It is going to go in 
the red by 2017 if we don't do something to make sure it is on strong 
financial footing.
  With this bill, we start to do that. We extend Medicare solvency by 
10 years. I am encouraged that my legislation can create a value index, 
which the Senator from Washington discussed, as part of the formula 
that is used to determine Medicare's fee schedule. That was included in 
the Senate's bill. This indexing will help reduce unnecessary 
procedures because those who produce more volume will also need to 
improve care or the increased volume will negatively impact fees. 
Doctors will have a financial incentive to maximize the quality and the 
value of their services instead of just the quantity.
  My favorite story along these lines is not from Minnesota but from 
Geisinger, PA. They were trying to figure out: How do we best treat 
diabetes. We are not happy with the results. They realized with the 
routine cases, those were the people they wanted someone to see more 
often, to check in on them. So they had them assigned to nurses and the 
more difficult cases to the endocrinologists. The endocrinologists 
would review the nurses' work and make sure there was proper followup 
if there had to be adjustments. At the end of year, they had much 
happier patients. The quality of care went way up, and they saved $200 
per month per patient.
  What does our system in America do now? What does the Medicare system 
do? It punishes them for that good work. So that is what we are talking 
about, actually getting that higher quality. You can save money if you 
have the right incentives in place.
  With this legislation, we also stop paying for care that doesn't 
result in quality patient outcomes. Who wants to go into the hospital 
to be treated and get sick from something else during that 
hospitalization? When you have to go back again, that is called a 
hospital readmission. In 1 year, hospital readmissions cost Medicare 
$17.4 billion. A 2007 report by the Medicare Payment Advisory 
Commission found

[[Page S13864]]

Medicare paid an average of $7,200 per readmission that was likely 
preventable. This practice must stop. This isn't good care for 
patients, and it is not a good investment for taxpayers.
  The bill also establishes an independent, 15-member Medicare 
Commission tasked with presenting Congress with comprehensive proposals 
to reduce health care costs and improve quality of care for Medicare 
benefits. The current Medicare payment policies are not working well 
for patients, doctors, and hospitals. We have to control costs and we 
have to get that high-quality care we see in Minnesota throughout the 
country.
  In this bill, we also work to stop fraud and abuse. Law enforcement 
authorities estimate that Medicare fraud costs taxpayers more than $60 
billion every year--$60 billion going to con men, $60 billion going to 
storefronts that say they are a doctor's office, when all that is 
behind it is a bunch of fraudsters and rip-off artists who are getting 
checks meant to go to providers of care to our seniors--$60 billion a 
year. Finally, we have a bill that puts the tools in place--enhanced 
criminal penalties--that allows for direct deposit of those payments 
from the government to those providers, so we don't have people ripping 
us off with an antiquated system of bad and false checks. With this 
change, we put a stop to criminals running phony businesses to steal 
Medicare checks from our seniors.
  We are also working to help our seniors with the cost of their 
prescription drugs. Millions of Americans depend on prescription drugs 
to help them manage chronic disease or other illnesses. But drug prices 
continue to skyrocket. That is why I voted for reimportation, to allow 
these safe drugs to come in from places such as Canada. We are not 
afraid of getting our medications from Canada. Canadians come to shop 
and to vacation and to fish in Minnesota, and we go to Canada to shop 
and to work and to fish. We don't have a problem with their drugs. 
Sadly, that proposal did not pass the Senate, but I will continue to 
advocate for that.
  What does this bill do so far? What it does is to help fill that 
doughnut hole, that point where seniors who had been getting help with 
paying for their prescription drugs stop getting that help. That 
doughnut hole is now filled.
  This legislation provides relief for our small businesses. Right now, 
small businesses pay 20 percent more than large businesses for the cost 
of care. In a recent national survey, nearly three-quarters of small 
businesses that did not offer benefits cited high premiums as a reason. 
Beginning in 2011, with this legislation, small businesses will be 
eligible for tax credits worth up to 35 percent of their contribution 
to their employees' health insurance plans. In 2014, these tax credits 
will even increase more.
  This legislation, as we all know, also creates insurance exchanges 
known as small business health option programs--or SHOP programs--where 
small businesses can finally pool their numbers and do what big 
businesses do--negotiate for better rates for their insurance.
  Beginning with the passage of this bill--and this is one of my 
favorite parts--kids can't be denied coverage due to preexisting 
conditions. So if your son or daughter gets sick, an insurance company 
can't look at you and say: I am sorry your kid got sick, you don't have 
any insurance.
  Look at the story I just read with Micki, the woman whose husband 
lost her insurance. She has cystic fibrosis, and she is not sure if she 
is going to be able to get insurance. This puts an end to that and for 
kids it does it the minute the bill gets signed into law.
  Insurance companies will be barred from limiting the total benefits 
Americans can use over the course of a year or over their lifetime. 
Affordable insurance coverage options will also be made immediately 
available through a high-risk pool for Americans who have been 
uninsured and have been denied coverage because they have a preexisting 
condition.
  With this bill, insurance companies immediately must fully cover 
regular checkups and tests that help prevent illness, such as 
mammograms or eye and foot exams for diabetics.
  In addition, children would continue to be eligible for family 
coverage through the age of 26.
  I see my friend, the Senator from Pennsylvania, is here. Maybe he has 
four children who will soon be 26. I know many people are glad this 
bill has contained in it a provision that says you can keep your kids 
on your insurance until they are 26.
  We know this bill isn't perfect, no big piece of legislation ever is. 
There is still work that needs to be done in conference committee. 
There are still negotiations that will take place. There are still 
things that need to be fixed. We know this is only the beginning of 
reform, not the end, but we must keep looking to the future. For too 
long, health care costs have been spiraling out of control. That is why 
we can't afford to hold off any longer on reforming health care.
  I am going to close by reading something Vicki Kennedy--Ted Kennedy's 
widow--wrote for the Washington Post. This is what she wrote this 
weekend:

