[Congressional Record Volume 156, Number 47 (Wednesday, March 24, 2010)]
[Senate]
[Pages S1923-S2012]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 2010

  The ACTING PRESIDENT pro tempore. Under the previous order, the 
Senate will resume consideration of H.R. 4872, which the clerk will 
report.
  The assistant legislative clerk read as follows:

       A bill (H.R. 4872) to provide for reconciliation pursuant 
     to Title II of the concurrent resolution on the budget for 
     fiscal year 2010, S. Con. Res. 13.

  Pending:

       Gregg-Coburn modified amendment No. 3567, to prevent 
     Medicare from being used for new entitlements and to use 
     Medicare savings to save Medicare.
       McCain amendment No. 3570, to eliminate the sweetheart 
     deals for Tennessee, Hawaii, Louisiana, Montana, Connecticut, 
     and frontier States.
       Crapo motion to commit the bill to the Committee on 
     Finance, with instructions.
       Enzi motion to commit the bill to the Committee on Finance, 
     with instructions.
       Barrasso amendment No. 3582, to ensure that Americans can 
     keep the coverage they have by keeping premiums affordable.
       Grassley-Roberts amendment No. 3564, to make sure the 
     President, Cabinet members, all White House senior staff and 
     congressional committee and leadership staff are purchasing 
     health insurance through the health insurance exchanges 
     established by the Patient Protection and Affordable Care 
     Act.

  Mr. REID. Mr. President, would the Chair report how much time is left 
on general debate on the bill.
  The ACTING PRESIDENT pro tempore. The majority has 7 hours 32 minutes 
and the minority has 8 hours 30 minutes.
  Mr. REID. Mr. President, I yield back all time remaining on the bill 
on the majority's side.
  The ACTING PRESIDENT pro tempore. The leader has that right. The time 
is yielded back.
  The Senator from Tennessee is recognized.


                            Motion to Commit

  Mr. ALEXANDER. Mr. President, I ask unanimous consent to temporarily

[[Page S1924]]

set aside the pending motion so that I may offer a motion to commit, 
which is at the desk.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  The clerk will report the motion.
  The assistant legislative clerk read as follows:

       The Senator from Tennessee [Mr. Alexander] moves to commit 
     the bill H.R. 4872 to the Committee on Health, Education, 
     Labor, and Pensions of the Senate with instructions to report 
     the same back to the Senate within 1 day with changes to 
     reduce the interest paid by student borrowers by 1.5 
     percentage points and to add an offset.

  The ACTING PRESIDENT pro tempore. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I wonder if the Senator from Tennessee 
would agree to modify his request so that the earlier amendments be set 
aside until a time designated by the leaders and this motion then be 
taken up at a time to be decided by the leaders, which is the customary 
practice we have been utilizing with previous amendments.
  Mr. ALEXANDER. Mr. President, I wonder if the Senator from Montana 
would permit me to consider that request and then respond to him within 
a few minutes.
  Mr. BAUCUS. The Senator would withdraw the request and make the 
request later?
  Mr. ALEXANDER. If I may consult with Senator Gregg, then respond. If 
you will make the request later, I would be grateful.
  Mr. BAUCUS. OK.
  Mr. ALEXANDER. Thank you very much.
  The ACTING PRESIDENT pro tempore. The Senator from Tennessee is 
recognized.
  Mr. ALEXANDER. Mr. President, 19 million American families will be 
interested in this motion because it will reduce the cost of student 
loans which 19 million Americans have. This is the season of the year 
when a great many students have been admitted to a college or a 
community college and are making plans and looking for where they are 
going to get their money. This motion is aimed at reducing the interest 
rate on 19 million student loans from 6.8 percent to 5.3 percent. For 
the average student loan debt of about $25,000, it would save that 
student $1,700 or $1,800 over their ten-year loan. More specifically, 
it would not only help the student, but it would prevent the Federal 
Government from overcharging 19 million American college students on 
their student loans to help pay for the health care bill and other 
government programs.
  One may say: Wait a minute, I thought we were debating the health 
care bill. How did we get to student loans? That is a very good 
question because it just came up over the weekend. Of course, we have 
talked about student loans. There have been proposals, but there have 
been no hearings in the Senate, no consideration in the Senate 
committee of which I am a member. Yet over the weekend, the Democratic 
majority said: Well, look, while we are at it, let's have another 
Washington takeover. Let's take over the Federal student loan program. 
Let's take a program which is working very well, in which 15 million 
American students have voted with their feet to say they would prefer 
to get a regular student loan backed by the government, which they get 
at their college campuses, through their community bank, through a 
nonprofit institution. Even though they do have an option for a 
government loan, three out of four students have said they prefer the 
student loan through the private lender. Yet over the weekend, the 
Democratic majority has said: While we are at it, let's take over the 
Federal student loan program.

  That means that starting July 1, students have no choice. They go to 
the Federal Government to get their student loan, all 19 million of 
them, which is a new experience for 15 of the 19 million.
  The way they are going to do it--and this is all going to be set up 
in a very short period of time--is they are now going to have to go to 
four Federal call centers. So instead of going to their local lender or 
to their nonprofit institution, that can help them with their 
application form and see what their options are and encourage them as 
they make their plans for college, welcome to the new government loan 
program. They have no choice. That is what they are going to do.
  What are the other aspects of this? Well, other than denying choice 
to 19 million students on more than 2,000 campuses who prefer the 
Federal loan program, the Federal Government is going to have to borrow 
another $\1/2\ trillion in order to make these loans. Let's think about 
this for a moment. What is the No. 1 issue that most Americans worry 
about today? It is that we have too much debt. So what did this weekend 
takeover do? It adds about $\1/2\ trillion to the Federal debt in order 
to make student loans, at the rate of about $90 billion or $100 billion 
a year for 4 or 5 years.
  So we take away choice, we add to the debt, and we also put 31,000 
people out of their jobs. These are a lot of loans, and so we have a 
lot of people in these organizations, such as Edsouth in my State, a 
nonprofit organization that helps students get their loans. So all 
these lenders are out of business and we have one big bank--the Federal 
Government.
  The Education Secretary is the new banker of the year. He is a very 
good Education Secretary, but I don't know how good a banker he is 
going to be.
  But here is the rub, and this is what my motion is about. The Federal 
Government is going to be borrowing money at 2.8 percent and loaning it 
to students at 6.8 percent and taking the difference and spending it on 
new government programs, including the health care bill. So we are 
going to be overcharging 19 million students to help pay for the health 
care bill. And, according to the most recent Congressional Budget 
Office estimates, about $8.7 billion of the overcharged money is going 
to go to pay for the health care bill.
  My friends on the other side have already spent the money, of course. 
They have announced to everybody that we are going to spend it on this 
and on that and on this, but what they do not tell you is, where they 
get the money. Where they get the money is overcharging students--
overcharging students.
  These aren't Wall Street financiers we are overcharging. This might 
be a single mom going to a community college in Tennessee who has a job 
but who wants a better job and so she borrows some money to go to the 
community college and the Federal Government is going to overcharge her 
to pay for some government program. She might not like that.
  In fact, I think there will be about 19 million student loan holders 
across the country who will go to school next year and say: Wait a 
minute here. You mean you are overcharging me on my student loan to pay 
for this health care bill and to pay for other government programs? The 
answer will be: Yes, that is what we are doing, unless my colleagues 
support this motion.
  The estimate by our friends on the other side is that their Federal 
takeover of the Federal student loan enterprise will save $61 billion. 
If they are correct, let's give it to the students. Let's reduce their 
interest rate. I mean, $1,700 or $1,800 per student in interest over 10 
years is the average amount of savings, and that is a lot of money. It 
may not seem like a lot of money to Congressmen and Senators in 
Washington, but to the single mom going to the community college who is 
borrowing the money to go to school in order to get a better job, 
$1,700 or $1,800 is a lot of money.
  So in addition to the higher premium numbers, the higher taxes, the 
Medicare cuts, and the new cost to States, we are going to be 
overcharging on student loans. Let me use a specific example from 
Tennessee, if I may. I was at the University of Tennessee earlier this 
week. This is the University of which I used to be president. The 
University of Tennessee has 30,000 students, and 37 percent of them--or 
11,251--have Federal private loans today. The average student debt is 
about $20,000. After July 1, all 11,000 students at the University of 
Tennessee, with these Federal loans from private lenders, are going to 
have to switch to the government loans, and the government is going to 
overcharge 11,000 students who go to the University of Tennessee at 
Knoxville and use that overcharged money to pay for new government 
programs, including the health care bill.

[[Page S1925]]

  They are going to do the same thing to the University of Tennessee at 
Martin. There they choose to use the private loan program. They like it 
better than the government loan program. They think it is more 
convenient for the students. They have chosen--3,600 students at UT 
Martin--have chosen Federal private loans. They are going to be out of 
those loans by July 1. They are going to have government loans, and the 
government is going to overcharge them to help pay for the health care 
program.
  Maryville College--I will be there Saturday night to help dedicate 
their arts center. There, 824 students have Federal loans today. They 
are going to have government loans. They are going to switch from 
private to government loans. They will have no choice after July 1. I 
know a lot of these students. They come from modest families, in most 
cases. They are not going to be very happy to learn that when they 
switch to a government loan after July 1, and if they have an average-
size loan, which is about $25,000, that over 10 years they are going to 
pay $1,700 or $1,800 to help pay for the health care program or other 
new government programs.
  In Carson-Newman College, it is 1,259 students. In East Tennessee 
State University, it is 8,187 students. In all of Tennessee, it is 
200,000 students who have student loans who are going to be overcharged 
an average of $1,700 or $1,800 a year to help pay for the health care 
program or some other government program, and this amendment would say: 
No, we are not. If we are going to take over the student loan program, 
at least we are not going to overcharge the students and use it for the 
health care program. We are going to give the money back to the 
students.
  The point of my amendment is very simple. We are going to reduce the 
interest rate we charge on 19 million student loans from 6.8 percent to 
5.3 percent and let the students have the savings instead of letting 
the government have the savings. That is what the other side has not 
told people about the student loans.
  If we had an ample opportunity to debate this in the Senate, if we 
had a committee hearing on it, if we had taken it through the regular 
process, maybe we could have pointed this out, but no, we do it over 
the weekend, put it in the House bill, send it over here, jam it 
through with great breast beating and protestations: Look what we have 
done for the country. I am accustomed to that. I used to be a Governor. 
I remember lots of Members of Congress who would say I did a great 
thing in Washington and then send the bill to me to pay. And then, as 
Governor--in this case the health care bill will do the same thing. It 
will send to the Governors and to the States new costs. Our Governor 
estimates it is $1.1 billion over 5 years, to $1.5 billion. That is 
about $300 million a year new costs that State taxpayers will have to 
pay.
  As the Medicaid cost goes up, we will get the second blow to the 
students of Tennessee because either the State is going to have to 
reduce funding for public higher education--which I believe this health 
care bill will help permanently damage--or they are going to have to 
raise taxes, or they are going to have to raise tuition, or they are 
going to have to do all three. If I am a student at Maryville College, 
Carson-Newman, or the University of Tennessee, first this health care 
bill is going to overcharge me on my student loan to help pay for it; 
second, it is going to send such big new costs to the government that 
the Governor is going to have to reduce funding to my college or 
university and my tuition is going to go up.
  All those students in California who are protesting a 34-percent 
increase in tuition probably do not realize the reason for that 
happening. The main reason is that over the years the Federal 
Government has so regulated the Medicaid program that the States pay 
about a third of, that the State budgets have grown and grown and the 
Governors, such as Governor Schwarzenegger in California, have had no 
choice except to cut, knowing that when you get down through the budget 
process you have had no choice except to cut other programs. Governors 
know when you get down through the budget process in the State, it 
usually comes down to Medicaid or higher education. So a great 
university such as the University of California is on its knees, and if 
it even hoped to keep its quality, it raises tuition 34 percent.
  My amendment will not help that problem. The law the President signed 
yesterday already will transfer to States these huge new costs that are 
going to permanently damage higher education and raise tuition. But 
what my amendment will do is say we are not going to overcharge 200,000 
students in Tennessee for their student loans and use $8.7 billion to 
help pay for health care.
  Sometimes I think the motto of the Obama administration is: If you 
can find it in the Yellow Pages, the government ought to be doing it.
  This is breathtaking. While we are taking over cars, banks, insurance 
companies, while we are taking over more of health care, we will also 
take over the student loan program, add $\1/2\ trillion to the Federal 
debt, overcharge 19 million students, cause 31,000 people to lose their 
jobs and say ``all in a day's work.'' That is what happened last 
weekend. Over the weekend that is the decision they made. Then over 
here bragging about how much we are going to do for everybody. We are 
going to do a little more for everybody if we have a chance to vote on 
this amendment because when we go home we will have a chance to say 
either I cut the interest rate on your student loan from 6.8 to 5.3 
percent and give you the savings, or I voted to overcharge you $1,700 
or $1,800 a year and give the money to the government to help pay for 
the health care bill.
  Mr. President, I ask unanimous consent to have printed in the Record 
following my remarks a few communications I received from Tennessee.
  The ACTING PRESIDENT pro tempore. Without objection, it is ordered.
  (See exhibit 1.)
  Mr. ALEXANDER. Here is a letter from Vanderbilt University to 
Congressman Cooper from the Chancellor which says:

       Our overarching concern with [this proposal] is that the 
     legislation forces institutions, including Vanderbilt, to 
     switch to direct lending.

  Here is a distinguished university, one of the top research 
universities in the world. They have chosen--they believe it is best 
for their students and for their campus to use the private banks and 
non-profits. We know better, of course, than Vanderbilt University, 
what is best for the campus and best for the students. We say no, July 
1, only the government.
  In their letter they continue:

       Vanderbilt opposes the elimination of the FFEL program. We 
     encourage Congress to carefully study the many alternate 
     proposals. . . . In addition to our concerns about the 
     elimination of choice, competition, and the high level of 
     services, products and debt management we believe would come 
     with this switch, we are very concerned that the proposed 
     timeframe for this mandated conversion is unreasonable.

  So Vanderbilt opposes that. So does the Baptist College of Health 
Sciences, so does Maryville College, so does the Middle Tennessee 
School of Anesthesia, so does Dyersburg State Community College.
  I ask to have these remarks printed in the Record and an article I 
wrote in the Washington Post that was published on Sunday, March 7, 
about the student loan takeover.

                               Exhibit 1


                                        Vanderbilt University,

                                               September 10, 2009.
     Hon. Jim Cooper,
     Longworth House Office Building,
     Washington, DC.
       Dear Congressman Cooper: The House of Representatives will 
     soon consider H.R. 3221, the Student Aid and Fiscal 
     Responsibility Act which would fundamentally restructure the 
     federal student aid system and funnel the projected savings 
     into a variety of higher education and K-12 programs as well 
     as deficit reduction. While Vanderbilt supports efforts to 
     restructure and expand federal student aid programs, we have 
     serious reservations about this legislation.
       As you know, one proposed change has to do with the Direct 
     Loan (DL) program, in which the government acts as the 
     lender, and the Federal Family Education Loan (FFEL) program, 
     in which lending institutions provide loans to students. 
     Vanderbilt has a long and successful history of participation 
     in the FFEL program which has provided our students with 
     superior loan products, service, and choice in their federal 
     loans for many years.
       Earlier this year, the administration proposed eliminating 
     the FFEL program, requiring all institutions to participate 
     in DL and using the projected $87 billion in savings over 10 
     years from this switch to fund a mandatory Pell Grant and 
     expand the Perkins

[[Page S1926]]

     Loan program. [Other estimates have put the ten-year savings 
     figure at closer to $47 billion.] H.R. 3221 seeks to 
     implement those proposals. Unfortunately, the legislation has 
     attracted a host of other education-related provisions which, 
     while perhaps meritorious in their own right, we believe 
     should not be attached to federal student aid legislation.
       We applaud and strongly support a number of provisions of 
     H.R. 3221:
       Modest increases to Pell Grants. Any increase in Pell 
     Grants is deeply appreciated and will benefit undergraduate 
     students. Although the bill does not create the mandatory 
     Pell Grant proposed by the administration, it calls for $40 
     billion of the projected savings to be invested in the Pell 
     Grant program, moving it toward a $6,900 maximum grant by 
     2019.
       Converts Stafford Loan interest rates from fixed to 
     variable. The bill provides $3.25 billion to change the fixed 
     interest rates on subsidized loans to a variable rate capped 
     at 6.8 percent.
       Simplifies the FAFSA. We support reasonable efforts 
     included in the bill to simplify the FAFSA for federal 
     student aid programs.


                      Eliminating the FFEL Program

       Our overarching concern with H.R. 3221 is that the 
     legislation forces institutions, including Vanderbilt, to 
     switch to Direct Lending. Of additional concern is the fact 
     that the proposed legislation does not then direct all of the 
     savings from this federal mandate back into federal aid 
     programs. Vanderbilt opposes the elimination of the FFEL 
     program. We encourage Congress to carefully study the many 
     alternate proposals to a mandatory conversion to DL. In 
     addition to our concerns about the elimination of choice, 
     competition, and the high level of services, products and 
     debt management that we believe would come with this switch, 
     we are very concerned that the proposed timeframe for this 
     mandated conversion is unreasonable. Institutions will need 
     sufficient time to make changes to their IT systems and 
     update their printed and on-line recruitment materials. 
     Completing this by the proposed July 1, 2010 deadline is 
     simply not feasible. In fact, Vanderbilt has already printed 
     many of its recruitment materials and launched its 2010-2011 
     admissions and financial aid efforts. We would advise that, 
     if a mandated conversion to DL is implemented, the earliest 
     effective date be July 1, 2011.


                       A New Perkins Loan Program

       The bill restructures the Perkins Loan program into 
     essentially a second DL program that is campus-based, with an 
     additional $5 billion. The legislation proposes a complex 
     institutional allocation formula based on holding past 
     participants, such as Vanderbilt, harmless, while 
     significantly expanding participation based on low tuition 
     and improved Pell recipient graduation rates. We believe that 
     a Perkins program allocation formula should be based on the 
     aggregate need of an institution's students relative to the 
     aggregate need of all students at institutions participating 
     in the program nationally, subject to and including the hold 
     harmless provisions.
       While Vanderbilt supports expanding participation in the 
     Perkins Loan program as well as the provisions that would 
     hold harmless existing participants, we are troubled by 
     proposals to eliminate the in-school interest subsidy and 
     loan forgiveness programs. These features have made Perkins 
     Loans uniquely attractive for many of our students. 
     Vanderbilt also opposes proposals to require institutions to 
     pay the accrued interest while students are still enrolled in 
     school. This would impose significant costs on our financial 
     aid budget and could jeopardize our participation in the 
     program. H.R. 3221 is also not clear as to whether 
     institutional matching funds will be required or how that 
     determination would be made.


       Creates Access, Completion, and Persistence Grant Programs

       Included in the bill is $3 billion for the College Access 
     Challenge Grant program. These funds would be allocated 
     primarily to states and guaranty agencies with a small 
     portion retained for a national competition. While Vanderbilt 
     supports the goals of this program, and is proud of our 95 
     percent freshman retention and 92 percent six-year graduation 
     rates, we are concerned that diverting up to 75 percent of 
     the funding to the states could severely restrict the ability 
     of private institutions to compete for the funding and could 
     inappropriately increase state oversight of private 
     institutions. We also believe that any savings generated from 
     the switch to DL should remain in the existing federal 
     student aid programs.
       In addition to these, there are several other provisions of 
     the legislation that are troubling to us:
       Family Asset Cap. Students with family assets of more than 
     $150,000 would be ineligible for any need-based federal aid. 
     While the value of a family's house, farm, business, or 
     employee pension benefit plan would be excluded, we believe 
     this cap should be increased to at least $250,000, geographic 
     factors should be applied, and an option established for 
     financial aid administrators to be able to use their 
     professional judgment such that students and parents in 
     unique circumstances can be held harmless by this provision.
       Beyond Student Aid. H.R. 3221 goes far beyond federal 
     student aid to include funding for other higher education 
     programs as well as K-12 school construction and early 
     childhood education. We believe that all savings generated 
     from the student aid programs should remain in these 
     programs. These initiatives, while potentially meritorious, 
     should be funded through avenues other than student aid 
     programs' savings.
       H.R. 3221 truly is a mixed hag. While Vanderbilt supports 
     the significant new investment in the Pell Grant program, we 
     are concerned that allocations to other initiatives have 
     significantly reduced the possible level of support for the 
     Pell Grant program. We remain strongly opposed to the 
     elimination of the FFEL program. And, although it could bring 
     low-cost Perkins Loans to millions of new students, we are 
     troubled by proposals to eliminate the in-school interest 
     subsidy and other changes to that program.
       Vanderbilt remains committed to the federal student aid 
     programs, which provide a foundation to our aid packages for 
     both undergraduate and graduate students. We look forward to 
     continuing to work with you to ensure that all capable and 
     eligible students, regardless of financial circumstances, are 
     able to access and complete post-secondary education. If you 
     have any questions or if I can provide any additional 
     information, please let me know.
           Sincerely,
                                                Christina D. West,
     Director of Federal Relations.
                                  ____

         Tennessee Association of Student Financial Aid 
           Administrators,
                                                November 25, 2009.
     Hon. Lamar Alexander,
     U.S. Senate, Dirksen Senate Office Building, Washington, DC.
       Dear Senator Alexander: On behalf of the Executive Board of 
     the Tennessee Association of Student Financial Aid 
     Administrators (TASFAA), I want to communicate to you our 
     collective concerns regarding the Federal Student Loan 
     Program (Stafford and PLUS).
       TASFAA represents financial aid officers from 106 
     postsecondary institutions in Tennessee. The Tennessee 
     postsecondary institutions serve several thousand students, 
     many who are student loan borrowers. While our membership and 
     schools are located within Tennessee, we have students from 
     every state in the Union. We seek your support of our 
     requests, which are made on behalf of the students and 
     parents we serve. These students and parents have been well 
     served by not only the institutions and individual 
     professionals, but by the Federal Direct Lending Program 
     (FDSLP) through the Department of Education and by private 
     sector lenders within the Federal Family Education Loan 
     Program (FFELP) also. Importantly, our students and parents 
     have benefitted by the opportunity to seek out lenders who 
     offer loans with savings and service that aid the borrowers 
     throughout repayment.
       TASFAA is an advocate for choice within the respective loan 
     programs. As President Obama stated in his address to a Joint 
     Session of Congress, ``Consumers do better when there is 
     choice and competition.'' We also want to focus on the timing 
     of all schools currently participating in the FFELP having to 
     switch to the Federal Direct Student Loan Program should the 
     Senate version of H.R. 3221 be enacted. Recent information 
     from the Department of Education showed that 1,990 of the 
     5,455 schools that participate in federal student loan 
     programs are currently participating in the Direct Loan 
     Program. Therefore, 3,465 colleges and universities across 
     the country, that serve millions of students, are not yet 
     participating in the FDSLP.
       Many elected officials have expressed their concerns 
     regarding the timing of such a transition. Most Tennessee 
     institutions will begin awarding financial aid packages to 
     traditional students in early spring. In addition to the 
     traditional calendar, some institutions have non-traditional 
     students in year-round programs who borrow student loans 
     throughout the year in what is known as the Borrower-Based 
     Academic Year (BBAY). For these students, loans will be 
     packaged in approximately four weeks, and the precarious 
     status of the legislation may greatly harm these student 
     borrowers. The Secretary's assistant has noted it will take 
     3-4 months for schools to convert their programs. Due to the 
     issues related to the transition to a new program (shortage 
     of staff members, new software systems, lack of training, 
     financial issues at small schools, etc.), we ask that you 
     consider the dilemma that these students face by the timing 
     of such an action and at the very least, delay the 
     implementation of full conversion to FDSLP to July 1, 2011.
       If you choose to support the Senate version of H.R. 3221 
     and move forward with full conversion to FDSLP but allow for 
     the delayed implementation date, we implore you to support S. 
     2796 to extend the Ensuring Continued Access to Student Loans 
     Act (ECASLA). ECASLA has assured that students have been able 
     to obtain the loan(s) necessary to ensure their educational 
     goals and dreams. This action will ensure that every 
     educational loan borrower will be able to continue to secure 
     the respective loan with no interrupted service.
       As of the date of this letter, the Senate committee of 
     jurisdiction has not acted on this proposed legislation, as 
     well as the entire Senate or any conferees. This is of major 
     concern to us as the timing of the possible conversion to, 
     and implementation of, 100 percent FDSLP is further delayed. 
     The Senate had noted it would vote on H.R. 3221 by

[[Page S1927]]

     October 15, 2009, but as of the date of this letter, proposed 
     legislation still has not reached the Senate for a vote.
       With all of the above taken into consideration, the 
     Executive Board of TASFAA, on behalf of our entire 
     membership, urges you to support ``choice and competition.'' 
     But if not, we ask you to implement a reasonable timeframe 
     for transition.
           Sincerely,
                                            Marian Malone Huffman,
     President, TASFAA.
                                  ____

                                                   Baptist College


                                           of Health Sciences,

                                   Memphis, TN, November 24, 2009.
       Members of Congress: I ask that you support H.R. 4103 and 
     S. 2796 to ensure uninterrupted FFELP funding of Federal 
     Student Loans for students and parents attending colleges and 
     universities across the country.
       I have worked in the student financial aid profession since 
     1982, ALWAYS at FFELP schools. In my many years of 
     experience, I have witnessed tens of thousands of students 
     being well served by the FFELP system. The idea of the 
     Federal Direct Student Loan Programs certainly contributed to 
     needed improvements to FFELP, and the two programs have 
     served to keep each other ``on their toes.'' To shift now to 
     a federal monopoly in the student loan business could prove 
     to be a monumental mistake.
       Schools have had plenty of time to choose between FFELP and 
     Direct Lending. It is clear that FFELP works better for some 
     schools and Direct Lending for other schools. And most 
     importantly, BOTH programs do a good job of serving needy 
     students attend college. Let's please keep it that way.
           Sincerely,

                                           Janet Bonney-Baker,

                         Financial Aid Supervisor, Baptist College
     of Health Sciences.
                                  ____

                                          Office of Financial Aid,


                             Dyersburg State Community College

                                  Dyersburg, TN, November 25, 2009
       As a student financial aid administrator for over thirty-
     five years, I have concerns regarding students receiving 
     needed funds to attend post-secondary institutions in the 
     2010-2011 academic year. Regardless of our stance on direct 
     lending, we all have one common bond, and that is helping the 
     students we serve.
       All schools are planning for the 2010-2011 academic year, 
     and we feel trapped. I implore you to consider extending the 
     Ensuring Continued Access to Student Loans Act (ECASLA) as 
     quickly as possible, so that the students in this country 
     will not suffer with the uncertainties accompanying delays in 
     implementation of new programs. Timing is critical for higher 
     education in this country.
       Please consider choice as the loan option for the students 
     of this country. Competition and choice is a foundation of 
     our economy. As President Obama stated in his address to a 
     Joint Session of Congress, ``consumers do better when there 
     is choice and competition''.
       The Secretary's assistant has noted that it will take 3-4 
     months for schools to convert their programs. Due to the 
     issues related to the transition to a new program (shortage 
     of staff members, new software systems, lack of training, 
     financial issues at small schools, etc.), please consider 
     delaying the implementation of full conversion of the Federal 
     Direct Student Loan Program to July 1, 2011, at the earliest 
     which will provide us with a reasonable timeframe for 
     transition, if choice is not an option for us.
           Sincerely,
                                                   Sandra Rockett,
     Director of Financial Aid.
                                  ____

                                                  Middle Tennessee


                                         School of Anesthesia,

                                                November 24, 2009.
       Members of Congress: I ask you to support H.R. 4103 and S. 
     2796 to ensure uninterrupted FFELP funding of Federal Student 
     Loans for students and parents attending colleges and 
     universities across the country.
       I am the sole worker in Financial Aid at Middle Tennessee 
     School of Anesthesia, (MTSA) and we like the FFELP program. 
     The students here at MTSA DO NOT want to use Direct Lending. 
     The decision to end the FFELP program takes away the right to 
     choose. The advent of the Federal Direct Student Loan 
     Programs certainly contributed to needed improvements to 
     FFELP, and the two programs have served to keep each other 
     ``on their toes.'' To shift now to a federal monopoly in the 
     student loan business could prove to be a monumental mistake. 
     Having the ability to use both programs gives the Financial 
     Aid Industry a healthy competition.
       Schools should have the ability to talk to different 
     lenders and choose between FFELP and Direct Lending. It is 
     clear that FFELP works better for some schools and Direct 
     Lending for other schools. And most importantly, BOTH 
     programs do a good job of serving needy students attending 
     college.
           Sincerely,
                                          M. Joanna Hayes Dickens,
     Financial Aid Coordinator.
                                  ____

                                                   Rhodes College,


                                         Financial Aid Office,

                                    Memphis, TN, December 8, 2009.
     Senator Lamar Alexander,
     Dirksen Senate Office Building,
     District of Columbia.
       Dear Senator Alexander, I write to urge you to vote in 
     favor of extending the Ensuring Continued Access to Student 
     Loans Act, H.R. 4103 and S. 2796. As a financial aid 
     professional, I know firsthand the importance of these funds 
     in meeting students' educational expenses. I believe that 
     competition breeds excellence and I am in favor of keeping 
     both the FFEL and Direct programs in place. To eliminate FFEL 
     especially during this particular time in history, would be a 
     mistake that would cost institutions and students time and 
     money that we simply can't afford.
       An interruption in the delivery of these funds would create 
     a hardship for many students and make the neediest among them 
     unable to attend college. This bill will ensure that 
     sufficient funds will be available for students in the 2010-
     2011 academic year.
       Please Vote YES to H.R. 4103 and S. 2796! Thank you for 
     your understanding and support of our students!
           Most Sincerely,
                                                   Ashley Bianchi,
     Acting Director of Financial Aid.
                                  ____


                    And Now for Students, Big Lender

                          (By Lamar Alexander)

       While health-care reform occupies the spotlight, the Obama 
     administration is pushing for another Washington takeover--
     this time of the student loan system. Last month, U.S. 
     Education Secretary Arne Duncan made the administration's 
     latest pitch on this page.
       Here is what the administration and congressional Democrats 
     have told us about this latest attempt: Starting in July, all 
     19 million students who want government-backed loans will 
     line up at offices designated by the U.S. Education 
     Department. Gone will be the days when students and their 
     colleges picked the lender that best fit their needs; 
     instead, a federal bureaucrat will make that choice for every 
     student in America based on still-unclear guidelines. They 
     say that this will save taxpayers up to $87 billion in 
     subsidies that now go to ``greedy'' banks. In gleeful 
     anticipation, members of Congress have lined up to spend 
     those billions on Pell Grants and almost a dozen other 
     programs. Banks are punished. Students are helped. Members of 
     Congress look good.
       Here is what they haven't told us: The Education Department 
     will borrow money at 2.8 percent from the Treasury, lend it 
     to you at 6.8 percent and spend the difference on new 
     programs. So you'll work longer to pay off your student loan 
     to help pay for someone else's education--and to help your 
     U.S. representative's reelection.
       And there are some other things the government should tell 
     you: The estimated $87 billion in savings isn't real. 
     According to a July 2009 letter from the Congressional Budget 
     Office (CBO) to Sen. Judd Gregg (R-N.H.), the savings are 
     closer to $47 billion including administration costs, if we 
     use the same ``scoring'' (i.e., cost analysis) method that 
     Congress required the CBO to use when it scored the Troubled 
     Asset Relief Program last year because the method would more 
     accurately calculate the cost to taxpayers.
       Finally, the government should disclose that getting your 
     student loan will become about as enjoyable as going to the 
     Department of Motor Vehicles.
       Today, roughly 2,000 lenders offer government-backed 
     student loans on more than 4,000 campuses. One lender, 
     Edsouth, offers Tennessee students college and career 
     counselors, financial-aid training, and college-admissions 
     assistance; performs hundreds of presentations at Tennessee 
     schools; and works with 12,000 Tennessee students to improve 
     their understanding of the college-admissions and financial-
     aid process.
       Nonprofit lenders such as Edsouth use the revenue generated 
     under the student-loan system to operate and provide these 
     valuable benefits--but of course, these services cost money. 
     If--under this latest Washington takeover--Edsouth and other 
     nonprofit lenders are prevented from making the number of 
     loans they make today, they will no longer be able to provide 
     these services, depriving students of real choices in 
     lending.
       The student loan ``Banker of the Year'' will be the only 
     student loan banker left calling the shots; the education 
     secretary in Washington. Imagine trying to get all Edsouth's 
     services from a federal call center.
       I was education secretary for President George H.W. Bush 
     when, in 1991, Congress offered students a choice for borrow 
     from a local lender or the Education Department. In 2008, 15 
     million students voted with their feet and chose 
     nongovernment lenders--and only 4 million students chose to 
     get their loans from Washington.
       Congress has reduced subsidies paid to lenders twice in the 
     past four years, investing the savings in Pell Grants and 
     other programs. But if there really is $47 billion in savings 
     to be found, Congress should return it to students as lower 
     interest rates, not trick students by overcharging them so 
     Washington can create more government programs.
       Seven-eighths of students who applied for federal aid using 
     the Free Application for Federal Student Aid (FAFSA) had an 
     average loan debt of $24,651. Assuming a standard 10-year 
     repayment at 6.8 percent, those students would pay roughly 
     $9,400 in interest. If we really want to have students money, 
     why not just reduce the interest rate by 1.5 percentage 
     points, to 5.3 percent, saving students $2,240 in interest?
       If this Washington takeover happens, I propose that all 19 
     million-plus student loans made by the government carry this 
     warning label:
       ``Beware: Your federal government is overcharging you so 
     your representative can

[[Page S1928]]

     take credit for starting new government programs. Enjoy the 
     extra hours you work to pay off your student loan.''

  The ACTING PRESIDENT pro tempore. The Senator from New Hampshire is 
recognized.
  Mr. GREGG. I am recognized, correct?
  The ACTING PRESIDENT pro tempore. That is correct.
  Mr. GREGG. I ask unanimous consent at this time to withdraw the 
amendment of the Senator from--on behalf of the Senator from Tennessee, 
I ask to withdraw his amendment.
  The ACTING PRESIDENT pro tempore. Is there objection?
  Without objection, the amendment is withdrawn.
  Mr. BAUCUS. Mr. President, reserving the right to object.
  The ACTING PRESIDENT pro tempore. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I regret, I object.
  The ACTING PRESIDENT pro tempore. Objection is heard.
  The Senator from Tennessee is recognized.
  Mr. ALEXANDER. Mr. President, I withdraw my motion.
  The ACTING PRESIDENT pro tempore. The motion is withdrawn.
  The Senator from New Hampshire is recognized.
  Mr. GREGG. Mr. President, at this time I yield such time as he may 
take off the bill to Senator Alexander to discuss his amendment, which 
he is not offering at this time, while retaining the right to the 
floor.
  The ACTING PRESIDENT pro tempore. The Senator from Tennessee.
  Is there objection?
  Mr. BAUCUS. Mr. President, reserving the right to object, what is the 
parliamentary situation at the moment?
  The ACTING PRESIDENT pro tempore. There is a Grassley amendment 
pending.
  Mr. BAUCUS. Mr. President, who has the floor?
  The ACTING PRESIDENT pro tempore. The Senator from New Hampshire has 
yielded time off the bill.
  Mr. GREGG. Without losing my right to the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Tennessee has been 
recognized.
  The Senator from New Hampshire cannot reserve his right to the floor.

  Mr. BAUCUS. May I ask who has the floor?
  The ACTING PRESIDENT pro tempore. The Senator from Tennessee has the 
floor.
  Mr. ALEXANDER. Mr. President, would you let me know when 10 more 
minutes has expired, please?
  I have a little history with the student loan program. I see the 
distinguished Senator from Utah is here. When he was the ranking 
Republican on the Senate Health and Education Committee 20 years ago, I 
was the U.S. Education Secretary. He even helped me in my confirmation 
process, for which I have always been deeply grateful. But he and I 
worked together during that time when the question of having a 
government loan program or a direct loan program came up. It was widely 
discussed. We had a Republican President then and a Democratic 
Congress. We came to a compromise. The compromise was to say let's have 
both. We will give students the option and help them stay on and keep 
the organizations on their toes. So if you are a student at the 
University of Tennessee, University of Utah, you have a choice. You can 
either say I don't want to fool with all these private lenders or the 
local bank or the nonprofit organizations in my State or Edsouth or 
others or the State organization, I want to go straight to the 
government. All institutions have that choice. That is 6,000 colleges 
and universities and 19 million students. Only one-fourth of them 
choose the government direct lending program.
  In the United States of America where choice and competition is an 
important part of our culture, that usually teaches us a lesson. That 
would suggest to us that most campuses, most students, by overwhelming 
majorities prefer being in the private market to lining up to go to the 
government. Otherwise we would have the government grocery store, we 
would have the government car company. Actually we are beginning to 
sound like that in this country. We would have the government insurance 
company and all banks would be government banks. Everything would be in 
the government.
  They used to have a system like that in the Soviet Union. Ours did a 
little better over time. Generally, our motto has been if you can find 
it in the Yellow Pages the government should not be doing it. What is 
happening with this administration and this Congress is the reverse. If 
you can find it in the Yellow Pages, the government should be doing it.
  Here is the situation that developed over the last 20 years. There 
are roughly 6,000 institutions of higher education in this country. 
Many people say all higher education is like the University of 
Tennessee or Harvard or University of California, but there are many 
kinds of colleges and universities--for-profit, nonprofit, private, 
public, historically Black colleges, many different kinds of 
institutions. The genius of our system is that we let Federal dollars, 
either through Pell grants or through loans, follow the student to the 
institution of their choice. Choice and competition in our system of 
higher education has given us by far the best system of higher 
education in the world.
  Of those 6,000 institutions, last year, 2008, 4,421 schools chose to 
use the regular student loan program. That is three out of four. About 
one out of four used the government loan, the direct loan program, the 
one that everybody is going to be made to use now. Currently there are 
just under 2,000 lenders who participate in the student loan program. 
They are banks and they are nonprofit institutions such as Edsouth in 
Tennessee.
  Last year nearly $100 billion in student loans was made. Let's keep 
in mind as the government takes this over we go from a system where we 
have government-backed loans, which cost the taxpayers very little, to 
government loans at the rate of $100 billion a year which means we are 
going to have to run up a half trillion more in debt at a time when our 
debt is ridiculously out of control. That is this weekend's newest 
Washington takeover that just occurred.
  There is not definitive evidence to suggest that the Federal 
Government can make these loans better than lenders can make these 
loans. I don't think the Department of Education has the manpower to do 
it. I think that by July 1 there is going to be consternation all over 
the country from families who have applied for student loans and are 
applying through their Federal call center or through the Internet.
  Edsouth, a nonprofit provider in Tennessee, for example, has five 
regional outreach counselors who canvas Tennessee and provide career 
training. They made 443 presentations to Tennessee schools to help 
students understand--remember, we have 200,000 of these students in 
Tennessee--to help them understand their options. They worked with 
12,000 students to help them understand what they could do. They worked 
with 1,000 school counselors.
  The U.S. Department of Education will soon be providing all of these 
services.
  Senator Gregg earlier had written the Congressional Budget Office 
asking how much money this Federal takeover would save. They came back 
with an explanation that it is not $67 billion or $61 billion, which is 
the current number being used today, but more like $47 billion. My own 
suspicion, and I cannot prove it, but my own suspicion, having been a 
university president, having been Secretary of Education and having 
watched this program for 20 years, is that in the real world the 
Federal Government is not going to make these 19 million loans more 
convenient for students. It is not going to be able to do it any 
cheaper. It is just going to deny people choice, run up the debt, throw 
31,000 people out of jobs, and the icing on the cake, and it is a sour-
tasting icing, is that the 19 million students who have student loans 
after July 1 are going to be overcharged by the Federal Government, 
which will be borrowing money at 2.8 percent, loaning it at 6.8 
percent, and using the money to help pay for the health care bill and 
other programs.
  Our friends on the other side, they will be saying--they like to 
blame everything on the bankers or the lenders--well, the lenders are 
charging too much money. Well, if they are charging too much money, 
reduce what they get.

[[Page S1929]]

You are saying there are $61 billion in savings, much of which comes 
from the fact that the Federal Government can borrow money more cheaply 
than private lenders can.
  But then you are saying, we are going to take the savings and we are 
going to spend it. We are going to overcharge these students. I can't 
believe the brazenness of this, and I believe neither will 19 million 
students understand it.
  So I am glad to come to the floor today and talk about my motion, 
which I will be glad to introduce at the appropriate time. No Senate 
bill has been introduced. Our committee has held no hearings. We have 
not had a markup of this bill. This is a wondrous Washington takeover 
over the weekend.
  We stick into the health care bill another Washington takeover, this 
time of 19 million student loans. On top of it: Congratulations, Mr. 
and Mrs. Working Student, you are going to get to be overcharged on 
your loan to help pay for the health care bill and other government 
programs.
  I hope my friends in the Senate, on both sides of the aisle, will see 
the injustice of this and say: OK, you are right, Senator Alexander. If 
we are going to take it over, and if we are going to create $61 billion 
in savings, at least let's give the students the savings. Let's not 
give it to the government. Let's not overcharge the students, on an 
average $25,000 student debt, $1,700 or $1,800 over 10 years.
  I think we need to have a truth-and-lending stamp that goes on every 
single student loan starting July 1 that says: Warning. Your government 
is overcharging you in order to help pay for other government programs.
  We will let the single mom who has a job, who is going to school to 
help improve her circumstances, see what she thinks about the idea of 
her being overcharged to help pay for other government programs.
  So my motion, when it is voted on, will do a very simple thing. It 
will say to the 19 million students in the country: We are going to 
reduce your interest rate on your student loan from a typical 6.8 
percent to 5.3 percent. That is going to save you $1,700 or $1,800 on 
an average loan over ten years. It says: We are not going to overcharge 
19 million students to help pay for the health care bill.
  Before I yield the floor, I see my friend from New Hampshire is 
engaged in conversation. I wonder if I could address the Senator from 
New Hampshire through the Chair. Before I yield the floor, I wished to 
ask, through the Chair, whether that is what I should do.
  Mr. GREGG. Well, I would like to ask the Senator from Tennessee a 
question on the substance of his proposal.
  Mr. ALEXANDER. I will be glad to take the Senator's question.
  Mr. GREGG. Because I do think it is an important proposal. As I 
understand it, what the Senator is saying is that they put this baggage 
on the train, which is the nationalization of all student loans in this 
country, the government is going to take them all over, which will be 
the fourth major nationalization event this administration has 
undertaken.
  First, they nationalized the auto industry. Now, they are in the 
process of quasi-nationalizing the health care industry. Now they are 
going to nationalize the educational industry. If the House final 
reform bill passes, they will essentially be nationalizing the 
financial industry--or having the capacity to--because they can break 
up any company, whether they are healthy or not, under the Kanjorski 
amendment.
  So my question is: They threw this proposal on the train, 
nationalizing the student loan industry, in order to use student loan 
money to finance the health care bill because this bill would have 
violated the budget rules if it did not have the student loan money 
basically paying for it?
  Mr. ALEXANDER. Mr. President, I am afraid the Senator from New 
Hampshire is exactly right. According to the Congressional Budget 
Office's updated estimate, $8.7 billion of this money that is being 
overcharged to students will be used to help pay for the health care 
bill.
  The other money, except for a small part, will be used for other 
government programs. So you are right on both counts--one Washington 
takeover after another. That is why I am saying, I think we ought to 
hide the Yellow Pages from these fellows because if they find something 
in there that is being done in the private sector, they are going to 
say: Oh, we can cut out the profit, we can cut out the business; why 
does not the government do it?
  Then, second, I mean this is astonishing to me. These are not Wall 
Street financiers going to community colleges in New Hampshire and 
Tennessee, these are people with jobs who are trying to improve their 
lot. Their student loan levels are already too high. We are worried 
about that. So we are going to take another $1,700 or $1,800 on a 
$25,000 average loan over 10 years. We are just going to say: Well, we 
will overcharge you. We are going to use that in government. The answer 
is, yes, to your question, Senator; $8.7 billion of the money taken 
from students by overcharging them on their student loans will go to 
help pay for the health care bill.
  Mr. GREGG. If I can ask a further question of the Senator. If they 
did not have that $8.7 billion of student loan money being used to 
finance the health care bill, this reconciliation bill would fall; 
would it not? Because it would not meet the budget instructions of 
having $1 billion of savings.
  Mr. ALEXANDER. The Senator is correct.
  Mr. GREGG. The Senator had a further question about whether the floor 
could be yielded. We are in the process of seeking a unanimous consent 
agreement.
  Mr. BAUCUS. I was going to ask the Senator from Tennessee a question.
  Mr. ALEXANDER. I will be glad to have a question.
  Mr. BAUCUS. Is it not true that the Congressional Budget Office 
stated in a letter, dated March 20, commented on the bill in a letter 
to the Speaker on page 13, where it states: The title as a whole--that 
is referring to the education title--states that the title as a whole 
would reduce budget deficits in both the 10-year projection period and 
in subsequent years.
  Is it not true that the Congressional Budget Office reached that 
conclusion and so states in their letter of March 20?
  Mr. ALEXANDER. Mr. President, I do not have that letter in front of 
me, and I do not know what that has to do with my amendment.
  What I am saying is, the Democratic majority is deliberately 
overcharging 19 million students to help pay for the health care bill. 
Those are the Congressional Budget Office's figures, not mine.
  I would ask, through the Chair, to the Senator from New Hampshire, 
whether I should at this point yield the floor.
  Mr. GREGG. I appreciate the Senator from Tennessee's courtesy. At 
this time, we are ready to go forward with a unanimous consent request.
  Mr. ALEXANDER. I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Montana is 
recognized.
  Mr. BAUCUS. Mr. President, I will propose a unanimous consent. 
Following that, I will state my intention on the order of votes, which 
I have yet to clear with the leader's office.
  I ask unanimous consent that the total time on the bill be divided 
equally between the majority and minority leaders or their designees 
and that the offering of amendments not add additional claims to the 
time.
  The ACTING PRESIDENT pro tempore. Is there objection?
  Mr. GREGG. Reserving the right to object, I would simply note that 
the next amendment on our side would be offered by Senator Hatch.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. GREGG. Mr. President, I would ask further unanimous consent----
  Mr. BAUCUS. Mr. President, I wish to finish up that business. It is 
something, I think, the Senator will appreciate.
  It is my intention--I am not asking for a unanimous consent 
agreement, but it is my intention that the order of amendments would 
be, beginning with the Gregg amendment, Medicare; McCain, target 
provisions; then the Crapo amendment on taxes; then the Enzi motion to 
commit, regarding employer mandates; the Barrasso amendment regarding 
premiums; and then,

[[Page S1930]]

next, the Grassley amendment regarding executive personnel should be in 
the exchange.
  Mr. GREGG. As I understand what the Senator is asking, is that the 
voting order be in the order they were offered.
  Mr. BAUCUS. That is correct. I am not asking consent. That is my 
intention, but there is no unanimous consent request at this time.
  Mr. President, I yield 10 minutes to the Senator from----
  Mr. GREGG. May I make a point? Mr. President, I spoke 
inappropriately. I believe the Senator from Tennessee will want to 
submit his amendment back for the Record. He had withdrawn it. Can we 
do that?
  I ask unanimous consent that the pending amendment be the Senator 
from Tennessee's amendment.
  The ACTING PRESIDENT pro tempore. Is there objection?
  Mr. BAUCUS. Reserving the right to object, I might ask if the 
understanding be that the motion, as on the earlier amendments, that 
this motion be set aside until a time to be determined by the leaders.
  Mr. GREGG. Why don't we do that on every amendment we offer so we do 
not have to do that.
  Mr. BAUCUS. That would be fine.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered. The Alexander motion is pending.
  Mr. BAUCUS. Mr. President, I yield 15 minutes to the Senator from 
Michigan, under the motion.
  The ACTING PRESIDENT pro tempore. The Senator from Michigan.
  Mr. LEVIN. Mr. President, the debate which will come to a close this 
week has, in one sense, been going on for a year. But in another sense, 
it has been going on for a century.
  In 1912, Theodore Roosevelt campaigned on the promise of a national 
health insurance program. Workers, Roosevelt said, are entitled to a 
basic standard of protection from injury and illness.