       The bill before Congress will finally deliver on the urgent 
     need of all Americans. It would make their lives better and 
     do so much good for this country. That, in the end, must be 
     the test of reform. That was always the test for Ted Kennedy. 
     He's not here to urge us not to let this chance slip through 
     our fingers. So I humbly ask his colleagues to finish the 
     work of his life, the work of generations, to allow the vote 
     to go forward and to pass health-care reform now. As Ted 
     always said, ``When it's finally done, the people will wonder 
     what took so long.''

  After all the work and debate that has gone into this bill over the 
past year, we are finally having the votes the American people deserve. 
Tomorrow morning, Christmas Eve, will be the vote.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Pennsylvania is recognized.
  Mr. CASEY. Mr. President, I ask unanimous consent to speak for up to 
10 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. CASEY. Mr. President, I wish to commend my colleague from 
Minnesota, Senator Klobuchar, for the outline of the bill and the 
important priorities we are here to debate. This is the last night, the 
last couple of hours, before we vote on the bill tomorrow morning, and 
I wish to do two things. One is to highlight, in very brief fashion, 
some of the main benefits of this bill to the American people--and 
especially to our families--and then to speak of one particular family 
from Pennsylvania who I will talk about in a moment.
  By way of overview, what we tried to do in this bill, and I believe 
we have accomplished it, is not only to meet the goals President Obama 
set forth in the early part of this year as he assumed the Presidency 
and began to make health care reform a priority, but I also believe we 
are trying to meet the goals and the objectives of the American people. 
I think we have reached that point.
  This legislation to reform health care will, first, not only be 
deficit neutral, but over the first 10 years of the bill it will save 
$132 billion--reduce the deficit $132 billion.
  Something we haven't talked enough about, although we have had a lot 
of important debates, but in terms of covering those who don't have any 
coverage today, this bill will cover 31 million Americans. We know, for 
example, the Medicaid Program, which is more than 40 years old, covers 
61 million Americans, and Medicare covers 45 million. So in this one 
piece of legislation, not after 10 or 20 or 30 years but once it is 
fully implemented over the next couple years, it will cover 31 million 
Americans. That will not only be beneficial to those individuals and 
their families, but I would argue it is good for our economy. They will 
be more productive workers and our economy will be stronger because we 
covered them.
  The bill extends Medicare solvency. That is something we hear a lot 
about. We have heard a lot of discussion about Medicare but what about 
making sure it is solvent. Our bill does that.
  Prescription drugs. A lot of families have benefited from our 
prescription drug program, but then they fall into a time period where 
they are paying the whole freight. It has been referred to as the 
``doughnut hole,'' but that doesn't capture the gravity of the problem 
for a family and for an individual, older citizen. When they fall into 
that so-called doughnut hole, they are in big trouble because they have 
to carry the