       Wherever such standards are not met by given 
     establishments, by given industries, are unprovided for by a 
     Legislature, or are balked by unenlightened courts, the 
     workers are in jeopardy, the progressive employer is 
     penalized, and the community pays a heavy cost in lessened 
     efficiency and in misery.

  Well, since Teddy Roosevelt said that, Presidents and Members of 
Congress from both parties, seeing the same costs Theodore Roosevelt 
saw in the failure to assure health care for all, have grappled with 
this issue.
  These attempts at reform have largely fallen short. They have 
foundered for many reasons: Health care is personal and complex. The 
timing was wrong or the politics were difficult. Leaders on all sides 
failed to find the compromises that would have enabled them to move 
forward. But the recurring theme is that time and again, reformers have 
failed to overcome the enormous obstacles that those who profit from 
the status quo have been able to erect. Because we have fallen short in 
the past, Americans today face a health care system that costs too much 
and too often delivers too little.
  In our United States today, mothers and fathers wonder what else they 
can cut from the family budget to afford yet another increase in their 
health care premiums. Parents file for bankruptcy because their 
insurance fell thousands of dollars short in providing for a child's 
lifesaving treatment. Nearly two-thirds of bankruptcies in this country 
involve medical costs, and more than half of those involve people who 
had insurance.
  Small business owners eliminate health coverage for employees because 
they cannot afford another year of massive premium increases. Thousands 
of Americans who woke this morning with health care insurance will go 
to bed tonight without it.
  Despite those tragic facts, entrenched interests have sought again to 
prevent reform to consign our Nation to an unsustainable status quo 
because what is good for the American people will not necessarily 
profit some company.
  The health insurance industry has dominated health care decisions in 
this country for too long. How often have our constituents come to us 
with stories of insurance companies that deny them coverage of 
necessary treatment? How often have our constituents told us of 
insurance companies that deny coverage because of preexisting 
conditions or canceled coverage because of minor inaccuracies the 
company conveniently discovered just after diagnosis of a serious and 
costly illness?
  It is time to end the unhealthy dominance of the health insurance 
industry. So I will cast my vote again against those entrenched 
interests and my vote will be for health care reform. I hope our 
colleagues will do the same.
  We have the opportunity to finish the task of overcoming the 
entrenched opposition to do what so many Presidents and so many Members 
of this body have fought for decades to accomplish.
  The months of debate have been difficult. They have too often been 
filled with too much heat and too little light, with exaggeration, with 
half-truth, with untruth, with innuendo designed to obscure rather than 
to inform.
  That is no different in many ways from some previous debates on major 
reforms. When Congress approved Social Security in 1935, one Republican 
Senator warned that it would ``end the progress of a great country.'' 
When Medicare was debated in 1965, one critic charged that cooperating 
with the plan would be ``complicit in evil.'' Scare tactics of the past 
proved absurd, but they worked.
  Now we get more scare tactics. A number of our Republican colleagues 
continue to claim this is a big government takeover of health care. The 
American Medical Association supports this health care plan. Surely the 
American Medical Association is not a supporter of a government 
takeover of health care. Then we are told this will hurt Medicare. Yet 
the association that represents more seniors than any other, AARP, 
endorses this health care plan.
  The scare tactics are coming at it again, but there is a difference. 
While scare tactics were able to derail health care reform in the past, 
scare tactics are just not working this time. The American people have 
expressed their disapproval of wild, inaccurate claims in many ways, 
including personal conversations with most of us.
  It is true that because health care is so complex, because changes 
must be phased in and transition periods are often necessary, many of 
the benefits of this bill will not take effect for some time. But 
improvements in health care for millions of Americans will take place 
almost immediately.
  After President Obama signed this bill into law, small businesses 
immediately got a tax cut to help defray the cost of providing 
insurance to their employees. Within 3 months of the signing yesterday, 
the bill will allow people with preexisting conditions to access a 
special fund to help cover the gap until insurance exchanges, where 
they can obtain coverage, become operational. And retiree health plans 
will qualify for a reinsurance program to help lower cost. In October, 
the Federal Government will begin helping States set up agencies to 
help consumers choose new health plans or to challenge unfair decisions 
by their current insurance plan. Eventually, those agencies will help 
consumers enroll in insurance exchanges that will help millions of 
people find dependable coverage that meets minimum quality standards at 
a price they are more likely to afford. Within 6 months of the 
President's signature yesterday, insurance reforms will begin to take 
hold. New health plans will be required to let women see an OB/GYN 
without seeking insurance company approval. They will be prohibited 
from denying coverage to children based on preexisting conditions and 
required to allow children to remain on their parents' policies until 
age 26. Insurance companies will have to provide preventive care 
without copays or deductibles, and they will be barred from setting 
lifetime coverage limits. Those historic improvements in our health 
care system will take place within the first 6 months after enactment 
of this legislation.
  More sweeping changes will come with full implementation of this 
bill's provisions. We will protect Americans of all ages from denial of 
coverage based on preexisting conditions, from annual limits on 
treatment, from exorbitant out-of-pocket costs, and from confusing and 
opaque language that disguises the cost or the scope of coverage. We 
will even require insurers to give customers a rebate if those insurers 
don't spend enough revenue on patient care. We will fill the Medicare

[[Page S1931]]

doughnut hole that hurts many seniors.
  At its heart, this bill and its improvements in this reconciliation 
effort aim to tackle the central problems of our health care system--
rising costs and the insecurity many Americans rightly feel about the 
lack of dependability of their insurance.
  The cost of health care already exceeds the ability of many American 
families to pay, will price more and more families out of the system if 
it continues to rise, and will present enormous problems for the 
Federal budget if not contained. We can and we will make the health 
insurance system work for those who already have coverage by holding 
down those unsustainable increases in premiums. In ways large and 
small, we attempt to tame this beast that threatens to swallow family 
budgets and our Federal budget.
  How are we going to do this?
  I ask the Chair how many minutes I have remaining.
  The ACTING PRESIDENT pro tempore. The Senator has 5\1/2\ minutes 
remaining.
  Mr. LEVIN. I thank the Chair.
  Mr. President, even though health care experts believe these measures 
are going to help lower costs for families and the government, the CBO 
is not even taking into account the savings which will come into 
existence by ending wasteful subsidies to insurance companies using 
Medicare Advantage, by requiring Medicare Advantage to spend at least 
85 percent of revenue on benefits, and by other kinds of savings. Some 
of those savings cannot be figured out precisely by the Congressional 
Budget Office. So they are prudent. They don't even take those savings 
into account. But what they do, obviously, take into account and do 
count are savings which will lead to $140 billion for the Federal 
budget in the first 10 years and $1 trillion over the next decade. 
Those savings are real savings. Those are savings which they can figure 
out and cost.
  We are going to subject investment income of the Nation's wealthiest 
families with incomes over $250,000 to the Medicare tax. We are going 
to impose a moderate Medicare tax increase on those who have that kind 
of earned income, over $\1/4\ million.
  This bill cracks down on artificial financial structures. I commend 
the Finance Committee, Senator Baucus and his colleagues. They are 
cracking down on artificial financial structures with no economic 
substance whose only purpose is to allow their users to avoid taxes. 
The Finance Committee has struggled with that issue for years. They 
have been trying to do this for years. They have succeeded. We pick up 
an awful lot of revenue that is owed to Uncle Sam by ending this kind 
of loophole which has allowed wealthy individuals to avoid paying taxes 
through the use of artificial financial structures that have no 
economic substance, whose only purpose is to avoid paying income taxes.
  We will take an enormous step with the passage of this reconciliation 
bill, joined with the bill the President signed yesterday. Leaders of 
our country--from Franklin Roosevelt to Harry Truman, Richard Nixon to 
Ted Kennedy--have fought so hard for these kinds of reforms. We are 
finally going to provide health insurance to millions of Americans who 
do not now have it, and we are going to protect those workers who Teddy 
Roosevelt warned nearly 100 years ago were in jeopardy unless every 
American had health insurance.
  Opponents of reform are vocal. They are strident. We are going to 
hear amendment after amendment being offered in an attempt to derail 
this effort. I hope our colleagues will answer history's call and make 
the real and lasting changes these bills provide, which will improve 
the lives of our citizens in ways we have been struggling to do in this 
Senate for decades and long before many of us got here.
  To those who continue to oppose reform, let me ask some questions. 
Isn't it long overdue to end discrimination based on preexisting 
conditions? The American people believe we should. So do I. Isn't it 
long overdue to end the insurance industry practice of rescissions, the 
denial of coverage to those who paid for it? The American people 
believe we should, and so do I. Should we not do something about the 
thousands of Americans who are forced into bankruptcy because of health 
expenses even though they have insurance they thought would protect 
them? The American people believe we should, and so do I. Should we not 
take strong steps to rein in enormous, ever-growing health care 
expenses, expenses that threaten to put health care out of reach for 
more and more Americans and to bankrupt our Nation? The American people 
believe we should. So do I. And should we not clear the way for 32 
million Americans who do not now have health insurance to obtain it? 
The American people believe we should, and so do I.
  I hope we will join together this week and do what so many before us 
have tried and been unable to do--to reform a system that leaves so 
many of our fellow citizens in jeopardy. I urge approval of this bill, 
this essential reconciliation bill, passed by the House as part of a 
package of historic legislation to finish the task of bringing landmark 
change to American health care.
  I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Montana is 
recognized.
  Mr. BAUCUS. Mr. President, I ask unanimous consent that Senators 
Warner, Begich, Burris, Tom Udall, Mark Udall, Shaheen, and Merkley be 
allowed to engage in a colloquy for up to 25 minutes.
  The PRESIDING OFFICER (Mr. Whitehouse). Without objection, it is so 
ordered.
  The Senator from Virginia is recognized.
  Mr. WARNER. Mr. President, as we approach the end of this long 
journey, at least the end of the first step of this long journey, I and 
a number of my colleagues are going to come one more time to the floor 
to engage in a conversation for a few moments about what this health 
care bill will mean to our constituents and to the people of the United 
States. We are going to talk about some of the causes of how we got 
here and some of the consequences of what would happen if we don't act. 
At the end, I will add some comments about how we make sure we 
implement this bill in the appropriate fashion.
  Recognizing that the hour is late and colleagues have other business, 
I first ask my good friend, the Senator from Illinois, Mr. Burris, if 
he would like to give a brief recap of why he has been such a firm 
supporter of this legislation and why he thinks this bill is so 
important, not only to the people of Illinois but to the people of the 
United States.
  Mr. BURRIS. Mr. President, I thank Senator Warner. I compliment him 
for his leadership in getting the freshmen engaged and involved in 
making sure we are getting the message out to the American people.
  This piece of legislation, which was signed yesterday by President 
Obama, is historic. I am proud and appreciative that I had the 
opportunity to play a part. As you know, my position was for a very 
strong public option. But as to the issues that are in it, we deal with 
cost and accountability for the insurance companies. Therefore, it is a 
major piece of legislation which we want the public to understand.
  We want the public to understand that for some people this law takes 
effect immediately. Small businesses benefit in that they will get a 
tax credit right away. These tax credits can total as much as 35 
percent of total premiums. Secondly, for children there will be no 
elimination for preexisting conditions. Within the next 90 days, these 
provisions will kick in on behalf of children. So there are a lot of 
things in this bill that will benefit all of us.
  We have been trying to do this for over 97 years.
  I say to my colleagues on the other side, the reconciliation bill is 
important to make some corrections. The battle they are waging, not 
from the standpoint of policy but certainly from the standpoint of 
politics, seeking to make a failure out of this issue, is not really 
fair to the American people. The misinformation that has been going out 
about this legislation is not fair.
  Not only are we going to see immediate benefits, but the long-term 
benefits of this legislation are also helpful. Situations dealing with 
preexisting conditions--in 2014, that will kick in. I remember when my 
daughter was changing jobs, she needed to get insurance because she had 
a headache problem. They wouldn't insure her. I had to

[[Page S1932]]

battle to get insurance for my daughter.
  This is good legislation. It is history. I want the American people 
to know that it is on the books, and we are going to make necessary 
corrections. The people will go forward.
  I thank my colleague from Virginia.
  Mr. WARNER. I thank Senator Burris for his comments. I know how hard 
he fought for this legislation, since day one.
  This legislation is going to have wide-ranging effects for people 
from all across the Nation.
  I now know my colleague, the Senator from North Carolina, wishes to 
speak. North Carolina and Virginia are neighbors. We both share a 
number of small businesses. We have a vibrant entrepreneurial flavor in 
Virginia and North Carolina. I know Senator Hagan has been concerned 
not only on the overall aspects of health care but particularly how 
this health care bill is going to affect small business in her State.
  I wish to now ask Senator Hagan to tell us how this bill will affect 
people in North Carolina.
  Mrs. HAGAN. I thank Senator Warner. I too appreciate the time for us 
to come down here and talk about the need for health care reform. The 
bill that was signed into law yesterday is getting us on that track.
  The new and historic law, combined with the bill we are now 
considering in the Senate, is going to reform our health care system to 
reduce costs and improve patient care for those families in North 
Carolina and in Virginia and families across America.
  In 1996, the average premium in North Carolina for a family of four 
was $6,000. Today it is $12,000. It is projected, in 2016, to be 
24,000. People cannot afford that. That is why we need to have change.
  After decades of working to fix a broken health care system, this law 
controls exploding costs, increases access to health care, and reduces 
our long-term deficit, which I know we are very concerned about, by as 
much as $1.2 trillion over the next 20 years.
  But in addition to containing costs, health care reform will improve 
access and quality of health care for millions of Americans. Right now, 
in North Carolina, we have 1.7 million people without insurance. They 
will now have access to a family doctor.
  This bill provides immediate benefits to small businesses, middle-
class families, and seniors in North Carolina. The small business 
owners whom I talk to want to provide coverage for their employees, but 
the costs are prohibitive.
  This month, I received an e-mail from a small chiropractic practice 
in eastern North Carolina that had to drop its health plan for its 
employees because the rates doubled over the last 2 years. But starting 
today, 112,000 North Carolinian small businesses will be eligible for 
tax credits to provide health care to their employees.
  Within the next 6 months, hard-working, middle-class families will be 
able to add their children up to the age of 26 on their health care 
plans. This will benefit about 870,000 young adults in my State.
  This year, insurance companies will no longer be able to deny 
coverage to a child for a preexisting condition, such as asthma or 
diabetes. And it means insurance companies will no longer be able to 
drop your coverage because you get sick or because you file too many 
claims.
  In North Carolina, 1.4 million seniors will receive preventive 
services with no additional costs, and 250,000 seniors will have their 
drug costs in the doughnut hole immediately reduced and eventually 
eliminated.
  I am proud of these immediate benefits and our efforts to reform the 
health care system over the long term. The health care reform effort 
would not have been possible without the work of tenacious Capitol Hill 
staffers. I personally want to thank two incredible health care 
staffers on my team, Michelle Adams and Tracy Zvenyach, who worked 
countless hours for reform in our country.
  Mr. WARNER. I thank Senator Hagan. I appreciate her leadership on 
this issue. Again, I also appreciate her recognition of not only the 
Members who have been struggling with the bill for almost a year, but 
the staff members who help us put together the facts, put together the 
case studies, who help us crunch the numbers, as we try to make sure we 
get this right.
  I now want to call on my friend, the Senator from Alaska. One of the 
things the freshmen have always said, as we have come to the floor over 
these months--as we have pointed out--is that the price of doing 
nothing is extraordinarily high to our economy, to our families, to our 
businesses, and that the status quo is not sustainable.
  I know this has been a theme Senator Begich has echoed repeatedly on 
the floor. As we come to the closing hours of this debate, if you could 
share with us one more time why you think the status quo is 
unacceptable. What is the price of doing nothing? How would that affect 
the people and businesses in the great State of Alaska?
  Senator Begich.
  Mr. BEGICH. I thank the Senator. Thank you again for your leadership, 
and especially as the freshmen group worked on the cost containment 
piece of this legislation. That was an important part we will see for 
many years to come.
  Over the next few days we are focusing on making a good bill a little 
bit better. Yesterday, the President signed the landmark legislation 
moving health care reform into law. So over the next few days, again, 
we are going to work on making that bill a little bit better. You are 
going to see clearly the differences. You are going to see our side of 
the equation has worked hard on this legislation. Those who voted for 
health care reform are on the side of American families, not on the 
side of the insurance industry. We are on the side of seniors who will 
see lower prescription drug costs--because reform is going to work in 
that direction--not on the side of big drug companies. We are on the 
side of American small business--not business as usual.
  I was truly proud to vote for and help pass that legislation last 
December. But as mentioned already this morning, there are many 
benefits that occur right now, this year. This year, for example, there 
is help for small businesses. As you just heard, immediately, firms 
with fewer than 10 workers get a tax credit worth 35 percent of what 
they will spend now on health insurance. It will eventually ramp up to 
a 50-percent tax credit, and firms with up to 25 workers will get a 
partial credit. For small businesses--truly the backbone of the Alaska 
business community and this country's business community--that is an 
immediate benefit.
  Coverage for preexisting conditions: Within 3 months, people with 
preexisting conditions and no insurance will get help. A $5 billion 
fund is being set up to provide them with affordable coverage.
  Coverage for dependent children: Within 6 months, parents will be 
able to extend their policies to cover their dependent children up to 
the age of 26.
  Some of these points you have already heard, as I said, this morning, 
but it is important to repeat them because I think in the noise over 
the last year and a half a lot of it got lost.
  Another--a very important one--free preventive care: Within 6 months, 
all insurance plans must provide free checkups. This includes seniors 
on Medicare. And there is much, much more when you look at this 
legislation.
  For my own State, the bill addresses many specific concerns I have 
heard in Alaska. It includes several of my amendments, including a 
panel to improve Federal health care in Alaska, increased loan 
forgiveness for thousands of new primary care providers, and added 
funding for community hospitals.
  We also, as a team of freshmen, wrote a cost containment amendment 
that cuts prices for consumers, increases value and innovation in the 
health care system and, as mentioned earlier--let's not forget--it is a 
deficit reducer: in the first 10 years, $143 billion, and in the next 
10 years, $1.3 trillion in deficit reduction.
  This bill is paid for--paid for. These are many of the improvements. 
Again, these improvements will save lives; add 32 million people, those 
uninsured--making sure they have coverage--save seniors on prescription 
drug costs by closing the doughnut hole; save families, by providing 
tax relief to help them afford health care; and crack down on waste and 
fraud.
  It has been an enormous time in this last year and a half working on 
this. But I also want to say, the next 3 days

[[Page S1933]]

will also be tedious and confusing to the public because what you will 
see on the other side is every imaginable amendment we would love to 
see--many of them we probably would love to vote for. I am not voting 
for any of them because the whole tactic is to delay the delivery, to 
ensure that people who want a family doctor will not get one, to 
protect the insurance companies instead of what we are trying to do to 
make sure people get a fair shake from their companies. So you are 
going to see that over the next 3 days.
  I think what is important for us is to remind Americans--Alaskans in 
my State--why this bill is important. It helps small business, 
families, seniors. It does it now. It is important. It is important for 
us to get it done. But do not be fooled by the next 3 days on what goes 
on this floor.
  We have passed health care reform. All we are doing now is making a 
good bill better.
  I thank the Senator from Virginia.
  Mr. WARNER. I thank the Senator. Thank you for your comments. Thank 
you for your leadership, particularly on a series of freshmen 
amendments that dealt with cost containment. And if time exists after 
my colleagues speak, I am going to go back to that issue.
  But I now want to ask my good friend from Oregon a question. No one 
has come to this body with more passion about making sure working 
families get a fair break, not only in health care but in the world of 
financial reform and issues that cut across the spectrum. I know one of 
the issues Senator Merkley has worked on tirelessly throughout this 
whole conversation is how to make sure the Oregon families get that 
fair break, get that fair shot, how to make sure health care is 
affordable.
  I would like you to share with our colleagues and those Americans who 
are at home watching what this health care bill does to help those 
middle-class Americans, middle-class Oregonians to make sure they get 
that fair shot, fair break in health care reform.
  Senator Merkley.
  Mr. MERKLEY. I thank the Senator so much. It is a pleasure to come 
here with my colleagues on the floor.
  I know when all of my colleagues go home, they hear stories from 
their constituents about our broken health care system. That certainly 
is what I hear. I hear it in my townhalls. I hear it on the street, as 
people stop me and share their story. And I certainly hear it in my 
mail.
  I have in my hand a few of the stories citizens in Oregon have sent 
to me. To give you a sense of the type of frustration we are hearing, 
Don writes:

       Last year my premium went up 65 percent even though I've 
     made no significant claims against my policy.

  Or we can turn to Jane, who says:

       . . . we are subject to being turned down for health 
     insurance [because] I have a chronic illness. . . .

  Or we can turn to Adrienne, who observes:

       The medical debt was crushing, and we were forced to file 
     for bankruptcy.

  Or we can turn to Amanda, who says:

       My daughter cut her finger. I took her to emergency, the 
     hospital is a network provider. The ER Physician said she 
     needed surgery. Okay, what do I know, they are the experts. 
     It turns out that the Surgeon is not a network provider. She 
     bills [me] over $9,000.00. . . .
       . . . I have little hope. Do I file [for] bankruptcy?

  Or we can turn to Art, who says:

       In less than 5 years, I had to change my health insurance 5 
     times. It was never a matter of choice; I simply had to take 
     whatever plan my employer decided to offer.

  Or Dagne, who observes: When I started to fill out my insurance form, 
I had ``Questions such as `Have you ever had . . . ' ''--for instance, 
I had asthma.
  And he goes on to describe his challenges. And the list goes on and 
on and on. That is why we are in this health care dialog. Because we 
need to fix our health care system that is broken for working 
Americans.
  The bill we have passed and the President has signed has three 
terrific provisions. It creates State-based markets for health care 
policies, where consumers can shop for the best policy. These markets 
will increase choice and competition. Second, the bill ends insurance 
company practices that victimize our working families--practices such 
as turning people down for preexisting conditions or dumping them off 
of their policies when they are injured or when they have a disease. 
And, third, it invests in our provider workforce to counter the rapid 
retirement of baby boomers. Out in Oregon, we are going to lose 20 
percent of our primary care physicians in the next 5 years, while many 
of us, as baby boomers ourselves, are going to need more health care.
  So those things are huge challenges. This bill takes a stride that is 
very significant, and this week we will work to pass--with an up-or-
down vote--a bill that will make further improvements to the bill the 
President signed yesterday.
  I am pleased to join my colleagues in this fight to repair a broken 
health care system that is not working for our working citizens.
  Thank you.
  Mr. WARNER. I thank Senator Merkley. Thank you for sharing those 
stories from real folks who are dealing with the current broken health 
care system. There are enormous stress, challenges, and burdens that 
our current system places on those families. I think we are taking a 
giant step forward. The President already has by signing into law the 
bill yesterday. We will continue that step with passing this 
reconciliation bill later this week.
  I now wish to call on another one of my colleagues, Senator Tom Udall 
of New Mexico. Senator Udall has, again, along with all the other 
freshmen colleagues, been a leader in this fight. He has particularly 
taken on the issue of prevention and the fact that we have a health 
care system in this country that is more a sick care system than it is 
a wellness and prevention system. I want to hear from Senator Udall 
about how the bill is going to affect the good folks of New Mexico.
  Senator Udall.
  Mr. UDALL of New Mexico. Mr. President, I thank Senator Warner for 
leading us and pulling us together in this freshman effort. It has been 
a pleasure to work with all of my fellow freshman Senators on the floor 
again and to join them right now. Last fall, we gathered right here in 
this Chamber to fight for health care reform. As a group, we helped 
lead the charge to make quality, affordable health care accessible to 
all Americans. Yesterday, the change we have been fighting for became a 
reality. With President Obama's signature, health care reform is now 
the law of the land.
  This moment has been a long time coming. Teddy Roosevelt first called 
for health care reform nearly a century ago. His banner was taken up by 
a long and distinguished list of men and women who advocated for 
change. For too many years, New Mexicans, like Americans across the 
country, have struggled to find or afford health insurance. They have 
struggled to hang on to policies that get more and more expensive and 
more and more restrictive every day. With this reform, all of that 
begins to change.
  No longer will insurance companies be able to discriminate based on 
preexisting conditions. No longer will they be able to dramatically 
increase rates without public scrutiny. No longer will 32 million 
Americans worry every day about what would happen to their families if 
they get sick or are in an accident. I am proud to have fought for and 
voted in favor of this historic legislation.
  This reform will benefit all Americans, including our country's First 
Americans, the 1.9 million American Indian and Alaska Natives who have 
spent too many years suffering because the federal government hasn't 
lived up to its promise to them.
  With this reform, we begin meeting our obligations to Native 
Americans by reforming the Indian health care system and permanently 
reauthorizing the Indian Health Care Improvement Act. This law, which 
provides a framework under which health care programs for Native 
Americans are delivered, hasn't been reauthorized in more than 10 
years. As a result, American Indian and Alaska Natives are three times 
as likely as whites to be uninsured, and almost half of low-income 
American Indians and Alaska Natives lack health coverage.
  With this reform, no longer will Native Americans be forced to suffer 
needlessly. No longer will they have to go without treatment for 
chronic conditions like diabetes and heart disease.

[[Page S1934]]

No longer will they have to put off basic care like colonoscopies or 
cholesterol screenings.
  I say again, today is a new day for health care in America. I am 
proud to have fought for, and voted in favor of, this historic 
legislation.
  Yesterday, we began taking back control of our own health care. 
Today, the journey continues. I pledge to continue fighting every day 
to ensure New Mexican families and small businesses have the security 
and stability that comes with access to quality, affordable health 
care.
  The reason I have fought so hard for reform is simple. For my 
constituents, the status quo is not an option. So it is the people of 
New Mexico I wish to talk about today. They are the reason I stand up 
every day and fight for comprehensive reform.
  People such as Katheryn Whitesides--Katheryn lives in Clayton, NM. We 
met last year when she attended one of my health care townhalls. 
Katheryn worked hard all her life. She had affordable insurance through 
her employer. But since she retired, Katheryn's health insurance 
premiums have risen dramatically from $110 a month when she was 
working, to more than $800 a month today. Katheryn's insurer recently 
denied a claim for a treatment she received. Now, on top of 
skyrocketing monthly premiums, she also owes about $4,000 in medical 
bills. That is more money than she receives from 5 months of pension 
payments.
  As Katheryn herself said:

       It's unsustainable for me. And I know I'm not the only one. 
     I'm just looking for some relief--not just for me, but for 
     all those people coming behind me.

  To folks such as Katheryn, I say: Relief is coming. This reform will 
make health insurance more affordable by placing caps on out-of-pocket 
medical expenses. It will make it more affordable by providing premium 
assistance through tax credits for low- and moderate-income families.
  I am fighting for New Mexicans such as Katheryn, and I am also 
fighting for New Mexico's small business and for entrepreneurs such as 
Arvind Raichur. Arvind has owned a small business in Albuquerque for 
more than a decade. As the boss, he has made it a priority to provide 
his employees with good benefits. For years, he paid 100 percent of his 
employees' health care premiums, but he is not sure how much longer he 
will be able to do that and stay afloat. You see, for the past few 
years, Arvind's insurer has increased his company's health care 
premiums by between 30 and 40 percent every year, and there is nothing 
Arvind can do about it.
  As Arvind said:

       We've got no bargaining power. We've got no leverage. I'm 
     insuring maybe a dozen people at my company here. It's very 
     hard. The insurance companies give you a 30 or 40
     percent increase and that's what you get. . . . It's too big 
     a bite.

  To small business owners such as Arvind and their employees, I say: 
Relief is coming.
  This reform will help small businesses by making it more affordable 
for them to offer coverage for their employees. We do this by providing 
tax credits for up to 50 percent of premiums and by creating small 
business health exchanges to build a larger employee pool.
  In New Mexico, the vast majority of our insured are employed, but 
they and their employers can't afford coverage. These new tax credits 
will help our small businesses provide insurance for their employees at 
a cost they can afford.
  For hardworking New Mexicans like Katheryn and for small business 
owners like Arvind, health care reform can't come fast enough. Katheryn 
and Arvind can't afford the health care status quo. Katheryn and Arvind 
are the reason I stand here today. To my friends on both sides of the 
aisle I say: Let's get this done.
  I am proud to be part of this body as we cast our final votes in 
favor of this landmark reform. With this final vote, we will finish 
this leg of the race. I look forward to building on this solid 
foundation in the coming months and years.
  I yield the floor.
  Mr. WARNER. I thank Senator Udall. I know our time is running out; 
just a final comment I wish to make.
  As many of my colleagues know, I had the honor of serving as Governor 
of Virginia before becoming a Senator. I think one of the differences 
between an executive and a legislator is, as a former executive I 
realize that passing the bill is just the first step. What happens is 
going to be in the implementation afterwards.
  The appeal I would make, particularly to my colleagues on the other 
side, is, I agree with some of their points that we don't go far enough 
on cost containment, but there are a lot of things in this bill where 
we grant the Secretary the ability to start experimental programs--on 
cost containment, on bundling of payments. How this bill is implemented 
is going to be where the rubber hits the road. I, for one, believe 
there is more we can do around this issue of cost containment, and I 
hope in the coming weeks and months, rather than being for repeal, they 
would join with us in finding that common ground to make this 
legislation even better.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I wish to let Senators know that we intend 
to alternate blocks of time, roughly a half hour on each side. So I ask 
unanimous consent that the next half hour be under the control of the 
Republicans and the half hour thereafter be under the control of the 
majority.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  The Senator from Florida.


                           Amendment No. 3586

  Mr. LeMIEUX. Mr. President, I ask unanimous consent to temporarily 
set aside the pending motions and amendments so that I may offer an 
amendment which is at the desk.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  The clerk will report the amendment.
  The legislative clerk read as follows:

       The Senator from Florida [Mr. LeMieux] proposes an 
     amendment numbered 3586.

  Mr. LeMIEUX. Mr. President, I ask unanimous consent that the reading 
of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

    (Purpose: To enroll Members of Congress in the Medicaid program)

       At the end of subtitle C of title I, add the following:

     SEC. 1207. MEMBERS OF CONGRESS REQUIRED TO HAVE COVERAGE 
                   UNDER MEDICAID INSTEAD OF THROUGH FEHBP.

       (a) In General.--Notwithstanding chapter 89 of title 5, 
     United States Code, title XIX of the Social Security Act, or 
     any provision of this Act, effective on the date of enactment 
     of this Act--
       (1) each Member of Congress shall be eligible for medical 
     assistance under the Medicaid plan of the State in which the 
     Member resides; and
       (2) any employer contribution under chapter 89 of title 5 
     of such Code on behalf of the Member may be paid only to the 
     State agency responsible for administering the Medicaid plan 
     in which the Member enrolls and not to the offeror of a plan 
     offered through the Federal employees health benefit program 
     under such chapter.
       (b) Payments by Federal Government.--The Secretary of 
     Health and Human Services, in consultation with the Director 
     of the Office of Personnel Management, shall establish 
     procedures under which the employer contributions that would 
     otherwise be made on behalf of a Member of Congress if the 
     Member were enrolled in a plan offered through the Federal 
     employees health benefit program may be made directly to the 
     State agencies described in subsection (a).
       (c) Ineligible for FEHBP.--Effective on the date of 
     enactment of this Act, no Member of Congress shall be 
     eligible to obtain health insurance coverage under the 
     program chapter 89 of title 5, United States Code.
       (d) Definition.--In this section, the term ``Member of 
     Congress'' means any member of the House of Representatives 
     or the Senate.

  Mr. LeMIEUX. Mr. President, I rise in support of the amendment I am 
offering today.
  I wish to thank my colleague from Virginia who asked us to think 
about the practical aspects of this health care reform. I just listened 
to my freshman colleagues on the Democratic side talk about all of the 
good things, in their opinion, this bill is going to do. There is one 
thing I didn't hear them speak about. I didn't hear them speak about 
the fact that half of the new people who are going to be covered by 
health care in this country--some 16 million of the 30-some million who

[[Page S1935]]

have the opportunity for health care under this law--are going into 
Medicaid.
  The practical impact my friend from Virginia asked us to think about 
is that our States right now are finding themselves in bankruptcy, 
realistically, because of the obligations of Medicaid. Our States, 
unlike the Federal Government, have to balance their budgets. Medicaid 
is a program that the States pay some 50 percent of, and they can't 
make it work. We are finding out in Florida right now that this 
program--this new law--will cost Florida $1 billion in the next 10 
years. Because they balance their budget and because they can't print 
money, that means the dollars will go away from teachers, away from 
students, and away from police.
  The point I wish to make today and the amendment I am offering is 
this: Several times, as I have been on the floor and heard from my 
Democratic colleagues, they have made this point: Why shouldn't the 
American people have the same health care that we in the Congress 
enjoy? Why shouldn't they, as do all Federal employees, be able to pick 
from a comprehensive and rich plan of benefits in order to take care of 
their health and the health of their families?
  That is a good point, but what is going to happen to these 16 million 
new Americans? They are going to go on Medicaid. That is not the plan 
we have. That is not the rich benefits the Members of Congress enjoy. 
Medicaid--health care for the poor, which will now have some 50 million 
Americans in it after these 16 million join it--is a program in crisis. 
It is a program that is failing.
  Let me give my colleagues some real examples. Right now we know 
patients on Medicaid can't find doctors who will treat them. We know in 
California, for example, 49 percent of family physicians do not 
participate in Medicaid.
  I entered this document into the Record last week. On March 17 the 
Seattle Times reported that Walgreens will no longer take new Medicaid 
patients in the city of Seattle. On March 15, the New York Times 
reported about Mrs. Vliet. She is in Flint, MI. She has cancer. For 2 
years she has been receiving treatment, but now her doctor is dropping 
her from Medicaid. He says:

       But after a while you realize that we're really losing 
     money on seeing those patients, not even breaking even. We 
     are starting to lose more and more money, month after month.

  All across America, health care providers are dumping Medicaid, and 
we are about to add 16 million new people. So I wish to take a page 
from my friends on the other side because they say the American people 
should have the same rich benefits we have.
  What I am proposing today with this amendment is that 535 Members of 
Congress should have the same benefits as these 16 million new people 
and these 50 million Americans. Under this amendment, the Members of 
Congress will go into Medicaid. If it is good enough for 50 million 
Americans, it should be good enough for us.
  So I have offered amendment No. 3586. It will require that the 
benefits that are paid for health care by the Federal Government for 
the 535 Members of Congress go to the State Medicaid agencies, and then 
we can all enjoy this program that 50 million people in America are 
struggling with. If it is good enough for 50 million Americans, it is 
good enough for Members of Congress.
  I wish to call upon my distinguished colleague from Arizona whom I 
know wishes to speak on this issue as well.
  Mr. McCAIN. Mr. President, I ask unanimous consent to engage in a 
colloquy with the Senator from Oklahoma, the Senator from Florida, and 
myself.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. McCAIN. Mr. President, I strongly support the amendment. Let me 
also just for a moment point out where we are.
  Where are we now that all the champagne has been drunk and all the 
celebration has gone on; the inside-the-beltway excitement has subsided 
along with the adoring media? Here we are: We have a budget deficit 
that is still $1.4 trillion. We still have 9.7 percent unemployment. 
Beginning right away we have $\1/2\ trillion worth of Medicare cuts 
that will take place over the next 10 years--$\1/2\ trillion beginning 
right away, $\1/2\ trillion worth of tax increases over the next 10 
years.
  Beginning in 4 years, $2.5 trillion in new health care entitlements 
spending begin. The plan still puts government in control. It still 
mandates that every American must purchase a government designed and 
approved health policy. It still mandates that employers have to 
provide health insurance or pay a fee, and 330,000 Medicare Advantage 
members in my State are going to be exposed to drastic cuts.
  Fortunately, we took out one of the sweetheart deals so that now, at 
least the 800,000 who were carved out before in Florida will be subject 
to the same cuts. No one, no one, no one believes--the so-called doc 
fix--that the 21-percent cut in physicians payments for treatment of 
Medicare patients is going to happen.
  You can put lipstick on a pig, but this is still a pig. I noticed the 
Senator from Illinois came to the floor this morning and said how great 
this is and how there is going to be real reductions in the deficit as 
a result of this legislation. I wonder what his response has been to 
one of the biggest corporations in the State of Illinois, Caterpillar, 
who sent him a letter saying:

       In our fragile economy, we can ill afford increases that 
     place us at a disadvantage versus global competitors that are 
     not similarly burdened.

  They state:

       Elements of the legislation would drive up Caterpillar's 
     health care costs by more than 20 percent, over $100 million.

  The Senator from Illinois is sponsoring legislation that increases 
costs for one of the largest manufacturers and exporters in America 
that is going to increase their cost by $100 million. I wonder when he 
is going to go out and visit headquarters out there in Peoria. I hope 
it is soon.
  The fact is, there are things in this legislation that are wrong, and 
there are things that are left out of this legislation that are wrong, 
including $100 billion a year that could be saved by medical 
malpractice reform. Is there anything in those 2,073 pages that have 
anything to do with medical malpractice reform? That is the dirty 
little secret. The dirty little secret in this body is that trial 
lawyers control the agenda, certainly as far as this legislation is 
concerned.
  The State of Texas has reduced costs, has reduced premiums, and has 
increased the number of people who have been able to--lawsuit filings 
are down from defensive medicine increases for annual costs by 10 
percent. Physician recruitment is up. The largest malpractice insurance 
company in the State has sliced its premiums by 35 percent, saving 
doctors some $217 million over 4 years in the State of Texas. And I 
would like to ask my friend from Oklahoma why in the world we would not 
enact medical malpractice reform if we are truly interested in reducing 
the cost of health care in America.

  The Senator from Oklahoma and our other doctor in the Senate, Senator 
Barrasso from Wyoming, can testify because of their experience of the 
requirement to practice defensive medicine, which could be as much as 
$100 billion a year. So here we are, looking at dramatic increases in 
cost, and the President is going around the country saying that 
insurance premiums will go down. Individual premiums will go up between 
10 and 13 percent. You know, facts are stubborn things.
  So I would ask my friend from Oklahoma if he might talk a little bit 
about not only what is in this bill but what is not in this bill, and 
medical malpractice reform is certainly something that anyone would 
logically assume would be part of any real reform if you are interested 
in reducing cost.
  If you are interested in increasing government bureaucracy, I hear 
this bill could mean the employment or hiring of some 16,500 new IRS 
agents. We are trying to track down the facts behind that. So we are 
now embarked on one of the greatest expansions of government in the 
history of this country.
  Mr. COBURN. I thank the Senator for his question. If you look at 
Thomson Reuters and several others who have studied the health care 
field, the estimate for defensive medicine costs is $250 billion a 
year. It is not just that we order tests that protect us from frivolous 
lawsuits, but those tests have consequences. Some of those tests 
actually hurt patients or expose them to radiation or, in fact, limit 
our ability

[[Page S1936]]

to do what is best for the patient because we are more interested in 
protecting ourselves.
  Mr. McCAIN. May I ask the opinion of the Senator from Oklahoma as to 
why he thinks there is no address of medical malpractice reform 
whatsoever in this legislation that has the slightest impact on 
reducing health care costs?
  Mr. COBURN. I think there are two reasons. One is because there is 
large support of those who wrote this legislation by those who benefit 
from suing doctors. That is pretty straightforward. And the doctor's 
only defense is to order tests which they need but which the patient 
doesn't necessarily need. The second is because they couldn't get--or 
wouldn't put it in the bill because they knew it would pass and the 
American people would agree with it. You know, it is beyond me.
  But let me go to the point of this current amendment. I have 
delivered somewhere over 4,000 babies, and 2,000 of those were Medicaid 
babies. Over half the babies I have delivered in my life I have cared 
for through Medicaid. The State of Oklahoma just cut, in February or 
March, Medicaid reimbursements 3 percent. They are going to cut it 
another 8 percent. Forty percent of the primary care doctors don't see 
Medicaid patients because the price that is paid for the coverage 
doesn't cover the cost, let alone any margin. It doesn't cover the cost 
of nurses, the rent, the malpractice, and everything else.
  The second point is, of the specialists who are available, 65 percent 
of the specialists in this country won't see Medicaid patients. So when 
I am taking care of Medicaid patients, I have trouble finding somebody 
better than me in a specialized area to care for my patients.
  What is the other thing we know about Medicaid? Even if you normalize 
for social factors, their outcomes are worse. The cost in terms of the 
number of procedures, the failure of therapeutics--all are worse.
  So why is this a good idea? It is not just a political stunt. If 
Members of Congress are enrolled in Medicaid, the first thing that is 
going to happen is Medicaid and reimbursements are going to go up so 
that the availability of the finest and the best and the brightest in 
this country is available to Members of Congress. So it is not just a 
stunt to say we put our membership in Medicaid; it is a very important 
ulterior motive to improve Medicaid.
  Think about it. If you are one of the 16 million people who are going 
to get health care under Medicaid, supposedly, in this bill--and I 
doubt that seriously, simply because we are going to see a marked 
decrease of 50 or 60 percent of doctors who won't see them--think about 
what is going to happen: You are not going to be able to find a doctor. 
You may have coverage, but you won't be able to get anybody to care for 
you. Is that coverage? Is that care? Is that prevention? Is that 
management of chronic disease? No. None of that will happen.
  So the whole idea of placing us in a leadership position into 
Medicaid is so that we will lead and fix it and make it what it should 
be. There is only one health care system worse in America than 
Medicaid, and that is the Indian Health Service. That is the only one 
that is worse. Everything else outside of those two programs is better. 
So why would we consign 16 million Americans to a health care program 
that is failing today? So the way to fix that is to put us into it. And 
I guarantee you, the self-interests of the Members of Congress will fix 
Medicaid and make it what it should be.
  With that, I yield back to the original author of the amendment.
  Mr. LeMIEUX. I thank my friend and colleague from Oklahoma.
  How could anyone in this body not vote for this amendment? Why should 
we have better health care than the 16 million people whom we are going 
to put into Medicaid, and now will be 50 million Americans? Why should 
we have it better? Why should we have a gold-plated premium health care 
plan?
  Look, I have a family of five. We are going to have a baby any day--
could be today--so it will be a family of six. I pay $400 a month on 
the government program--$5,000 a year. Could I get that in the 
marketplace? Of course I couldn't. There is a doctor here in the 
Capitol, a whole staff of them, anytime I want to see a doctor. I get 
fantastic health care as a Member of Congress.
  Why shouldn't we have the same health care we are subjecting 15 
million new Americans to and 50 million Americans in total? As my 
friend from Oklahoma says, certainly won't that make the point to us 
that this health care system is failing? What will happen when a Member 
of Congress tries to find a doctor and can't find a doctor who will 
take him? What is going to happen when he tries to find a specialist 
and no specialist will take him? You don't hear our friends on the 
other side talking about the fact that half of the people getting 
coverage under this legislation are going into a failing system. That 
is not one of their talking points, but it is the truth. So I challenge 
my friends who say that they should walk among the least of us to vote 
for this amendment.
  I want to turn again to my colleague from Arizona. He and I have 
expressed our distress about this bill for lots of reasons, but a 
specific reason is that we both represent States with lots of seniors.
  We have this Medicare Advantage Program that is going to get $200 
billion cut out of it. That will really affect our two States. So I 
wonder--and I would ask my colleague, the distinguished Senator from 
Arizona, to speak on this issue--how is this going to affect seniors in 
Arizona when we are raiding Medicare to start this new program?
  Mr. McCAIN. I thank my friend from Florida. The fact is, Medicare 
Advantage is a program that provides seniors with choices. That is one 
of the reasons it is a major target of the other side--because it 
doesn't fit in, then, with the government mandates this whole bill 
embodies. So I am worried about the 11 million Americans who have the 
Medicare Advantage Program.
  I would like to refer my colleagues to an article--I know the Senator 
from Utah is waiting, if he would just give me another minute or so 
here--today in the Wall Street Journal titled ``Now, Can We Have 
Health-Care Reform?'' And I want to quote from part of it, as follows:

       Health insurers, and indeed Corporate America as a whole, 
     are like monkeys who are caught by staking a glass jar to the 
     ground with a shiny trinket inside. They won't let go so they 
     can't get their hands out of the jar. That trinket is the 
     ruinous and regressive $250 billion-a-year tax benefit for 
     employer-provided insurance.

  That is the elephant in the room, my friends.

       Corporate America isn't brave enough to argue against a 
     direct subsidy to its employment costs, no matter how 
     perverse its impact in insulating consumers from the true 
     cost of their health care choices. Insurers are not brave 
     enough to say: Give us a tax code that lets us go back to 
     being insurers rather than a tax laundromat for the middle 
     class's health care spending.
       Almost any bill would have been worth having that 
     fundamentally fixed this tax distortion, regardless of its 
     other elements.
       We say this because any bill, including the one signed by 
     the President yesterday, will be revisited many times in the 
     future. Millions of pages of rules will be written by 
     regulators before we see how it really works. Congress itself 
     will return in predictable ways: It will reverse the proposed 
     Medicare cuts that created ObamaCare's illusion of fiscal 
     probity. It will tighten the mandate that requires insurers 
     to cover the sick at favorable prices. It will not tighten 
     the requirement that the young and healthy buy insurance at 
     prices that subsidize the old and unhealthy.
       More and more tax money will have to be found to keep the 
     jalopy on the road. More and more administrative controls on 
     medicine will attempt vainly to keep the jalopy from 
     bankrupting the Nation.
       Under the law just signed, employers have even more 
     incentive than they did yesterday to lavish excessive health 
     insurance on their high-end employees.

  Mr. President, I ask unanimous consent to have printed in the Record 
this entire Wall Street Journal article.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

             [From the Wall Street Journal, Mar. 24, 2010]

                  Now, Can We Have Health-Care Reform?

                      (By Holman W. Jenkins, Jr.)