[[Page S13865]]

whole burden. They have to pay for those prescription drugs all by 
themselves. This bill addresses that, something that has gone 
unaddressed for a number of years.
  The number of children in our country who are covered by the 
children's health insurance and other initiatives has grown, 
thankfully. We will be growing from 7 million kids covered under the 
prior legislation to 14 million under the children's health insurance. 
But a lot of those children who don't have the benefit of the 
Children's Health Insurance Program might be caught in the preexisting 
condition problem. Their ability to have coverage will be limited 
because they have a preexisting condition. What our bill does is to say 
that upon passage of this bill, within months of the passage of this 
bill, in 2010, children will be fully protected in this sense: Any kind 
of act by an insurance company to deny them coverage because of a 
preexisting condition will be illegal in 2010.
  We also, over a number of years, will make it illegal for an 
insurance company to deny someone coverage due to a preexisting 
condition for adults. For those who are discriminated against, even 
before the bill is implemented, we provide a high-risk pool for them.
  We protect consumers in other ways. I was holding a copy of the first 
half of the bill here. Sometimes bills get real complicated, and I know 
our colleagues on the other side have complained about the size of the 
bill. But to get it right, you have to put in a lot of detail. On page 
78 of the bill, it is very clear. On page 78, the bill deals directly 
with the preexisting condition problem. Millions of Americans have been 
denied coverage over the last couple of years because of this one 
problem--millions of Americans. Here is what it says, very simply, on 
page 78:

       A group health plan and a health insurance issuer offering 
     group or individual health insurance coverage may not impose 
     any preexisting condition exclusion with respect to such a 
     plan or coverage.

  It is not long or complicated. It is one sentence--one sentence that, 
at long last, provides the kind of protection insurance companies have 
refused to provide to adults and children, and the protection for 
children goes into effect within a matter of months after enactment.
  Let me make two more points, and then I wish to talk about an 
individual and her family. The Children's Health Insurance Program, as 
I said, has been extended. But what happened in the earlier versions of 
the bill was the full funding of it would cut off in 2013. In the bill, 
we now have added to that. So now the children's health insurance 
funding will be extended 2 more years. So at least through the end of 
September 2015, the Children's Health Insurance Program is fully 
funded.
  We need to do more than that. We will have to get to that as we move 
forward, but we have extended it 2 more years.
  We also have done some things in this bill that didn't get a lot of 
attention.
  When we were in the early stages of this bill way back in the summer, 
in the Health, Education, Labor, and Pensions Committee, Senator Dodd 
and I and others included provisions in the bill long before it was 
amended in the original bill we put before our committee this summer.
  For example, mandating prevention and screenings for children. No. 2, 
ensuring pediatric benefits as well as pediatric input into the 
formation of benefits; vision and oral health care for children, and, 
finally, in this section, strengthening the pediatric workforce. If we 
are going to give children the kind of expert help they have a right to 
expect and we have a right to expect for their care, we have got to 
make sure we have the workforce, the high-skilled work force, the 
doctors, who are, in fact, pediatricians; so all kinds of benefits for 
our children and for our families.
  But this isn't just a debate about policy and the provisions of the 
bill. That is, obviously, part of what we are here to do. What we are 
here to do is meet the needs of real families in America. I have met a 
number of them in Pennsylvania, and every Member here, whether they are 
for or against the bill, whether they are trying to kill the bill on 
the other side or whether they are trying to support and pass the bill 
on this side, could tell a story. Each of those Senators could tell a 
story about many families in their State.
  One story is to remain an inspiration for me from day one, going way 
back in February when I received a letter. This woman in Pennsylvania 
who wrote to me remains an inspiration. Her name is Trisha Urban, from 
Berks County, PA, right near Reading and the eastern side of our State. 
She wrote this letter. I will quote major portions of the letter. She 
talked about herself and her husband. She said her husband had to leave 
his job for 1 year to complete an internship requirement to complete 
his doctorate in psychology. ``The internship was unpaid and we could 
not afford COBRA.'' She goes on to say that because of preexisting 
conditions neither her husband's health issues nor her pregnancy--
Trisha talked about her pregnancy in the letter--``nor my pregnancy 
would be covered under private insurance. I worked four part-time jobs 
and was not eligible for any health benefits. We ended up with a 
second-rate insurance plan through my husband's university.
  ``When medical bills started to add up, the health insurance company 
decided to drop our coverage,'' stating that the internship didn't 
qualify us for benefits. It didn't stop there for a second. So within 
the space of two sentences, she has highlighted at least two, if not 
three, of the major problems we have heard so much about: the 
preexisting condition problem that I pointed to in the bill and we have 
heard about from so many others, and also dropping of coverage, 
arbitrary actions by an insurance company to drop coverage when they 
believe it is in their best interests and not in the interests of the 
family.
  Let me pick up with the letter. I am quoting here again from the 
letter from Trisha Urban:

       We are left with close to $100,000 worth of medical bills. 
     Concerned with the upcoming financial responsibility of the 
     birth of our daughter and the burden of current medical 
     expenses, my husband missed his last doctor's appointment 
     less than one month ago.