       A certain kind of person--we get emails from them all the 
     time--understands exactly nothing about the health-care 
     debate, but thinks they know who the villain is: the 
     insurance industry.
       Barack Obama is not one of them. In the desperate hours he 
     played to public ignorance. But from the beginning, the 
     industry was his ally because he set out to solve its

[[Page S1937]]

     biggest problem--which is not the same as America's biggest 
     problem.
       We'll let Angela Braly, CEO of insurer WellPoint, take the 
     story from here. She was recently hauled before Congress to 
     justify her company's proposed 39% rate hike in California. 
     She explained the source was two-fold: rising medical costs 
     and healthier customers dropping their coverage, forcing the 
     sick to pick up the tab.
       Now this sounds like two problems, but for WellPoint and 
     other insurers it's really only one problem. Once everyone is 
     required by government mandate to buy insurance, the 
     industry's survival is no longer threatened: It can just pass 
     its skyrocketing costs along to customers. Once customers can 
     no longer refuse to buy the industry's product, the problem 
     of costs won't be fixed, but it no longer is the insurance 
     industry's problem.
       There, in that one sentence, we give you the failure of 
     ObamaCare, the failure of the congressional health-care 
     debate, the failure of health-care politics in this country.
       Health insurers, and indeed Corporate America as a whole, 
     are like monkeys who are caught by staking a glass jar to the 
     ground with a shiny trinket inside. They won't let go so they 
     can't get their hands out of the jar. That trinket is the 
     ruinous and regressive $250 billion-a-year tax benefit for 
     employer-provided insurance.
       Corporate America isn't brave enough to argue against a 
     direct subsidy to its employment costs, no matter how 
     perverse its impact in insulating consumers from the true 
     cost of their health care choices. Insurers are not brave 
     enough to say: Give us a tax code that lets us go back to 
     being insurers rather than a tax laundromat for the middle 
     class's health-care spending.
       Almost any bill would have been worth having that 
     fundamentally fixed this tax distortion, regardless of its 
     other elements.
       We say this because any bill, including the one signed by 
     the president yesterday, will be revisited many times in the 
     future. Millions of pages of rules will be written by 
     regulators before we see how it really works. Congress itself 
     will return in predictable ways: It will reverse the proposed 
     Medicare cuts that created ObamaCare's illusion of fiscal 
     probity. It will tighten the mandate that requires insurers 
     to cover the sick at favorable prices. It will not tighten 
     the requirement that the young and healthy buy insurance at 
     prices that subsidize the old and unhealthy.
       More and more tax money will have to be found to keep the 
     jalopy on the road. More and more administrative controls on 
     medicine will attempt vainly to keep the jalopy from 
     bankrupting the nation.
       Under the law just signed, employers have even more 
     incentive than they did yesterday to lavish excessive health 
     insurance on their high-end employees. They have less 
     incentive to cover low-end workers, or even hire them.
       For the young, healthy or anyone not stumbling into a giant 
     tax handout, buying insurance at the inflated prices 
     available in the marketplace would be an even crazier 
     financial decision today than it was yesterday--because now 
     you can wait and buy it when you're sick.
       For insurers, the check is in the mail: So watered down is 
     the individual mandate that it must accelerate the industry's 
     death spiral if not for the massive subsidies the government 
     now has obliged itself to provide to keep the industry afloat 
     and allow insurers to continue scalping their 15% off the top 
     for serving as gatekeeper to a tax loophole.
       When all is said and done, with unerring accuracy, 
     ObamaCare has ended up doubling down on the system's existing 
     perversities. The one thing it doesn't do (though it would be 
     perfectly consistent with the Democratic goal of universal 
     access) is incentivize a health-care marketplace based on 
     competition in price and quality.
       A world-class hospital in India does heart surgery the 
     equal of any heart surgery in America, but does so at one-
     tenth the cost (and increasingly attracts a world-wide 
     clientele). The reason is not what you think: low-paid 
     doctors and nurses. The reason is that competition works in 
     medicine as it does in everything else when the patient cares 
     about getting value for money. This is the great low-hanging 
     fruit of health-care reform. It continues to hang.

  Mr. McCAIN. Mr. President, I thank my friend from Utah for his 
indulgence.
  The other side is going around the country right now telling the 
American people things that simply are not correct, including the fact 
that these budget projections we know are patently false, not because 
CBO gave us false numbers but because the assumptions were wrong. One 
of the biggest assumptions--and we will be talking about this more--is 
the so-called doc fix. Is there anyone who believes we are going to 
have a 21-percent cut in Medicare physician payments this fall?
  I would ask my friend, the Senator from Utah, who is very familiar 
with this issue--I know he has an amendment, but this is one of the 
reasons Americans are so angry. They know they are not going to cut 
doctors' payments from Medicare by 21 percent, and that is a 
fundamental part of the assessments as to the cost by CBO. It is a sham 
perpetrated on the American people.
  So I would say to my friend from Florida and my friend from Utah, we 
will be back on the floor probably this fall sometime or early next 
year, and we will be talking about the fact that this doc fix--the 
doctor payments provision of health care for Medicare enrollees--was 
not cut 21 percent, as the other side is telling the American people 
that it will be. It is not fair to the American people, I would say to 
my friend from Utah.
  Mr. HATCH. I agree with my friend from Arizona, no question.


                            Motion to Commit

  Mr. HATCH. Mr. President, I ask unanimous consent to set aside the 
pending motion to offer a motion to commit.
  The PRESIDING OFFICER. Without objection, the clerk will report.
  The legislative clerk read as follows:

       The Senator from Utah [Mr. Hatch] moves to commit the bill 
     H.R. 4872 to the Committee on Finance with instructions to 
     report the same back to the Senate within 1 day with changes 
     to strike all cuts to the Medicare Advantage program and add 
     an offset if the Department of Health and Human Services' 
     actuary certifies that 1,000,000 or more Medicare Advantage 
     beneficiaries, American seniors, and disabled individuals, 
     will lose their current Medicare Advantage coverage or plan 
     benefits.

  Mr. HATCH. Mr. President, before I discuss my motion to commit to 
protect the Medicare Advantage Program for more than 10 million 
seniors, I would like to take a few moments to discuss the broader 
issue of health care reform.
  To be honest, we have never seen anything like the issues facing our 
country right now. We are at a pivotal point as a Nation. The line 
between private businesses and public government has never been so 
blurred. Government effectively owns several of our Nation's financial 
institutions, insurance companies, and auto manufacturers. CEOs have 
been fired by government bureaucrats, and Washington is now in the 
business of running our health care system more than ever before.
  Our fiscal outlook is bleaker than ever. According to the recent 10-
year outlook by the Congressional Budget Office, the CBO, the current 
administration's policies would add $8.5 trillion to our already record 
national debt. The report also confirmed that we would be facing a 
record deficit of $1.5 trillion this year, along with a dire prediction 
of our deficits only getting worse after 2015 and beyond.
  Let me put this in perspective. Our deficit this year is the largest 
yearly deficit since 1945. It is 10 percent of our entire economy. Our 
national debt is on a path to double in the next 5 years and triple in 
the next 10 years. According to CBO, our national debt will explode to 
$20.3 trillion by 2020 or 90 percent of our GDP. We are literally 
drowning the future of this Nation and the future of our kids and 
grandkids in a sea of red ink.
  I deliver these remarks with a heavy heart because what could have 
been a strong bipartisan bill reflecting our collective and genuine 
desire for responsible health care reform turned out to be an extremely 
partisan exercise resulting in one of the largest big-government 
spending bills being signed into law yesterday. We are jamming through 
another 153-page addition of new taxes and spending.

  Recent polls show that a majority of Americans remain concerned and 
skeptical about all the promises of reduced deficits and lower costs 
under this legislation. Why? Because they know there is no such thing 
as a free lunch, especially when Washington is the one inviting you 
over.
  According to the administration's own Actuary at the Centers for 
Medicare and Medicaid Services, CMS, the health care bill signed by 
President Obama yesterday will actually raise our total health care 
spending by $222 billion over the next 10 years. That does not even 
include the doc fix the distinguished Senator from Arizona was talking 
about, which is as much as $371 billion more.
  But the most cynical joke played by Washington on the American people 
in this entire exercise has been the promise of this $2.5 trillion tax-
and-spend bill actually reducing our deficit. Nobody believes that.
  The biggest bait and switch on the American people about the bill's 
impact on the deficit is a simple math

[[Page S1938]]

trick. If something is too expensive to do for a full 10-year period, 
just do it for 5 or 6 years. Most of the major spending provisions of 
the bill do not go into effect until 2014 or later--coincidentally 
after the 2012 Presidential elections. So what we are seeing is not a 
full 10-year score but rather a 6-year score. According to the Senate 
Budget Committee, the full 10-year score of the Senate bill would 
approach $2.5 trillion. We are already spending $2.4 trillion.
  More importantly, let me also clarify what the Congressional Budget 
Office has said on the nearly $500 billion in Medicare cuts which my 
friends on the other side argue will magically not only extend Medicare 
solvency but also pay for a large part of this bill. This is like 
telling American families that they can spend the same magical dollar 
to not only pay their mortgage but also their credit cards. It is 
nonsensical. Here is what the experts at CBO said:

       The key point is that the savings to Medicare trust fund . 
     . . would be received by 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.

  By the way, did I mention that at a time when major government 
programs like Medicare and Medicaid are already on a path to fiscal 
insolvency, it is interesting to note that more than half of the newly 
covered lives, 16 million out of the 32 million, are simply being 
pushed into the Medicaid Program. And if anyone thinks that States, 
that are facing more than $200 billion in deficits, will not be left 
holding the bag in the future, then I have a bridge to sell to you.
  I have said all along that this is not a fight between Republicans 
and Democrats, but a fight between the Democrats and a majority of 
Americans who did not want this bill. In townhall after townhall and 
poll after poll and election after election, Americans begged 
Washington to listen to their voices. But Washington ignored them and 
used every means necessary--from backroom deals to procedural 
trickery--to get this bill passed.
  We need to remember the real implications of these policies--not 
simply in terms of political legacies and ideological holy grails--but 
in terms of its impact on the future of our children and grandchildren. 
We need to ensure that they have the same opportunities to prosper that 
we have all been blessed with.
  I would now like to speak for a few minutes about a motion to 
commit that I will be offering. My motion to commit states that if the 
Actuary of the Department of Health and Human Services certifies that 1 
million Medicare Advantage beneficiaries lose their coverage or 
benefits, the cuts to the Medicare Advantage program will not go into 
effect. It is that simple.

  It is important to point out that the bill the President signed into 
law yesterday would slash $120 billion from the Medicare Advantage 
program. This reconciliation bill would cut the program by an 
additional $66 billion for a grand total of $202 billion.
  Before the health care reform bill was signed into law, CBO projected 
that Medicare Advantage enrollment would have increased from 10.9 
million in 2010 to 13.9 million in 2019. Now, Medicare Advantage 
enrollment will be 4.8 million less in 2019 due to the passage of the 
new health bill or almost 2 million less than today.
  CBO also projected that rebates for additional benefits and reduced 
cost- sharing offered through Medicare Advantage would be reduced by 50 
percent from $135 per member per month to $67 per member per month in 
2019. These lost benefits include lower premiums, lower copayments, and 
lower deductibles. It will also impact everything from hearing aids to 
dental and vision benefits. Most importantly, it would violate 
President Obama's own pledge ``if you like what you have, you may keep 
it.''
  Medicare Advantage works. Every Medicare beneficiary has access to a 
Medicare Advantage plan. Almost 90 percent of Medicare beneficiaries 
participating in the program are satisfied with their health coverage. 
It is time for us to stand up for more than 10 million seniors and 
ensure that this program is not used as a piggy-bank to finance 
Washington's big government plans.
  I appreciate my colleagues allowing me to go maybe a minute longer 
than I should have, but I urge my colleagues to support my motion to 
commit this bill.
  The PRESIDING OFFICER. Who yields time? The Senator from Montana.
  Mr. BAUCUS. Mr. President, have Republicans used up their time?
  The PRESIDING OFFICER. The Republicans have 1 minute remaining.
  Mr. BAUCUS. I don't mean to be picky, but I assume they will yield 
back that minute.
  Mr. HATCH. I will yield back the minute.
  Mr. BAUCUS. I will yield 15 minutes to the Senator from Maryland.
  The PRESIDING OFFICER. The Senator from Maryland.
  Ms. MIKULSKI. Mr. President, this is indeed a great day because we 
are passing real health care reform for American families, for American 
workers, for American small business, for seniors, and our communities. 
Health care reform will save lives. No longer will dreams and lives be 
endangered because people lost their health care insurance when they 
got sick, lost a job or had an accident.
  I listened to the other side which says they listen to the people. 
You heard the old saying, ``Men are from Mars, women are from Venus.'' 
I think that party is from Mars and we are from planet Earth. I think 
they have been out in orbit. The planet Earth that I am on tells me to 
pass health insurance reform.
  One of the reasons I am voting for this bill, the main reason I am 
voting for this bill, is the stories I heard from my constituents in 
Maryland--roundtables, townhalls, hearings, lots of letters, phone 
calls, e-mails. They told me about the situation in their lives, where 
they were terrified that one big health care incident could lead them 
into bankruptcy. They were terrified that if they had changed a job to 
one in our new high-tech communities that would have offered great 
opportunity for them--they didn't take it because they were not going 
to have health insurance.
  When I listen to people, I think about the lady in Cumberland who 
works full time, but her employer does not provide health insurance and 
she is terrified that she is one sickness away from a catastrophic 
situation, or from Karen, in Kensington, whose father had to quit work 
because he had Crohn's disease. He was making payments on his 
insurance. He was two payments short, and they canceled his insurance. 
It took him 6 months to try to get it back. He lost his coverage, and 
he was only 59 years old when he passed away.
  Then there were the breast cancer survivors, the wonderful women and 
the men they love who are out there raising money for the cure. But 
even in a prosperous community such as Annapolis, a woman told me how 
she lost her job and with it her family's health insurance, and when 
her insurance ran out, she was terrified she would lose her cancer 
treatment.
  Walking around the diners--and I love diners. I see myself as a diner 
Democrat. In every diner it is usually multigenerational people. What 
do they tell me? Barb, don't forget the old people. Senator Barb, no 
matter what, keep Medicare stable. If you are 50 years old, you are 
terrified your parents can lose their Medicare and it is going to fall 
on you. The sandwiches they are eating are eaten by the sandwich 
generation, worried about the oldtimers' health care, worried about 
keeping their own, and then trying to figure out how they were going to 
pay for college. Medicare has multigenerational implications.
  This is why in this bill I am so proud of the fact that we are going 
to stabilize Medicare for another 10 years and do very important 
reforms in Medicare.
  I am also pleased to respond to the people who said no matter what, 
make health care available and affordable. For every parent who has 
ever worried about covering a child with a chronic illness, whether 
autism or cerebral palsy or juvenile diabetes, they will always be able 
to get health insurance. The small business owner, such as my own 
father who once had a grocery store or my grandmother who had the best 
bakery shop, worried about how they were going to provide individual

[[Page S1939]]

health care for themselves--this generation will not have to worry 
about that.
  This bill is an exceptional one. We save Medicare, expand its 
solvency for another nearly a decade. We end the punitive practices of 
insurance companies. We expand uniform access, and we pay for it with 
an emphasis on wellness and quality, saying goodbye to quantity 
medicine and emphasizing quality medicine; goodbye to volume medicine 
and getting value for our dollar.
  For our seniors, one of the most important things we will do is close 
that doughnut hole. The doughnut hole has been hard to swallow ever 
since this bill was passed. We are going to provide a $250 rebate for 
seniors who hit the gap in the prescription drug benefit and also offer 
a better discount on prescription drugs.
  I am also very excited and honored because of the role I played in 
making sure we ended the punitive practices of insurance companies 
toward women. For too long, in too many ways, they treated simply being 
a woman as a preexisting condition. First of all, they charged us 30 
percent to 40 percent more just simply to be able to get insurance. 
Then they would have the punitive practices of denying us health 
insurance for a preexisting condition. In eight States, domestic 
violence was viewed as a preexisting condition. You talk about being 
abused--you were abused by your husband, then you were abused by your 
insurance company. We are not going to be battered anymore by these 
companies. We ended that in this bill.
  Then there was the hearing that shocked and chilled me, a hearing on 
gender discrimination in insurance. A woman told a compelling story, 
Peggy from Colorado, that after she had a C-section and a premature 
baby, the costs were high. She lost her health insurance and when she 
went to apply they told her in order to get health insurance, because 
she had a premature baby, because she had a C-section, they would not 
give her health insurance unless she was sterilized.
  I couldn't believe it. That is what fascist countries do. That is 
what authoritarian regimes do. It was not the Taliban in Afghanistan, 
it was an insurance company in Colorado. We took up that fight and 
ended those abusive practices in this bill. Never again will a woman be 
able to be denied health insurance because of any preexisting 
condition. We ended gender discrimination in charging women more.
  But as the debate went forward, they wanted to take the mammograms 
away from us and they didn't want to put mammogram and preventive 
services for women in the bill. They said it costs too much money.
  I didn't want to hear that. I asked the women to suit up and come to 
the floor and we offered an amendment. The good men of the Senate also 
joined us. Many remember we wore pink that day. Today we are in the 
pink as well. We offered our amendment to ensure preventive services 
for women so that if your doctor says you need a mammogram, you are 
going to get one. If you need screening for cervical cancer or a Pap 
smear, you are going to get one and you are not going to have to pay a 
copay and a deductible. But like the old song ``Bread and Roses,'' we 
fight not only for women, but we fight for men too. Because for us it 
is not gender, it is about the agenda, and the biggest agenda is to 
make sure we provide health care to as many Americans as we can in the 
most affordable way, with value, quality, and prevention as their 
underpinnings.
  We were able to make significant changes in this bill. But 
affordability is an issue. I believe we dealt with that by emphasizing 
quality. At Senator Kennedy's request, I led the quality task force. 
Because of proven ways that we are going to be able to offer in these 
initiatives, we are going to be able to increase the affordability of 
this bill to make people healthier. We want to prevent disease and 
manage chronic disease. By the emphasis on the management of chronic 
disease, we are going to save lives and save money.
  First of all, we are getting more value for the dollar. Yes, we will 
be looking at comparative effectiveness, so when you go for a treatment 
or you buy a drug, you know we are getting value for the dollar.
  The other is, we are going to emphasize the reduction of medical 
errors and also medical infections in hospitals by introducing quality 
initiatives that reward hospitals for being able to do that. But I also 
listen to the providers. I represent iconic international institutions 
such as Johns Hopkins medical institution and the University of 
Maryland.
  I listen to my primary care doctors as well. They said: Senator Barb, 
please reduce the hassle factor; too much paperwork and not enough time 
to be with patients; too many contradictory rules from the insurance 
companies and not enough of a clear path on what we can do to be able 
to help people.
  So we made sure we are going to save money by reducing the hassle 
factor by simplifying administrative costs, by emphasizing medical 
health information technology. We are going to promote evidence-based 
medicine through this comparative effectiveness research. We are going 
to also reward, following the recommendations of the Finance Committee, 
the encouragement of medical homes in order to be able to manage 
chronic disease.
  These are the many reforms that are in this bill and that I am very 
proud of. I am also, as the daughter of a small business owner, excited 
about how we are going to be able to help small business be able to 
provide health care to their employees. The fact that we are going to 
offer tax breaks for small business and be able to have health 
exchanges where they can buy those health care policies at a better 
cost is indeed important.
  So, again, the other party might be Mars, but I am glad my feet were 
planted in planet Earth, by listening to the people I represent, by 
listening to their concerns and then listening to the excellent ideas 
that came from both the people themselves and, I must say, the people 
who are the providers who could help us lead the way.
  I am going to vote for this bill. I know there is much to reform in 
it in the years ahead. But this is more than a beginning, this is a 
leap into the future. It is a leap we can take with confidence that 
when this bill passes with reconciliation, we will have won a major 
historic advance for the American people.
  Our job is about creating opportunity and opportunity to have health 
care is one of the greatest benefits we can provide.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Burris). The Senator from Montana.
  Mr. BAUCUS. Mr. President, I ask unanimous consent that at the 
conclusion of the half hour under the majority's control, at about 
roughly 11:21, the Republicans control the next half hour and the 
majority control the half hour after that, starting at about 11:51.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BAUCUS. Mr. President, I would like to take a couple moments to 
speak on two amendments, one offered by, I think, Senator Hatch, with 
respect to Medicare Advantage. Off the topic, it is important to 
remember that health care reform will reduce excessive overpayments to 
Medicare Advantage plans, while at the same time rewarding high-
quality, efficient plans for providing care to seniors.
  Medicare Advantage plans that achieve high-quality rankings under 
this legislation, let's say, for regular checkups for blood pressure, 
diabetes, will receive an increase in payments. That is very important 
because, today, Medicare Advantage plans are paid the same amount 
regardless of the quality of care they provide.
  For the first time, under this legislation, payments to plans would 
be based on performance. I think that is something all seniors would 
prefer. That makes this Medicare Advantage plan more fair, more 
reasonable. This will enable plans to participate everywhere in the 
country, both urban and rural, while eliminating overpayments that 
plans receive today.
  According to MedPAC--MedPAC is that bipartisan commission that 
advises Congress on Medicare payments--that organization says Medicare 
Advantage plans are paid 13 percent more than traditional fee-for-
service plans, on average, and in some parts of the country overpayment 
is as high as 20 percent. They strongly recommend that we reduce that 
overpayment because it causes great inefficiencies.
  I might also say that, today, because of the overpayments, all 
seniors on

[[Page S1940]]

Medicare--I am talking now especially about seniors who take fee for 
service--all seniors on Medicare pay for these overpayments, even if 
they are not in Medicare Advantage plans. How? Well, it is basically 
because every senior pays $3 more per month in Part B premiums, that 
totals about $80, on average. So seniors in traditional fee for service 
are paying for the overpayments for Medicare Advantage plans.
  Medicare Advantage overpayments drain resources for the Medicare 
trust fund. If they are overpaid, that means they are draining 
excessive resources from the Medicare trust fund. In fact, the 
government estimates that Medicare Advantage overpayments speed up 
insolvency of the Medicare trust fund by about 18 months.
  After that, there is no evidence that overpayments to Medicare 
Advantage plans--do not forget these are private insurance plans--even 
though they say Medicare, they are private insurance plans. There is no 
evidence that overpayments to them lead to better quality for Medicare 
beneficiaries.
  In fact, seniors can end up spending more out-of-pocket dollars under 
Medicare Advantage plans than under traditional Medicare, even if they 
have certain conditions. The bill eliminates these overpayments by 
decreasing the statutory rates in place today and giving quality 
performance payment increases to high-ranking plans. We are paying more 
than we do today to high-ranking plans.
  No senior in Medicare Advantage will lose access to any of their 
Medicare benefits under this proposal. We hear all these false claims 
across the aisle that these cuts, which cause more efficiency, prevent 
waste, prevent overpayments, are going to cut beneficiaries, Medicare 
Advantage beneficiaries' payments. That is not true. It is misleading.
  Plans will not be allowed to lower or drop their basic Medicare 
benefits that seniors are entitled to under the Medicare Program. So 
there are no cuts in basic Medicare benefits. In fact, they are 
guaranteed. The reforms in this bill will ensure that the dollars for 
the Medicare trust fund go toward improving the quality of care for 
seniors, rather than to support the operations of private insurers. I 
think that is something the vast majority of seniors would prefer. I 
wish to make that clear because some of the statements made on the 
other side of the aisle are quite misleading, which leads me to another 
point.
  Americans probably are a little confused about what is in health care 
reform because they hear all kinds of claims, both sides. Well, now 
health care reform has passed. The President signed the bill yesterday. 
This is sort of to help, a fixer-upper around the edges a little bit. 
Americans can look for themselves as to who is telling the truth. They 
will want to look more closely than they have in the past because now 
it is law. Now it affects people.
  Some people are going to ask: Gee, how does it affect me? I better 
find out. When people start to find out, they are going to learn--I say 
this somewhat presumptuously, but I believe it very strongly--they are 
going to find out that those who are claiming all the bad things that 
are going to happen, all the bad things about this bill, are basically 
not true.
  They are also going to start to realize that all the good things in 
this bill, that a lot of proponents have been mentioning, from the 
President on down, they are pretty much true, the good things are 
pretty much true. I think once people start thinking closely, 
separating the wheat from the chaff, they will start to realize that 
not only are the Medicare Advantage charges false, but a lot of the 
other charges that some make about why the bill is so bad are also 
false. Again, I say, somewhat presumptuously, the prevention 
provisions, I think are very good and help seniors, are basically 
accurate.
  One small, final point. The Senator from Florida offered an amendment 
basically requiring all Members of Congress to enroll in Medicaid. Now 
I ask you, that clearly is not a serious amendment. Medicaid is a very 
vital program for vulnerable Americans. It should be treated very 
seriously and should not be used for political games.
  I now yield the remainder of our time in this half hour to the 
Senator from Rhode Island.
  The PRESIDING OFFICER. The Senator from Rhode Island is recognized.
  Mr. REED. First, I wish to begin by recognizing the extraordinary 
leadership of majority leader Harry Reid, Chairman Baucus, Chairman 
Dodd, and Chairman Harkin to get us to this point.
  Commonsense and cost-effective health care reform is now the law of 
the land. The question before the Senate now is whether we will make 
some important improvements to that reform or whether we will respond 
to the wishes of the insurance industry and others who want to preserve 
a broken status quo of higher premiums and dwindling coverage for 
middle-class families.
  Yesterday, President Obama signed into law a health insurance reform 
bill that will cut the deficit by $143 billion over the next 10 years, 
ensure that health insurance companies actually provide Americans with 
the coverage that they pay for, and preserve Medicare for our senior 
citizens. That is no small achievement, and it would be a tragedy if 
the other side of the aisle persists in its effort to defeat health 
care reform by seeking to delay and up-end the package of improvements 
in the bill that we are now debating.
  It sometimes gets lost in the heated rhetoric of the other side, but 
under the status quo, the healthy are faced with ever-increasing costs 
and the ill are denied care, dropped from coverage, and prevented from 
purchasing coverage. The new health insurance reforms will provide 
relief for every American. Indeed, under the law just signed by 
President Obama, these five reforms will take place by the fall of next 
year:
  No child will be denied coverage because of a preexisting condition.
  Small businesses will receive a 35-percent tax credit to purchase 
insurance for their employees.
  Seniors on Medicare who confront the doughnut hole will receive 
additional assistance.
  Health insurers will be required to spend more of their premium 
revenues on clinical services, with less going to administrative costs 
and profits, or else they must pay a rebate to policy holders.
  And our State's Community Health Centers will receive a boost in 
Federal resources.
  Rhode Islanders will particularly welcome this relief. Just last 
week, Rhode Islanders learned that health insurance premiums in the 
State will go up 10 percent this year. In the same week, they also 
received news that as many as 21 percent of individuals in the State 
will be without insurance sometime during this year. This is double the 
rate of uninsured just 10 years ago.
  In Rhode Island, these two headlines, coupled with an unemployment 
rate of nearly 13 percent, have caused a perfect storm.
  As the economy took jobs away from Rhode Islanders, it also took away 
their health insurance. The healthy hoped not to get sick, the sick 
started showing up in hospital emergency rooms, and those who still had 
access to insurance stopped being able to afford it.
  Hospitals in Rhode Island can no longer shoulder the burden of the 
uninsured. Community health centers in Rhode Island can no longer 
shoulder the burden of the uninsured. Indeed, the economy can no longer 
shoulder the burden of the uninsured.
  Today we are considering a bill that makes further improvements to 
the health insurance reform law. Indeed, these are changes that 
Americans have consistently said they want, and that is why we should 
support this bill. It is also why I intend to oppose the legislative 
maneuvers from the other side of the aisle. They are interested in 
overturning the reform of our health care system, reforms which have 
replaced the costly status quo with a system based on more competitive 
markets. They are in favor of a system where the whim of insurance 
companies rule. They are in favor of a health care system in which 
costs continue to rise at astronomical rates each year for families and 
for businesses.
  It may be politically heartening for the other side to try and slow 
down reform through a series of repetitive amendments, but I think 
Rhode Islanders and all Americans want us to pass the bill because it 
contains straightforward proposals.

[[Page S1941]]

  First, this reconciliation bill, as it is known, would eliminate the 
so-called Corn-Husker kickback, which would have created an entirely 
inappropriate Medicaid reimbursement system exclusively for one State. 
Gone too are other provisions that would have unfairly supported some 
States and not others.
  Second, this bill begins the process of closing the Medicare 
prescription drug coverage gap, also known as the doughnut hole, which 
requires seniors to pay more for their medications than they ordinarily 
would. This year seniors would receive $250 when they enter the 
doughnut hole and pay less for drugs they purchase once they enter this 
coverage gap.
  Third, at a time when so many of us are worried about government 
spending, this bill does more to reduce the budget deficit so that we 
can save up to $1.3 trillion in the next two decades. Those are real 
savings. I find it ironic that some on the other side oppose them.
  Fourth, the bill makes sure the so-called Cadillac tax, which was 
intended to affect the most expensive health care plans, is reduced by 
80 percent so that it hits its intended targets, not middle-class 
families.
  Fifth, the bill recognizes that we should do even more to help 
struggling families afford health insurance, and so it provides new tax 
breaks to help make coverage more affordable.
  As I said, in the next few days my colleagues on the other side of 
the aisle are expected to file and attempt to offer numerous amendments 
to this bill. These are tactics that are purely dilatory. That is, 
again, another reason I will oppose the amendments. Some of these 
amendments may seem as though they are common sense, but each one is 
designed for the purpose of derailing this legislation, of sending it 
back to the House, of undercutting the most significant reform of 
health care in the last several decades.
  But there is another aspect to this legislation which is vitally 
important; that is, the improvement to the student support system for 
higher education. It is the dream of every parent that their child will 
have a better life, and a big part of that dream is that they will have 
the opportunity to go on to college or even an advanced degree. This 
bill ends the student aid system that gives away billions of Federal 
subsidies to private banks, including some that helped create the 2008 
financial meltdown, and instead puts those taxpayer dollars directly 
into the hands of students to pay for their education.
  During this economic downturn, paying for college has become all the 
more difficult for many families in Rhode Island and across the Nation. 
Like health care, one of the top concerns of families as they sit 
around their kitchen tables during these difficult times is how they 
will pay for their child's education. The key to ensuring our Nation's 
economic stability and progress is also providing access to education. 
It is the engine that moves people forward. It is what expands our 
capacity and our capabilities in a complex world.
  Now we have the opportunity so that we can, in fact, provide 
additional assistance through Pell grants, and we can do it by saving 
money from bank subsidies and reinvesting that in Pell grants. 
Approximately $42 billion will be freed up; over $35 billion will be 
committed to Pell grants. It will be expanded to additional recipients, 
and the maximum grant will increase to nearly $6,000. We will also 
provide in Rhode Island $7.5 million for information so that families 
and students can locate the best arrangements for their college 
education, for their financial aid. It will also invest $2 billion in 
community colleges, which have become a central part of our educational 
system, particularly for those people who are transitioning into the 
workforce or through the workforce.
  One final point: It is particularly fitting that we are investing in 
the Pell grant, named after my predecessor Senator Claiborne Pell. His 
vision to give people the opportunity to higher education and then to 
stand back and watch them do great things has been legitimized and 
vindicated over 30 years. I don't think Senator Pell foresaw the 
Internet. I don't know how much he used it even when it arrived. But he 
knew if we gave people the skills and talents, they would do great 
things. They have done great things.
  With this legislation, they will do even more.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from New Hampshire is recognized.
  Mr. GREGG. How much time does the majority have on their half hour?
  The PRESIDING OFFICER. The time of the majority has expired.
  The Senator from New Hampshire.
  Mr. GREGG. Mr. President, a couple comments need to be responded to 
because they are so patently inconsistent with the facts that they 
should be clearly rejected. It is almost as if somebody spent too much 
time at the movie ``Alice in Wonderland.'' The idea that by their own 
score, when you cut Medicare by $521 billion--$\1/2\ trillion cut out 
of Medicare by their own score, which is inaccurate, of course, because 
it doesn't count the full 10 years--if you count the full 10 years, it 
is $1 trillion taken out of Medicare--the idea that seniors are not 
going to be affected by that type of a cut is absurd on its face.
  The claim is, we don't affect senior benefits. That is nice. That is 
like telling somebody they can have a car, but there is no engine in 
it. I mean, the simple fact is, when you cut the providers of seniors 
by as much as this bill cuts them, clearly it is going to be harder for 
a senior citizen to see a provider, a doctor, a hospital group. Or when 
you reduce the spending on Medicare Advantage, which is an insurance 
program that many seniors appreciate--CBO scores the reduction as being 
so large that over 11 million seniors will be thrown off that system--
that affects seniors.
  If they genuinely believe their language, ``we don't do anything 
about Medicare; we don't do anything about seniors,'' even though the 
score says they cut Medicare by $500 billion, their own score, and the 
CBO has said over 11 million people will be knocked off of Medicare 
Advantage--if they believe that, if they believe their language, then 
they have to vote for my amendment. They have to vote for my amendment 
which makes it clear that we protect Medicare.
  Then there was some other comment made that somebody was going to 
vote against our amendments, not because they don't make sense but 
because they are dilatory. This is from a leadership on the other side 
of the aisle that produced the largest piece of social engineering in 
our history: 2,500 pages, $2.6 trillion of spending, $1 trillion of 
cuts in Medicare when fully implemented. They produced that bill in a 
closed room behind a secret door somewhere on that side of the Capitol, 
never open to the public, brought it to the floor of the Senate on a 
Saturday afternoon, filled up the tree, wouldn't allow any amendments, 
and within 3 days forced us to vote on it on Christmas Eve. Then they 
took it over to the House, where they rewrote this trailer bill, again, 
in a secret room, behind a closed door, and brought that bill to the 
floor and didn't allow anybody to amend that. But amendments are 
dilatory.
  Why have an opposition party? Maybe we should just go with the Cuban 
system. That seems to be the attitude of the other side of the aisle. 
The American people are an unfortunate inconvenience. The fact that 
they have elected a Republican membership to this Senate and to the 
House, they are an unfortunate inconvenience that should be ignored and 
not allowed to participate in the process.
  When they come up with ideas such as protecting the Medicare system 
or such as taking out the sweetheart deals or such as suggesting that 
the President and his people and the staff of the majority leader 
should be under the laws we are about to pass or suggest that we should 
live by the terms of the rhetoric which is, if your premiums go up, you 
won't be impacted by this bill, or that says that there won't be any 
taxes on people under $200,000 of income, amendments which just fulfill 
the statements of the other side of the aisle on issues--they are going 
to keep the bill clean, they are not going to tax people under $200,000 
of incomes, people's premiums won't go up, Medicare won't be affected, 
and everybody will be subject to this new law of the land, including 
the President of the United States and his people and the staff of the 
majority leader--when we offer amendments like that, they are dilatory. 
They are an inconvenience. They

[[Page S1942]]

should not be allowed. They should not be voted on, not because they 
don't make sense but get rid of them; they are the opposition.
  They are the American people speaking through their elected 
representatives and they ought to have a voice and they ought to be 
voted on and they ought to be given a vote based on the substance of 
the amendments, not on the fact that the other side of the aisle 
doesn't like opposition.
  It is so arrogant, this attitude which pervades Washington now that 
says: The American people, we know better than you do how to live your 
lives. Why do you get in our way? We in Washington know how you should 
live. Just stand back. Let us make your decisions as to what you should 
do with your life, especially relative to health care. We will do a 
much better job. Certainly, don't countenance any opposition. Don't 
countenance any dissent, and, certainly, don't hold us to our word, for 
example, when we say people with incomes under $200,000 won't be taxed 
or when we say premiums won't go up or when we say everybody will be 
covered by the bill or when we say Medicare recipients won't be 
impacted. Don't make us hold to those words by voting on amendments 
because those amendments are dilatory.
  The arrogance is palpable and inexcusable.
  Now we will hear from the Senator from Oklahoma who has another 
amendment that I am sure the other side will say is dilatory and 
inappropriate, even though it makes a heck of a lot of sense to me.
  I yield the floor.


                           Amendment No. 3556

  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. COBURN. I thank the Senator from New Hampshire.
  As I contemplate what is happening at 62 years of age and looking 
back through my life, this is undoubtedly the greatest assault on 
liberty this country has ever had. It is not direct; it is indirect. 
But it is what the Senator from New Hampshire talked about: we are 
going to decide for you what you get.
  What the American people still don't understand is there are three 
areas in this bill that in the next 5 years will put the government in 
charge of everybody's health care--what you can have, what you can't 
have, and who can give it to you. That is what is coming. So if you are 
a caregiver or you are a patient, you might think long and hard about 
the three provisions in this bill that are going to do that: a Medicare 
advisory commission, the cost-effectiveness comparative effectiveness 
panel, and the U.S. preventative task force panel. All of those are 
going to carry the force of law, and it will not just apply to 
government-run plans. If you have private insurance with your employer 
today, you are going to be told what treatments you can have because 
some group of bureaucracies in Washington are going to decide that. 
That is what is in this bill.
  The Senator from New Hampshire mentioned several claims that have 
been made.
  I ask unanimous consent to temporarily set aside the pending motions 
and amendments so I may offer an amendment which is at the desk, No. 
3556.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Oklahoma [Mr. Coburn] proposes an 
     amendment numbered 3556.

  Mr. COBURN. I ask unanimous consent that reading of the amendment be 
dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To reduce the cost of providing federally funded prescription 
 drugs by eliminating fraudulent payments and prohibiting coverage of 
Viagra for child molesters and rapists and for drugs intended to induce 
                               abortion)

       At the end of subtitle D of title I, add the following:

     SEC. 1306. REDUCING HEALTH CARE COSTS BY ELIMINATING PAYMENTS 
                   FOR FRAUDULENT CLAIMS AND PROHIBITING COVERAGE 
                   FOR ABORTION DRUGS AND ERECTILE DYSFUNCTION 
                   DRUGS FOR RAPISTS AND CHILD MOLESTERS.

       (a) Eliminating Fraudulent Payments for Prescription 
     Drugs.--The Secretary shall establish a fraud prevention 
     system and issue guidance to--
       (1) prevent the processing of claims of prescribing 
     providers and dispensing pharmacies debarred from Federal 
     contracts or excluded from the Medicare program under title 
     XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) or 
     the Medicaid program under title XIX of such Act (42 U.S.C. 
     1396 et seq.);
       (2) ensure that drug utilization reviews and restricted 
     recipient program requirements adequately identify and 
     prevent doctor shopping and other abuses of controlled 
     substances;
       (3) develop a claims processing system to identify 
     duplicate enrollments and deaths of Medicaid beneficiaries 
     and prevent the approval of fraudulent claims; and
       (4) develop a claims processing systems to identify deaths 
     of Medicaid providers and prevent the approval of fraudulent 
     claims filed using the identity of such providers.
       (b) Prohibiting Coverage of Certain Prescription Drugs.--
       (1) In general.--Health programs administered by the 
     Federal Government and American Health Benefit Exchanges (as 
     described in section 1311 of the Patient Protection and 
     Affordable Care Act) shall not provide coverage or 
     reimbursement for--
       (A) prescription drugs to treat erectile dysfunction for 
     individuals convicted of child molestation, rape, or other 
     forms of sexual assault; or
       (B) drugs prescribed with the intent of inducing an 
     abortion for reasons other than as described in paragraph 
     (2).
       (2) Exceptions.--The limitation under paragraph (1)(B) 
     shall not apply to an abortion--
       (A) in the case where a woman suffers from a physical 
     disorder, physical injury, or physical illness that would, as 
     certified by a physician, place the woman in danger of death 
     unless an abortion is performed, including a life-endangering 
     physical condition caused by or arising from the pregnancy 
     itself; or
       (B) if the pregnancy is the result of an act of forcible 
     rape or incest.

  Mr. COBURN. This is a constructive amendment that saves millions and 
millions of dollars in Medicaid. The fraud in Medicaid prescriptions is 
out of this world. It can be fixed. This amendment will prohibit 
prescriptions for recreational drugs for rapists and child molesters. 
Nobody can disagree with that. It is not in the bill. It is the current 
state. But if this bill goes through without this amendment, your tax 
dollars are going to be paying for Viagra for child molesters. That is 
what is going to happen. There is an Executive order that this will 
override. The bill overrides the Executive order. So there is no 
prohibition in the bill for this at this time.
  A Government Accountability Office audit of Medicaid found 65,000 
instances of improper prescriptions costing $65 million over the last 2 
years, including thousands of prescriptions written for dead patients 
by people prescribing and posing as doctors. The audit focused on 10 
types of frequently abused prescription drugs in just 5 States, which 
means this audit, which is just over 5 States, multiply by at least 10, 
and you get $650 million worth of fraud in prescriptions in Medicaid 
alone. We are not going to address that.

  Sixty-five doctors or pharmacists were banned from Medicaid for 
writing or filling prescriptions or illegally selling drugs--but just 
in those five States.
  About 1,800 prescriptions were written for dead patients and 1,200 
prescriptions were ``written'' by dead doctors--just in those five 
States.
  This amendment would direct the Centers for Medicare and Medicaid 
Services to enact the GAO recommendations to prevent and eliminate 
these fraudulent prescriptions. Specifically, it would direct CMS to 
establish a fraud prevention system for the Medicaid Program and issue 
guidance for States to prevent the processing of claims of all 
prescribing providers and dispensing pharmacies debarred from Federal 
contracts or excluded from the Medicare and Medicaid programs; ensure 
that drug utilization review and restricted recipient program 
requirements adequately identify and prevent doctor ``shopping'' and 
other abuses of controlled substances; develop a claims processing 
system to identify both duplicate enrollments and deaths of Medicaid 
beneficiaries and prevent the approval of fraudulent claims.
  For years, the Federal Government had required States to provide 
prescriptions for Viagra and other impotence drugs to Medicaid 
patients, including to convicted sex offenders, child molesters, and 
rapists. States had provided the coverage based on a 1998 letter from 
the Clinton administration. As a result of that, an Executive order was 
issued in 2005, which this bill, if

[[Page S1943]]

unamended, will reverse. Mr. President, 800 convicted sex offenders in 
14 States received Medicaid-funded prescription drugs for erectile 
dysfunction. That is according to a 2005 survey.
  The predators' victims have been as young as 2 years old. So we have 
convicted sex offenders, rapists, and child molesters who were taking 
Federal tax dollars and buying a drug so they can act again.
  In Florida, 218 cases; New York, 198 cases; Texas, 191 cases, and it 
goes down the list.
  This amendment would prohibit the new health care exchanges from 
providing coverage of ED drugs to convicted child molesters and 
convicted rapists. It is pretty simple.
  The claims that are made on this bill are outlandish. As somebody who 
has practiced medicine for 27 years, 50 percent of my patients were 
Medicaid patients. What you are going to do if you do not fix some of 
the things in this bill is destroy the best doctor-patient 
relationships in the world. That is what you are going to do.
  You are going to put 16 million people into a failing Medicaid system 
that the States cannot afford. Almost every State is cutting Medicaid 
reimbursement. At this time, only 40 percent of the doctors in the 
specialties will see Medicaid patients. It is going to go to 20 
percent. So we are going to put 16 million people in a system, and then 
they are not going to be able to find a doctor. Because of the costs, 
in my own State, we are going to have an 11-percent net reduction in 
Medicaid reimbursements, which is only 75 percent of Medicare.
  What do you think is going to happen in all the States in the country 
when the Medicaid reimbursement goes down and we add 16 million new 
people to Medicaid? You are going to call it care. You are going to rub 
your shoulder, rub that medal on your shoulder, and say: Oh, we fixed 
health care. You are going to promise them they are going to have care, 
but they are not going to have care. They are going to have a card, but 
they will have no care. We are going to have Indian Health Service-type 
care in Medicaid because nobody is going to be there to care for them.
  The claims under this bill keep me sleepless at night--not because of 
Washington but because of those 10,000 Medicaid patients I have taken 
care of through my career for whom I know you are going to destroy what 
care is left for them. You can claim otherwise, but the facts are going 
to prove you wrong. We are seeing it in every State in the country 
right now--the cuts to Medicaid reimbursements.
  So at least you ought to help save $650 million a year by getting rid 
of fraudulent prescriptions, eliminating prescriptions for convicted 
child molesters for erectile dysfunction, and recreational uses with 
drugs such as Viagra. The American people do not want to pay for that.
  To vote against this amendment, to not fix something that is very 
obvious, is criminal--it is not just not right, it is an active aid to 
help those who would hurt our children.
  I yield to the minority whip.
  Mr. KYL. Thank you, Mr. President.
  The PRESIDING OFFICER. The Senator from Arizona is recognized.
  Mr. KYL. Mr. President, I would say, we are fortunate to have a real 
doctor, a physician, Dr. Tom Coburn of Oklahoma, as one of our 
colleagues in the Senate to talk about the real impact of legislation 
like this as he sees it when he treats his patients. I think his words 
deserve a lot of attention.
  I just want to briefly address this morning a couple of the claims my 
Democratic colleagues are making about this new legislation, claims 
that are simply false.
  The first one: There is a big tax cut. One of my colleagues said this 
is the biggest tax cut we have ever had. There is no tax cut for 
taxpayers in this bill. What they are touting as a tax cut is, rather, 
a direct payment to insurance companies. I find it very odd that is 
called a tax cut. When I think of a tax cut, I think of money remaining 
in the pockets of taxpayers so they do not have to pay taxes they have 
been paying in the past. That is not what is in this bill.
  What the bill does is to provide a subsidy to insurance companies to 
dispense government-mandated insurance. It is not a tax cut for 
taxpayers. Instead, most of the so-called tax relief goes directly to 
the insurance companies. It never touches--you never touch the money--
it never touches an American family's pocket.
  These premium subsidies are delivered straight from the U.S. Treasury 
to help insurance companies, as I said, to purchase this government-
mandated, government-approved insurance. They are not extra dollars in 
people's pockets, as the chairman of the Finance Committee argued. They 
are, rather, advanceable, refundable tax credits, which is code for a 
new tax entitlement. In fact, that is exactly the way it is recorded in 
the Federal budget. It is recorded as a spending program, the reason 
being that the people receiving these so-called refundable credits paid 
very little if any taxes. These are folks who do not pay taxes, so they 
get what is called a refundable tax credit. But even then the money 
goes directly to the insurance company, not to them. I always thought 
you had to pay taxes to get a tax cut, but not in the rubric of this 
legislation.
  According to the Joint Committee on Taxation, only about 8 percent of 
all taxpayers making under $200,000 a year would actually benefit from 
this government subsidy for health insurance. The remaining 92 percent 
would receive no tax benefit under the bill.
  I have to say, when we are talking about tax cuts, we have to at 
least put in a little word about the tax increases in the bill because 
that is where the bill focuses, on taxes. It taxes many of those who 
have health insurance and taxes people if they do not have health 
insurance.
  The taxes in the bill hit families. They hit seniors and the 
chronically ill, small businesses, those who have flexible spending 
accounts, and those who use medical devices. All of those things create 
a tax people pay. The vast majority of the people who pay these taxes 
are not high earners. As the Congressional Budget Office has said, 
whenever there is a tax on some other entity that delivers health 
services, that tax flows directly through to the taxpayers in virtually 
the same amount of money.
  In fact, in order to collect all of these taxes, and especially the 
tax that is imposed on people if they do not buy this insurance, the 
Internal Revenue Service estimates it is going to have to have between 
$5 billion and $10 billion more just in order to collect the taxes. It 
has been estimated this would require 16,500 new IRS agents. Welcome to 
your friendly new health care bill.
  The second aspect my colleagues have been talking a lot about in the 
last 48 hours: The elimination of the problem of preexisting conditions 
in acquiring health insurance. The implication is that Republicans have 
not supported help for people who have preexisting conditions. That is 
not true. We have made that point clear. We made that point clear in 
the meeting we had with the President at Blair House. The argument is 
about the best way to do it.
  As you will see in just a moment, it turns out this bill has not done 
it very well. Republicans have suggested there are a lot of different 
ways to get to this problem--State reforms, risk pools, more 
competition, some subsidization. All of these things can help us with 
this problem. But for all of the Democrats' central planning in this 
bill, it looks as though the problems are already arising as a result 
of their specific provision to deal with this problem.
  According to a brand new Associated Press story of March 24, 
President Obama's claims about preexisting coverage for children are 
not what they seem. The article notes that ``the letter of the law''--
which Democrats took upon themselves to write behind closed doors--
``provided a less-than-complete guarantee that kids with health 
problems would not be shut out of coverage.''
  In your rush to do these things--behind closed doors, without proper 
vetting, always voting no on any attempts to correct it--you end up 
with problems like this, and they are going to have to somehow go back 
and try to fix this. If this blunder is discovered on the first day 
this law takes effect, how many more errors will be discovered in the 
next days and weeks, as people pour over the 2,733 pages of this new 
health care law, and the 150 pages of the reconciliation bill that is 
on the floor right now?