  Less than 1 month from February of 2009.
  Here is her story, the tragic part of her story, in addition to all 
of the problems she had with her health insurance company and all of 
the challenges she and her husband faced getting coverage for her 
family, her husband's heart condition and in her coverage, as well as 
her pregnancy, she talks about that night in early 2009 when she was 
ready to deliver her daughter. She said:

       My water broke the night before. We were anxiously awaiting 
     the birth of our first child. A half hour later, two 
     ambulances were in my driveway. As the paramedics were 
     assessing the health of my baby and me the paramedic from the 
     other ambulance told me that my husband could not be revived.

  Here's Trisha Urban, having lived through all of those difficulties 
with her own insurance and her problems with insurance and worrying 
about her pregnancy and worrying about her husband. She walks up to her 
driveway the exact day that her baby was born and she finds her husband 
dead in the driveway.
  The chart depicts the headline from the Reading Eagle dated February 
of this year: ``Tilden Township Woman Tends to Baby Born Hours After 
Her Husband's Death.''
  I will cite a few facts from the story:

       Just after noon, Thursday, Trisha A. Urban's husband, 
     Andrew D. Urban, died. Less than nine hours later, she gave 
     birth to their first child, Cora Catherine.

  Because of that tragedy and maybe only because of that tragedy I met 
Trisha Urban months after she wrote a letter to me, and I met her 
daughter. They came down to hear the President's speech to a joint 
session of Congress. I held her daughter Cora. I probably never would 
have met that beautiful child were it not for this tragedy, were it not 
for this story.
  I am not sure what I would do if I were in her case. I am not sure if 
I would have remained so saddened by it and so frustrated by what the 
insurance companies did to her or didn't do for her. Anyone would 
understand that, if she or I or anyone else who suffers that tragedy 
would look within themselves and suffer alone with their family. 
Patricia Urban didn't do that. She didn't just tell us about the 
problems she had with her insurance company; she didn't just tell us 
about the tragic death of her husband; she did more than that. She 
wrote to me.

[[Page S13866]]

  For those who say, well, we don't need to do anything about this 
health insurance problem, I would ask them to listen to Trisha Urban. 
She said at the end of her letter:

       I am a working class American and do not have the money or 
     the insight to legally fight the health insurance company. We 
     had no life insurance. I will probably lose my home, my car, 
     and everything we worked so hard to accumulate in our life 
     will be gone in an instant.

  But then she says this:

       If my story is heard, if legislation can be changed to help 
     other uninsured Americans in a similar situation, I am 
     willing to pay the price of losing everything. I'm asking you 
     to share my story with others in Congress and I'm willing to 
     speak on behalf of my husband so that his death will not be 
     in vain.

  So says Trisha Urban in this letter. She challenged me with that 
letter, or at least I took it as a kind of challenge I wanted to 
accept. I think she challenges all of us. If Trisha Urban, who lived 
through all of those problems with the health insurance company, denied 
coverage because of preexisting condition, dropped coverage, medical 
bills going through the roof, and then the ultimate tragedy, the death 
of her husband, if she can endure all that and still stand up and say, 
I am willing to pay the price of losing everything I need, I am going 
to do that to try to help pass a health care bill--if she can do that, 
the least we can do is to do what a lot of us have tried to do over 
many months, which is to work on this, to debate it, and to fight hard 
to pass it. So tomorrow morning in the early hours of the morning, when 
it might still be dark out, it is my hope and prayer there will be a 
little light in that darkness in the early morning tomorrow when we 
pass this bill, and we can say that we did our best.

  I know we are not done yet to get this bill out of the Senate. I know 
we are not done yet. We can at least say we did our best, that we tried 
as best we could to be responsive to, to answer the plea for help and 
the invocation of hope that Trisha Urban has in her letter.
  I have remained ever inspired by her courage, by her willingness to 
speak up, and by her willingness to be a witness not just to what has 
been going wrong with our system and not just giving testimony about 
her husband's death but the way Trisha Urban has been a witness to the 
hope and the promise of change that will come with this bill. I know 
tomorrow morning isn't the end of the road. But tomorrow morning is at 
least the beginning of the end of a lot of these tragedies and a lot of 
these stories.
  So on Trisha's behalf as we say on behalf of so many others, we need 
to get this legislation passed tomorrow morning and to move forward in 
a positive new direction in terms of what happens to our health care 
system.
  With that, Mr. President, 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.
  Mr. CASEY. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.

                          ____________________