[[Page S1944]]

  If you cannot draft a bill properly to protect children with 
preexisting conditions--which is a centerpiece of the bill's so-called 
immediate deliverables--then how are you going to be able to 
successfully make one-sixth of the economy work through this new 
government-operated system?
  Finally, I have talked about two things our Democratic friends are 
crowing about, neither one of which, it turns out, I think are worth 
crowing about. How about the things they are not talking about, the 
things Americans are very concerned about?
  Democrats love to talk about people who are allegedly helped by the 
legislation. How about those who are hurt by the bill? How about 
talking about seniors whose care is going to be jeopardized as a result 
of this bill? Seniors in my State of Arizona are very worried about the 
Medicare cuts. There are over $\1/2\ trillion in Medicare cuts in this 
bill.
  Well, our Democratic friends do not like to talk about that. But it 
is a reality. It is in the bill. The reconciliation bill slashes more 
than $\1/2\ trillion from Medicare and contains a whopping $202 billion 
reduction in Medicare Advantage. That is more than in the bill the 
Senate passed last December. But you do not hear about that. Medicare 
Advantage beneficiaries in my State like the health care they have 
right now, and it is simply not true if they like their health care 
they get to keep it. It is false. This bill takes health care benefits 
away from seniors who are on Medicare Advantage. That is the truth. It 
may be an inconvenient truth for our colleagues who like to stress what 
they think is good about the bill but conveniently ignore things that 
are going to hurt their constituents and certainly going to hurt my 
constituents.
  My senior citizens in Arizona do not want the government taking away 
their health care, and they are very concerned as a result. A 
constituent from Tucson--I will just close with this--wrote me a very 
short, a very direct letter, but it summarizes the point a lot of 
people feel.

       I am a senior citizen, age 83. If I lose my Medicare 
     Advantage coverage, I'll also lose my primary care physician 
     of 18 years because he does not accept Medicare Direct. 
     Senator Kyl, do not let them take away my Medicare Advantage.

  Well, all of us know physicians who are no longer taking new Medicare 
patients. They cannot afford to because we do not pay them enough. Mayo 
Clinic in Arizona has already said it is not going to accept any more 
Medicare patients at several of its facilities in the Phoenix 
metropolitan area.
  This health care bill is asking a lot of the American people, a lot 
in terms of tax collection, and a lot in terms of future debt that our 
children and grandchildren are going to have to pay.
  But just one group that ought to be very concerned--and is--are our 
senior citizens who face nearly $\1/2\ trillion in Medicare cuts. Taxes 
and premiums are going to be increased on all Americans. Small 
businesses will be hit with a litany of onerous new taxes and mandates 
and regulations. Probably worst of all from my perspective, just as 
these costs inevitably escalate, as time goes on, just as in the 
European countries that have had to deal with these same kind of health 
care issues, this legislation will ultimately lead to the rationing of 
health care. That is the cruelest result of all.

  I ask unanimous consent to have printed in the Record at this point 
an op-ed piece by Mr. Bob Robb who writes for the Arizona Republic. It 
is dated March 24. The last two sentences of this op-ed I think 
summarize the point I made very well. He says:

       But it is impossible to treat health care as a public good 
     without rate regulation and rationing. And those are the 
     inevitable next steps down the health care road the Democrats 
     have taken the country.

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

               [From the Arizona Republic, Mar. 24, 2010]

                            (By Robert Robb)

       Democrats tend to discount the influence of economic 
     incentives on human behavior. They had better hope they are 
     right because the incentives in the health-care bill point 
     toward an explosion in costs.
       The health-care bill is built upon a fundamental tradeoff. 
     Health-insurance companies will be treated as public 
     utilities, having to take all customers irrespective of 
     health status with sharp limitations on pricing and 
     underwriting. To pay for this increase in costs, everyone 
     will be required to purchase health insurance.
       This is an attempt to force the young and healthy to 
     subsidize the health care of the acutely or chronically sick 
     through the premium mechanism. But, as finally passed, the 
     incentives and timing are badly misaligned.
       The basic problem is that the penalty for not purchasing 
     insurance is substantially less than the cost of the 
     insurance. Even with the generous subsidies the bill 
     provides, young singles making more than $25,000 a year will 
     be money ahead paying the penalty rather than buying 
     insurance.
       Doing so would be risk-free for them. If necessary, they 
     can purchase insurance after they get sick and know that they 
     need it. The implementation timetable for the bill 
     accentuates the misaligned incentives.
       Insurance companies are saddled with additional costs right 
     away.
       They will have to accept children with pre-existing 
     conditions and carry children on their parents' policies up 
     to age 26. They can't impose lifetime benefit limits. Any new 
     policies have to cover preventive services without co-pays or 
     deductibles. But the individual mandate, the source of new 
     revenue to cover the additional costs, doesn't kick in until 
     2014.
       Moreover, the penalties start very low, only $95 in 2014, 
     while the requirement to accept all comers irrespective of 
     pre-existing conditions applies fully that year. So, the 
     additional costs are added full bore, while the additional 
     revenue is phased in slowly.
       This misalignment of incentives in the individual market is 
     compounded by a similar misalignment in the group market.
       The penalty for employers (with more than 50 employees) not 
     providing health insurance is $2,000 per employee. Employers 
     pay on average two to four times that to provide health 
     insurance.
       Employers do it now to compete for employees, since the 
     current individual market isn't an attractive alternative. 
     But, under the bill, the federal government is setting up and 
     heavily subsidizing an individual market with generous 
     benefits.
       So, the incentive will be for employers to drop health-
     insurance coverage, pay the fine and allow their employees to 
     go shopping in the subsidized exchanges.
       The Congressional Budget Office estimates that 8 million to 
     9 million Americans will lose employer-provided health 
     insurance. I think that's a gross underestimate.
       Moving people into the individual market could be a good 
     thing for cost control, if individual health insurance 
     operated like other individual insurance products, where 
     people pick up the cost of small stuff and insure against big 
     stuff. But the individual market mandated by the bill 
     requires first-dollar coverage and sharply limits deductibles 
     and co-pays.
       So, the bill gives incentives to move people into an 
     individual market with even less cost-control incentives than 
     the existing system, where at least employers worry about the 
     final tab. It also gives many people an incentive not to 
     participate in the new system until they are actually sick.
       If incentives matter, there are likely to be sharp 
     insurance-rate increases and insurance-company bankruptcies.
       Contrary to the rhetoric on the right, it is possible to 
     treat health care as a public good without being a socialist 
     country. And it is possible to treat health care as a public 
     good without having it delivered through government agencies.
       But it is impossible to treat health care as a public good 
     without rate regulation and rationing. And those are the 
     inevitable next steps down the health-care road the Democrats 
     have taken the country.

  Mr. KYL. Thank you, Mr. President. I yield the floor.
  The PRESIDING OFFICER. The Senator from Texas.


                           Amendment No. 3608

  Mrs. HUTCHISON. Mr. President, I ask unanimous consent to temporarily 
set aside the pending motions and amendments so that I may offer an 
amendment which is at the desk.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Texas [Mrs. Hutchison], for herself, Mr. 
     Enzi, Mr. Coburn, Mr. Burr, and Mr. Brown of Massachusetts, 
     proposes an amendment numbered 3608.

  Mrs. HUTCHISON. I ask unanimous consent that the reading of the 
amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To protect the right of States to opt out of a Federal health 
                             care takeover)

       At the end of section 1002, insert the following:
       (c) Right of States to Opt Out of Federal Health Care 
     Takeover.--Section 1321(d) of the Patient Protection and 
     Affordable Care Act is amended--
       (1) by striking ``Nothing'' and inserting:
       ``(1) In general.--Except as provided in paragraph (2), 
     nothing''; and
       (2) by adding at the end the following:
       ``(2) Exception for opt out of health care reform.--The 
     provisions of, and the

[[Page S1945]]

     amendments made by, this Act shall not preempt any State law 
     enacted after the date of enactment of this Act that exempts 
     the State from such provisions or amendments, including, but 
     not limited to, provisions and amendments relating to the 
     individual mandate, the employer mandate, taxes on 
     prescription drugs, taxes on medical devices, taxes on high 
     value health plans, Medicare cuts, and the unfunded expansion 
     of Medicaid.''.

  Mrs. HUTCHISON. Mr. President, the amendment I offer today is to 
allow States to opt out of this health care bill. If ever there was an 
encroachment on the tenth amendment, this bill is it.
  We are hearing from State leaders all across the country asking 
Congress to abandon this bill. It is an unconstitutional preemption of 
State innovation, State prerogative, and States rights they are 
guaranteed in the Constitution by the tenth amendment. Thirteen States 
have now filed suit against this legislation because the leaders in 
those States know the detrimental impact this broad, one-size-fits-all 
solution will have on their unique situations. States are the most well 
equipped to design and approve governmental programs to address the 
needs of their citizens. My amendment would restore the tenth amendment 
rights reserved for the States by allowing State legislatures to pass 
legislation that would allow them to opt out of this bill and the 
Federal takeover of their health care system with its mandates, many of 
which are unfunded.
  Let's walk through the harmful provisions in this bill from which the 
States could opt out.
  Taxes, the job-killing taxes. The bill imposes 10 years of taxes, 
about $\1/2\ trillion, on individuals and businesses as well as 
pharmaceutical companies, insurance companies, and medical device 
manufacturers. Some of these taxes will start almost immediately. More 
than $100 billion in taxes on prescription drug companies, medical 
device manufacturers, and insurance companies will begin to take effect 
before the actual supposed benefits of this bill would come into play. 
Studies show these taxes will be passed on to consumers. There is no 
doubt about it. Of course they are going to be passed on to consumers. 
They are going to be collected for years before there are any supposed 
benefits. Then there are the taxes on those who can't afford insurance: 
the higher of $695 per individual or 2.5 percent of household income. 
Employers will be hit with new taxes. The penalty could be as high as 
$2,000 or $3,000 per employee.
  What is this going to do to the small businesses of our country, 
which create 70 percent of the jobs? At a time when families are 
struggling, at a time when our businesses are struggling, at a time 
when our economy is at an all-time low--not all-time low, but almost 
all-time low; certainly bad--businesses aren't hiring. Why aren't they 
hiring? They aren't because they have a fear of the future. They don't 
know what to expect going forward. They are not going to start hiring 
people until there is a comfort level that the economy has stabilized 
and that we are in a real recovery mode. Yet, when people feel that way 
and when small businesses feel that way, what is the biggest deterrent 
to them being able to say, OK, things are getting better and I can hire 
new people? More taxes and more mandates and more burdens. That is what 
is going to keep them from taking that leap to hire more people. So it 
is like a revolving situation we are not going to get out of as long as 
we are continuing to put on more taxes, more expenses, and more 
mandates.
  We know premiums are going to go up. Premiums are already going up. 
Our purpose in this bill should be to bring premiums down by lowering 
the cost of health care, not by increasing the cost. That is so 
counterintuitive. It could only be thought of in Washington, DC.
  Cuts to Medicare. The Senate bill includes over $\1/2\ trillion in 
cuts to Medicare. About $135 billion of those are in cuts to hospitals.
  Mr. President, in conclusion, the Medicare Program is unsustainable. 
The Chief Actuary of Medicare has said that as much as 20 percent of 
Medicare's providers will either go out of business or will stop seeing 
Medicare beneficiaries.

  Millions of seniors, including those who have chosen Medicare 
Advantage, will lose the coverage they now enjoy. Medicare is being 
used as a piggy bank and it needs every penny that has been deposited.
  We cannot pay for reform on the backs of our seniors. Cuts to 
hospitals will threaten access to care for seniors in our States.
  Third, this bill imposes on States an unfunded mandate to expand the 
Medicaid Program. Putting millions of individuals in to Medicaid is a 
fast way to quickly reduce the number of uninsured.
  Yet by doing so, the Federal Government is sending a very large check 
to the States, $20 billion to be exact, with a note that says ``We 
decide--you pay.''
  At a time when so many States are struggling to balance their 
budgets, pay their teachers, improve transportation, maintain services, 
this bill imposes more costs.
  How much more are we going to ask of our States?
  States are in the best position to determine what is right for their 
citizens. Yet this bill will take away their right to innovate and 
determine fiscally responsible and effective ways to offer affordable 
health insurance coverage.
  In big government style, this bill manipulates that idea into a one-
size-fits all solution for every single State.
  Plus, states should have the option of implementing tort reform as we 
have done in Texas. Yet under this bill States are actually punished 
for implementing tort reform. Tort reform is essential to bring down 
the cost of health care. This bill stiffles the ability to achieve this 
commonsense option.
  Why not level the playing field for taxpayers by offering tax 
incentives to encourage the purchase of health insurance at the State 
level. Let citizens in each State decide which health insurance plan 
best fits their needs--a decision that should be free from interference 
by the Federal Government.
  Senator DeMint and I have a bill which would offer a voucher of 
$2,000 to individuals and $5,000 to families so they can purchase 
health insurance that is portable and not tied to their employer.
  These are the right steps to achieving reform and these steps empower 
the States rather than violate their rights and impose a heavy handed 
Federal approach to reform.
  I urge my colleagues to support this amendment which is cosponsored 
by Senators Enzi, Coburn, Burr and Brown of Massachusetts.
  The bottom line is I hope my colleagues will vote to support the 
States rights so that we will be able to address high unemployment as 
well as high uninsured rates in a way that will lower the costs and 
give more options.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I now wish to yield to the Senator from 
New York.
  I have already said we are going to divide the time in half-hour 
segments back and forth.
  I yield 10 minutes to the Senator from New York, Mr. Schumer.
  The PRESIDING OFFICER. The Senator from New York.
  Mr. SCHUMER. Mr. President, I thank the chairman of the Finance 
Committee, on which I am proud to serve, for yielding time, as well as 
for the great work he has done. I wish to commend Senators Dodd and 
Harkin for the great work they have done in the HELP Committee and all 
the members of the HELP Committee, as well as the Finance Committee 
and, of course, Majority Leader Reid, who has been as solid as a rock 
and steadfast in his own quiet way. He is more responsible for this 
bill passing than just about anybody else. So I thank our leadership 
for that.
  I rise today to talk about this historic accomplishment of health 
care reform. I congratulate all of my colleagues for their hard work 
and dedication. I congratulate the President. He, too, was like a rock. 
He never budged. The day after the Massachusetts election, when so many 
others were saying we can't get this done and to trim back, he was 
steadfast. I saw him and his steadfastness. His internal gyroscope got 
us over the goal line.
  I wish to address where the future is in this bill in terms of 
average Americans. We all know the American people are still trying to 
digest the health care legislation we have just passed. That is 
understandable. It is a large and complex piece of legislation and, of 
course, there has been a tremendous

[[Page S1946]]

amount of misinformation out there about what it does and what it does 
not do. To tell the average American that this is truly historic 
legislation doesn't get to them. They want to know how it is going to 
affect them.
  I fervently believe that the more the American people learn about 
this bill, the more they will like it. I believe this for two reasons. 
First: People very quickly come to see that the myths and lies that 
some have put forward about this bill will not come true, because they 
are not in reality, and now we are in reality--we are in health care 
reality--because the first part of the bill has passed, the major part, 
and we will pass the second.
  Second: There are so many good things in this bill that people like 
and need. As people learn the truth as to what those things are, many 
of which will improve their lives--some immediately and some in a few 
years--I am confident they will not only like health care reform but 
embrace it. When the crime bill was passed in 1994, at first the same 
thing happened. There was a parade of horribles. But over the years, we 
saw that it reduced crime and made America a better place, and it 
became a very popular piece of legislation. I believe the same thing 
will occur with this health care bill.
  So today I wish to take the rest of my time to describe to average 
Americans how this bill will affect them. The No. 1 group, the largest 
group of average Americans, is those who are covered by their employer 
plan. First, you will keep your coverage. For people who have been 
scared into thinking they might lose their health coverage or have the 
government telling them what to do or what treatments they could or 
could not receive, they are going to discover there is very little 
change for them. I had a firefighter employed by the city of New York 
on Long Island last week say to me: Don't pass the bill. I will lose my 
benefits. That firefighter will see his benefits will stay as good and 
as strong as they are now. In fact, it will get better for those folks 
who are already covered, because premiums to their employer won't go up 
and up and up, and their employer will not continue to ask them, as 
they have now, to pay so much more and to get so much less back.
  We cannot claim premiums won't go up at all, but we know they will go 
up much less. The likelihood of the employer calling a person, the 
average person, a worker in their company and saying: Jim, Mary, you 
are a great worker. I love you. I want you to stay in my company, but I 
am eliminating your health care benefits or I am greatly cutting them 
back, will be greatly reduced over the years as this bill becomes law 
and works its way.
  Beneficiaries, those on private health care, won't pay higher 
Medicare taxes. Their benefits will not change. Their choice of doctors 
will not change. They will be much better off, and they will learn 
that.
  Second: To small business owners who are trying to do the right thing 
and provide health insurance coverage to their workers and now find 
that costs are increasing, which makes it more and more difficult every 
year to keep those employees on health care, they are going to find 
this year that there is a generous tax credit to make it more 
affordable to provide coverage for their employees. The average small 
businessperson is going to like this bill because the average small 
business owner wants their employees to have good health care coverage, 
but they can't do it alone. Now they are going to get some help.
  What about to the small business owner who aches because he or she 
can't supply insurance because the employee has a preexisting condition 
or just because it is too expensive? They are going to find they will 
now be able to provide insurance for those folks.
  What about all of those families with kids who are now in college and 
they worry, once the kid gets out of college, they are not going to 
have health care? They are going to find that they are covered up until 
their 26th birthday on their parents' plan. They have to be. That is 
going to start this year. What a relief to millions of American 
families and millions of American students. I know this personally. My 
daughter is graduating from law school. When the bill passed at 1 a.m., 
she called me. She was watching when the House bill passed and said: 
Dad, I have been worried what I am going to do about health insurance 
next year. She is out in the job market. Now I don't have to worry. 
That phone call will be repeated by hundreds of thousands and millions 
of students to their parents in the next while. So it is great for 
them.
  What about retirees who are not yet eligible for Medicare, the person 
who fears that because they don't have their job or they are retiring 
at age 60 or 62, 61, what are they going to do? This bill will provide 
more assistance to bring down premiums. It will provide more choices to 
these retirees who right now have either no health insurance or a 
policy that is so expensive they can't afford it.
  What about average Americans who worry because say they have early 
stages of diabetes and their health care doesn't cover prevention? 
Average American families--and I see the Senator from Iowa is here, who 
has been a leader in the fight for prevention--will now get prevention 
in their benefits. For the average American who has recently gotten 
sick or who might in the future, they don't have to worry that their 
insurance company will take away their benefits. They will not be able 
to do that the way they do now. We won't have to hear stories anymore 
of health insurers looking for any excuse to cut sick people off from 
their insurance.
  What about those tens of millions on Medicare who, again, have been 
scared and worried that Medicare will change? Yes, Medicare will 
change. It will get stronger and still preserve the exact same benefit 
to every person on Medicare.
  Before this bill was signed into law, Medicare was going to go broke 
in 7 years. It has been given an extra decade. That should be a huge 
load off the shoulders of people who worry about Medicare.
  In addition, the doughnut hole will be closed, so all those Medicare 
recipients on prescription drugs will get relief--more relief.
  For the average senior citizen, as they learn about this bill, they 
are going to like this bill. They are going to say this was a great 
thing. It kept Medicare as is, surviving much longer than previously 
predicted. If we had done nothing and Medicare was about to go broke, 
guess who would have paid the price. Those senior citizens on it.
  What about young women looking for health insurance? Health reform 
means she will not be charged a premium 150 percent more than a young 
man's. Health reform ends that gender discrimination.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. SCHUMER. Mr. President, in conclusion, I will just say this: In 
November, this bill will be a positive--a strong positive for those who 
supported it. Those who were in favor of it will benefit. Those who 
opposed it will come to regret their opposition as America learns about 
what is in and what is not in this bill. It is not just a triumph for 
history; it is a triumph for the average American.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I yield to the chairman of the HELP 
Committee--I yield to another distinguished chairman, this one not of 
the HELP Committee but the Energy Committee, Senator Bingaman.
  The PRESIDING OFFICER. The Senator from New Mexico is recognized.
  Mr. BINGAMAN. Mr. President, I thank my friend and chairman of the 
Finance Committee, Senator Baucus. I congratulate him on his leadership 
on this issue for many months.
  I rise in strong support of the reconciliation bill that is before 
us. It is a historic time for our Nation. I am very glad that after 
decades of effort, national health reform has become law and that we 
are considering this set of changes to the law through this 
reconciliation bill.
  There is considerable confusion about what health reform, in fact, 
will accomplish. It is not surprising that there is confusion when one 
considers all of the nefarious charges that have been made and claims 
of nefarious provisions within the legislation. I am glad to see that 
most Americans, according to polling, believe the actual provisions 
that are described to them that are contained in the bill are 
meritorious and deserve support.
  Simply stated, the law has four main goals. It reforms health 
insurance markets to ensure Americans have access

[[Page S1947]]

to affordable care that meets their needs. Second, the bill improves 
the efficiency and quality of health care and does it in a way that 
helps contain rapidly rising costs. Third, the bill improves access to 
primary care and preventive services. Fourth, the bill significantly 
reduces the Federal deficit over the coming decades.
  I think we need to focus on what the effect of the legislation will 
be on particular individuals and families in our States.
  I look at our circumstance in New Mexico, which I am proud to 
represent. Let me pick out a few examples.
  First, there are families there who are very happy with their current 
coverage. For these folks, reform ensures they can keep that coverage. 
They do not have to purchase any new coverage offered through health 
insurance exchanges. The reform will help protect their coverage and 
introduces important policies to put downward pressure on the cost of 
premiums, requirements that the coverage continue to be meaningful, and 
significant improvements in the overall quality of and their access to 
health care.
  Small business owners or the people who work for small businesses--a 
third of the people in my home State fall into that category. For those 
who do offer coverage, we know that without reform, they have 
difficulty affording and keeping meaningful and affordable coverage for 
their employees. Premiums are rising quickly. These costs threaten the 
financial stability of these small businesses.
  CBO tells us that for small businesses, the impact of reform will be 
very significant. First, the businesses would have the option to come 
to the new health insurance exchanges and would have a guaranteed 
source of meaningful coverage for themselves and their employees. In 
addition, these small businesses may qualify for tax credits for up to 
50 percent of the cost of coverage. For businesses receiving tax 
credits, their employees' premiums would decrease by 8 to 11 percent 
compared to their costs under current law. Small businesses and their 
employees do well.
  What about individuals purchasing coverage in the individual market? 
This is particularly important in my home State, for over half of the 
workers in my State are not offered employer-sponsored coverage. We 
have the highest percentage of workers without coverage of any State in 
the Union.
  Like small businesses, individuals today have great difficulty in 
navigating insurance policies, securing affordable and meaningful 
coverage. This reform will provide these individuals with the options 
to come to new health insurance exchanges and have a guaranteed source 
of meaningful coverage for themselves and their families. The 
Congressional Budget Office predicts that the subsidies enrollees would 
pay would reduce the premiums they otherwise would have to pay by 50 to 
60 percent.
  Among higher income enrollees in the individual market who would not 
receive new subsidies--only about one-fifth of new enrollees--average 
premiums would increase by 10 to 13 percent.
  This is consistent with estimates of the impact in my home State of 
New Mexico, where average families may see a decrease in premiums of as 
much as 60 percent as compared to the premiums they would pay without 
reform. In addition, about two-thirds of New Mexicans could potentially 
qualify for subsidies or Medicaid.
  This reconciliation bill also contains important provisions to help 
Americans obtain a quality education. The higher education provisions 
of this bill will help put college within reach for more Americans. By 
eliminating subsidies to private student lenders, the bill supports 
large Pell grant increases for low-income college students, grants to 
States to help low-income students enter and succeed in college, and 
major new investments in minority-serving colleges and universities. 
And it does this without raising taxes; in fact, the CBO estimates that 
these student loan reforms will reduce the deficit by over $10 billion 
over 10 years.
  In challenging economic times, we can no longer afford to subsidize 
private lenders at the expense of college students and their families. 
In my home State of New Mexico, this bill will provide almost $240 
million in new Pell grant funding and an estimated $95 million for 
Hispanic-serving institutions and tribal colleges over the next 10 
years. In supporting economically disadvantaged college students 
through this bill, we help them to achieve the American dream. We also 
strengthen our economy by ensuring that we continue to have the 
smartest, most competitive workforce in the world.
  It is clear that the legislation before us and the new health reform 
law signed by President Obama yesterday are important steps forward for 
our country. Once we get beyond the rhetoric and discuss the specific 
reforms in this legislation--it becomes clear that this bill is vital 
to our Nation. It protects the aspects of our health care system that 
are working well while fixing those things that are broken including 
outlawing the nefarious games that health insurance companies play. It 
improves health care quality and it reduces costs; reforms the student 
loan system and expands important programs to help all America's 
children access a higher education--and it does all this while 
substantially reducing the Federal deficit.
  I hope we can join our colleagues in the House and move swiftly to 
pass this reconciliation bill.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. BINGAMAN. Mr. President, I will conclude by complimenting my 
other committee chair who is on the Senate floor, Senator Harkin, who 
has worked tirelessly to get this legislation through the HELP 
Committee. He deserves great credit for his leadership on this bill, as 
does Senator Baucus.
  The PRESIDING OFFICER. The Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, that is a good introduction to the next 
speaker, the distinguished chairman of the HELP Committee, Senator 
Harkin.
  The PRESIDING OFFICER. The Senator from Iowa is recognized.
  Mr. HARKIN. Mr. President, I thank my friend from New Mexico for his 
kind words, and I thank him for the great work he did on getting us to 
this point.
  I have a limited amount of time. I want to respond to the motion to 
commit made by the Senator from Tennessee yesterday that would reduce 
our investment in Pell grants and replace them with lower student 
interest rates.
  We all want lower student interest rates. I am, quite frankly, 
surprised. I do not remember my colleague from Tennessee or other 
colleagues on that side of the aisle raising much cane around here when 
the private bankers and Sallie Mae were charging students over 20 
percent interest. I did not hear a peep out of the other side.
  We have capped all of those interest rates now, and we are changing 
this program to a direct loan program to get the middlemen out. By 
cutting out the middlemen, by cutting out the huge subsidies to the 
bankers, we are able to save over $61 billion over the next 10 years, 
which we are using, again, to put into the Pell Grant Program to help 
our students.
  I said yesterday, and I repeat, think about the present status quo 
with this indirect guaranteed student loan program. Think about how 
bizarre it really is. The Federal Government pays fees to private banks 
to make entirely risk-free loans using taxpayer dollars. The loans, 
which are already guaranteed by the Federal Government, are then sold 
back to the Federal Government. The banks then pocket tens of billions 
of dollars, taxpayers' dollars, in fees and easy profits at absolutely 
no risk to them whatsoever. This has been going on for far too long. 
What this bill does is it ends that. It takes all those savings that 
otherwise would go to Sallie Mae and to the bankers and puts them into 
Pell grants.
  While I would agree that our students have too much debt--way too 
much debt; 73 percent of 4-year college graduates in my State of Iowa 
graduated with debt that averaged over $28,000. The national average is 
$23,200 for a student graduating from college. My Iowa students have 
the second highest debt loads in the Nation. We are taking charge of 
that.
  Three years ago, in the College Cost Reduction and Access Act of 
2007, we created the Income-Based Repayment program. What that bill 
said is that a borrower's payment would be capped at 15 percent of 
their net income after adjustments are made for living expenses

[[Page S1948]]

and provided total loan forgiveness after 25 years. We targeted that 
assistance to people who had the most difficult time repaying their 
loan.
  More can be done. Here is what we did in this bill. Starting in 2014, 
a new borrower's monthly payment will be capped at 10 percent of their 
net income. They will be eligible for total loan forgiveness after 20 
years. This is going to make college much more affordable for students 
even after they graduate.
  If my friend from Tennessee wants to look at ways of reducing 
interest rates, I am all for it. Some of the biggest users of credit 
cards are kids in college, and look what they are being charged under 
credit cards--well over 20 percent, 30 percent sometimes on their 
credit cards. And they need that for immediate needs. If you are a 
parent with a kid in college, you know what I am talking about.
  If you really want to help students, how about capping the interest 
rates they can charge on credit cards. I advocated that 20 years ago. 
We cap it at 12, 15 percent. They cannot charge any more than that. But 
I do not hear my friend from the other side talking about that. That 
would do more to help our students than just about anything else.
  Three years ago when we cut the interest rates on student loans, we 
were criticized by the Republicans for not doing enough to increase 
Pell grants. Now we are being criticized for doing too much on Pell 
grants and not enough on interest rates for students. We see what this 
is. It is just another attempt to try to kill this reconciliation bill. 
That is all it is. Of course I am for lower interest rates. Who 
wouldn't be? Of course we are all for making the interest rates lower. 
When this reconciliation bill is through, I intend to come to the floor 
on some bill that probably will be coming up--maybe a financial bill or 
something like that--and I will be proposing at that time that we have 
lower interest rates. I ask my friend from Tennessee to join us in that 
effort at that time. But now is not the time and this is not the bill 
on which to do this.
  We have to get our reconciliation bill through. Every amendment being 
offered by the Republicans is no more than an attempt to stop and kill 
this reconciliation bill, and we cannot allow that to happen.
  We are going to have an education bill this year. We are going to 
have an elementary and secondary education bill I hope sometime this 
year. Higher Education Act changes are in this reconciliation bill. We 
are going to make sure the students have the money to go to college and 
Pell grants for the lowest income students. And, yes, we have capped 
interest rates at 6.8 percent. Could they be lower? I invite my friend, 
when we have another bill up that addresses this, let's see if we can 
get lower interest rates. I would be glad to work on that issue at that 
time. But right now, let's put the savings, the $61 billion that we are 
saving--let's do what this bill does: put it into better Pell grants so 
the kids can get into college in the first place.
  We also put $2.5 billion into something we have neglected for far too 
long; that is, our Historically Black Colleges and Universities and 
other Minority-serving Institutions. So a big chunk of that money goes 
in there so they can also get a good education.

  So this bill was carefully crafted. We put the money in there in the 
Pell grants. Let's keep them there and let's address the issue of the 
interest rates later on. I invite my Republican friends to join with us 
in doing that, especially on credit cards when that issue comes up down 
the pike.
  Again, I urge my colleagues, when the vote comes up, to defeat the 
Alexander motion to commit and to keep the money in there for Pell 
grants.
  I yield floor.
  The PRESIDING OFFICER. The Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, I wish to say a few words about how much 
this underlying legislation helps small business. We hear a lot of 
claims to the contrary, and I wish to set the record straight.
  Essentially, small business people in America today spend about 18 
percent more than the large businesses for the same health care 
coverage. Why is that? Because of high broker fees--small businesses 
have to buy insurance through brokers--because administrative costs are 
higher for them compared to big businesses, and adverse selection hurts 
them much more than big business. There are a lot of reasons why small 
businesses pay 18 percent more for health care than big business.
  This legislation contains $37 billion in small business tax credits--
$37 billion in small business tax credits--most of which go into effect 
this year, not later but this year, tax credits for a businessperson 
who wants to offer health insurance for his or her employees. Add to 
that insurance reforms, which are very much going to help small 
business. What are they? Preventing insurance companies from 
discriminating against small employees based on preexisting conditions, 
preventing discrimination on the basis of older or sicker employees, 
discrimination based on the size of the plan or discrimination against 
those whose employees work in dangerous industries.
  All these insurance reforms are going to help small business. I might 
say the Congressional Budget Office also estimates the Senate bill will 
lower premium costs by nearly 7 percent for small businesses--lower 
premium costs, not increase them, as has been suggested, but lower 
premium costs for small business.
  The bill also provides for State-based exchanges. That is going to 
help small business because that will require more competition among 
insurance companies. That will help give better rates and better 
quality insurance to small businesses.
  I might say this as well. The legislation exempts small businesses--
that is a business with 50 or fewer employees--from the requirement 
that employers that do not sponsor health care insurance pay a fee for 
their employees receiving premium tax credits. That is an exemption for 
small businesses with fewer than 50 employees from paying any penalty 
if they do not provide insurance.
  So I wished to make it very clear that this bill very much helps 
small business--and I repeat--with $37 billion in small business tax 
credits, along with the other reasons I gave.
  Mr. Chairman, how much time remains?
  The PRESIDING OFFICER. There is 1\1/2\ minutes remaining.
  Mr. BAUCUS. Mr. President, I don't know if Senator McCaskill is in 
the Chamber. I doubt she wants to take 1\1/2\ minutes. If not, I will 
yield back the 1\1/2\ minutes.
  I understand Senator McCaskill is here now and wishes to speak, so I 
will try to find a way to squeeze in as much time as I can.
  You are on.
  The PRESIDING OFFICER. The Senator from Missouri is recognized, and 
she has 1 minute.
  Mrs. McCASKILL. Mr. President, I am confused about why the hearing we 
had scheduled this afternoon cannot go forward. The subject matter of 
this hearing is oversight of the contract that is engaged in police 
training in Afghanistan in the Subcommittee on Contracting Oversight. 
This is a hearing that is getting to the heart of the matter; that we 
have a real problem with the mission part in Afghanistan on police 
training because of problems with these contracts--problems with 
oversight at the State Department.
  We have now canceled the hearing because we have been told we can't 
have it. The witness from the State Department has been canceled, the 
witness from the Defense Department has been canceled, and the 
inspectors general who were coming to testify about a GAO report that 
just came out last week that was damning in its criticism in the 
oversight of these contracts.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mrs. McCASKILL. I don't get it.
  The PRESIDING OFFICER. The Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, is there an order providing for the next 
half hour?
  The PRESIDING OFFICER. There is not.
  Mr. BAUCUS. I ask unanimous consent that the Republican side control 
the next half hour and that the majority control the half hour 
following that.
  The PRESIDING OFFICER. Is there objection?
  Mr. GREGG. Reserving the right to object, that would be a half hour 
off, so

[[Page S1949]]

we should have the half hour after that because you got the first half 
hour.
  Mr. BAUCUS. We won't worry about that yet.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. GREGG. Mr. President, the Senator from Maine is about to take the 
floor.
  The PRESIDING OFFICER. The Senator from Maine is recognized.
  Ms. SNOWE. Mr. President, I wish to thank the Senator from New 
Hampshire very much for his leadership and for consideration of the 
time today.
  As consideration of health care reform draws to a close in the Senate 
with the pending reconciliation bill, I cannot help but arrive at this 
moment with a sense of profound disappointment in considering what 
might have been, rather than what has actually occurred with respect to 
one of the foremost domestic matters of our time.
  As I stated as a member of the Senate Finance Committee at the 
conclusion of our markup of health reform legislation last October, 
this is one of the most complex set of issues ever placed before us. At 
the same time, I have said the reality that crafting the right approach 
is arduous in no way obviates our responsibility to make it happen, 
given the enormous implications of reordering more than $33 trillion in 
health care expenditures over the next 10 years, representing one-sixth 
of our economy and affecting every American.
  Well, if there is one thing I have learned, it is that the only way 
to allay people's fears is by systematically working through the 
concerns, the issues, and the policy alternatives from all sides. When 
we hear proponents portraying the passage of health care reform as the 
equivalent of landmark legislation of the past, what they fail to note 
is, those efforts were all bipartisan. Regrettably, part of the history 
we made this week is that, for the first time, a truly watershed bill 
became law purely along partisan lines.
  As I mentioned on the floor last November, it is almost impossible to 
imagine how transformational legislation over the last nearly 100 
years, such as Social Security, Medicare, and civil rights could have 
been as strongly woven into the fabric of our Nation had they forsaken 
bipartisanship.
  We could have extended that bipartisan legacy. The majority had 60 
votes for health care reform, so they had a choice. They could have 
worked collaboratively to develop a more balanced, effective, and 
credible approach that--even if it ultimately failed to attract many 
Republican votes--could have resulted in legislation more widely 
embraced by the American people because, in the final analysis, no one 
party or person has a monopoly on good ideas.

  That is precisely the reality that originally brought six of us 
together in the Senate Finance Committee in the so-called Gang of 6, to 
the credit of Chairman Baucus, who convened a meeting last summer, 
along with Ranking Member Grassley, and that the chairman and ranking 
member referenced earlier in the debate on the floor. I commend them 
for what was the only bipartisan effort in any committee of the House 
and Senate. Certainly, that has been true and indicative of their 
collaborative, cooperative relationship. As the chairman pointed out, 
we met 31 times, week after week, for over 4 months, to debate policy 
and not politics because we were attempting to reach bipartisan 
consensus on reform legislation.
  While we ultimately did not reach an agreement, given our discussions 
were ended prematurely by an artificially imposed deadline, our efforts 
did, in many ways, form the foundation for the subsequent Finance 
Committee legislation that, while far from perfect, produced bipartisan 
reforms, including banning the egregious practices by the insurance 
companies that have been discussed so often. We tried to navigate the 
ideologies on both ends of the political spectrum.
  At the same time, as I stated at the conclusion of the Finance 
Committee markup, the issue of affordability remained one of my 
paramount concerns. I further expressed that we could not create vast, 
new bureaucracies and governmental intrusions. Finally, I said my vote 
to report the bill out of the committee was to continue to work to 
improve the legislation and, therefore, it would be imperative moving 
forward that the majority in the Senate give deference to the scope and 
the complexity of this issue, earn broader support, and resist the 
impulse to retreat into partisanship.
  Yet regrettably, since the Finance Committee vote on October 13, the 
wheels essentially came off. The process went behind closed doors, with 
only one party represented. Long gone was the transparency of the 
Finance Committee debate, and what came to the Senate floor was a 
2,400-page bill--900 pages longer than the Finance Committee bill--that 
we were forced to complete by Christmas Day, after a mere 21 days on 
the floor. In looking at a relative equivalence in terms of benchmark 
legislation, the Senate debated the Civil Rights Act of 1964 for 57 
days. In the FAA bill that we just considered--that we just voted on 
this past Monday--we disposed of 45 amendments. That is 17 more than we 
addressed in the amendment process on health care reform legislation in 
December. What exactly were people afraid of?
  Think what we could have been celebrating today if we would have had 
the open amendment process we had been promised or even if we had had, 
as I urged, that bipartisan summit last October instead of just last 
month. If it was a good idea now, it would have been a good idea then. 
Imagine if everyone had the opportunity to sit down with the actual 
legislative language and work through all the issues, determining what 
works and what doesn't work. We could have crafted a better product. 
But now we will never know. We could have, instead, developed something 
practical, rolled out in phases--something all the more critical, given 
we are already in treacherous economic and fiscal waters.
  It is not as though we lacked the time. After all, the major 
provisions of this initiative do not even take effect until 2014. In 
fact, CBO has said that with the majority of the reform measures not 
scheduled to commence until then--4 years from now, by year 2013--there 
will still be 50 million uninsured Americans, exactly the same number 
as today.
  There are those who will argue that the Senate-passed legislation was 
basically the same bill that emerged from the Finance Committee. But 
the facts tell a story of a different bill that, far from improving 
upon the finance measure, as I had indicated would be critical, instead 
went precisely in the opposite direction from what Americans wanted--
with greater bureaucracy, more taxes, and ill-conceived measures that 
will cost our Nation jobs rather than help to create them.
  Look at this chart, with respect to the employer mandate, to cite 
some examples. Something of critical importance to me, as ranking 
member of the Senate Small Business Committee, the Finance Committee 
proposal contained no employer mandate per se, forcing firms to offer 
health insurance. Rather, it specified that if a firm chose not to 
offer insurance and any of its workers received subsidized coverage in 
the exchange, the firm would pay a penalty equal to the lesser of an 
average credit amount that the employee received in the exchange or a 
flat $400 fee for all its workers.
  While I would have preferred a zero penalty, the Senate-passed bill 
actually got worse, as you can see with this chart. First, penalties 
nearly doubled from those in the Finance Committee package to $750 per 
employee. Then it greatly expanded the instances in which penalties 
would be applied, requiring employers with more than 50 full-time 
employees who don't at least offer coverage and have even one full-time 
employee receiving a subsidy through the exchange to pay $750 for each 
of its full-time workers.
  Under the reconciliation package that is pending before the Senate, 
firms with more than 50 workers would have to pay $2,000 per employee 
with just the first 30 employees exempted. That is a 167-percent 
increase over the $750 in the bill that was just signed into law. So we 
have gone from $400 to $750 and now to $2,000.
  If that is not enough, part-time workers and seasonal workers will 
now be counted in determining whether the mandate will apply. That will 
be devastating. It will be devastating to

[[Page S1950]]

small firms, middle-sized firms, restaurants, retailers, and seasonal 
industries, such as those in my State of Maine, that will be subject to 
this mandate, which now produces $52 billion in revenue, up from the 
$27 billion in the bill that just became law.
  Exactly how is this going to help our Nation's greatest job 
generators--our small businesses--that we are depending on to lead us 
out of this downturn?
  Now let's look at the Medicare taxes, the second chart. The finance 
bill did not contain any form of Medicare taxes. We did not increase 
Medicare taxes. The Senate bill that just now became law, signed by the 
President yesterday, included $87 billion in Medicare taxes. That 
disproportionately affects small businesses because they apply to the 
income those businesses would normally reinvest.
  Plain and simple, this .9 percentage point increase in Medicare 
payroll taxes is a job killer as it essentially takes away 1 additional 
percentage point of capital from the very small business owners we are 
depending on to create jobs, who are more than likely to employ between 
20 and 250 employees, all at a moment when we should be looking for 
ways to help bring capital into small businesses.
  If that were not bad enough, here we have reconciliation that is 
pending before the Senate that compounds the mistake with a 3.8-percent 
Medicare tax that is unprecedented because it is imposing a payroll tax 
on investment income. When combined with a capital gains tax increase 
the majority is planning for the end of this year, this 3.8 percent tax 
will raise the capital gains tax rate to an astonishing 23.8 percent, 
which is a 67-percent increase in taxes on investment during these 
precarious times.
  Taken together, it is a grand total of $210 billion in Medicare 
taxes. So we went from the Finance Committee at zero to the Senate-
passed bill that became law yesterday at $87 billion, and now in the 
bill pending before the Senate, we have a grand total of $210 billion 
in Medicare taxes.
  It is a hidden tax, by the way. It is not indexed for inflation, so 
it will be similar to the alternative minimum tax that is going to 
continue to ensnare more and more people in this tax. It is a major tax 
increase on individuals, small businesses, on capital, at a time when 
we desperately need that capital to be reinvested to create more jobs.
  Again, we have gone from zero to $210 billion in new taxes in 
Medicare. Do we seriously believe this is the time we should be 
instituting these breathtaking and job-killing increases, not to 
mention the unprecedented shift because not one dollar gets reinvested 
in Medicare--not one dollar--not to mention it does not address the 
physician problem with a 21-percent reduction in provider reimbursement 
that we have to extend this week for another month because it is a 
month-to-month problem. We need a 10-year fix. That will be over $200 
billion but, rather, we are taxing it for other purposes rather than 
into Medicare. But unfortunately, that's what becomes of a broken 
process.
  Look at what two of the largest organizations representing small 
business in America stated upon passage of the finance bill. The 
National Federation of Independent Business said at the time the 
finance bill passed on October 13:

       NFIB appreciates the many provisions in this package that 
     reflect small businesses' needs, which are rooted in 
     approaches that aim to lower costs, increasing coverage 
     options, and provide real competition in the private 
     marketplace.

  Fast forward to the Senate-passed bill in December that now became 
law as a result of the President signing it yesterday. Now what does 
NFIB, the National Federation of Independent Business, have to say?

       The impact from these new taxes, a rich benefit package 
     that is more costly than what they can afford today . . . 
     [and] a hard employer mandate--

  The one I referred to earlier--

     equals disaster for small businesses.

  On March 21, they said:

       We couldn't have been clearer how damaging this bill will 
     be to America's small businesses and the economic recovery of 
     this country.

  Particularly in these precarious economic times, shouldn't that make 
us all deeply concerned?
  Now consider what the National Small Business Association released 
this weekend. I have that on a chart as well.

       We have continued to work positively for needed changes . . 
     . but it is now clear that most of these recommendations have 
     not been accepted. . . .We understand that it is impossible 
     to create a significant reform such as this one without some 
     objections from nearly every constituency. But our objections 
     to this bill go beyond those reasonable expectations. 
     Congress can do better.

  To which I add, I could not agree more. They say they oppose the 
health care reform bill with regret but they base it on all the 
significant issues that have been incorporated in this legislation that 
will be damaging to small businesses. I could not agree more.
  Furthermore, I am deeply troubled by the manner in which the Medicare 
tax increases in this bill are to be utilized--$210 billion. According 
to CBO, and this is their exact words:

       To describe the full amount of the [Medicare] 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.

  So, No. 1, talking about the fact of the reduction of deficit, it is 
not going to improve that; and No. 2, whether or not it can be plowed 
back into Medicare, obviously it is not going to affect Medicare's 
insolvency issue because it is going to go to other purposes and is not 
intended for the Medicare trust fund. How are we going to strengthen 
Medicare when these new tax dollars are being diverted from their 
original intended purpose of actually paying for Medicare benefits?
  Another major difference in the legislation we passed in the Senate 
Finance Committee on October 13 and in the pending reconciliation bill, 
is the so-called CLASS Act. While proponents point to estimates that 
this provision would raise $72 billion over the first 10 years, that 
savings only occurs as a result of a fiscal shell game of using funds 
promised to pay beneficiaries later to lower the deficit today. As CBO 
says, ``The program would pay out far less in benefits than it would 
receive in premiums over the 10-year budget window,'' raising $70 
billion in premiums that will fund benefits outside the window, and as 
a result, CBO further concluded that ``in the decade following 2029, 
the CLASS program will begin to increase the deficit.'' Again, this is 
exactly the wrong direction for America.

  Perhaps most disturbingly, we don't even have answers from CBO to 
many of the most fundamental questions in the minds of Americans, the 
minds of small businesses--what will be the true impact? Those were 
questions I posed to CBO on December 3 to which I still don't have the 
answers. What provisions in the legislation would justify and 
facilitate premium increases, and to what extent would other provisions 
limit their outcome? What would go up and what would go down? We need 
to know what is going to drive up premium costs and what is going to 
lower premium costs. Indeed, the headline on Tuesday in my home State 
newspaper the Portland Press Herald was ``Mainers Wait and Wonder: How 
Will Reform Affect Us?''
  That is why I also requested from CBO specific state-by-state 
analysis of reform's effects on premiums, because while we do have from 
CBO a national average for premiums, what they would be for minimum 
credible coverage under the new law, the reality is that cost will vary 
widely from State to State. That is why I proposed and I asked CBO what 
the impact would be of opening up the legislation to extend the ``young 
invincibles'' plan, that catastrophic coverage for young people, to all 
Americans and extend those subsidies to that coverage as well so 
everyone at least has one affordable option to purchase health 
insurance. Why? Because the Federal Government is requiring for the 
first time that individuals purchase health insurance--that is, first, 
individual mandates; second, it sets new standards in the plan and the 
exchanges that could drive up premium costs for certain individuals and 
small businesses. So shouldn't we have the certainty that affordable 
choices are available? Yet we do not even have substantiation whether 
provisions of this reform will make health care costs higher or lower. 
In fact,

[[Page S1951]]

there is actually a presumption in the legislation that costs may well 
go up.
  I find it telling that the excise tax on high-cost insurance in this 
reconciliation contains a fail-safe provision, referred to as a health 
cost adjustment percentage, that automatically raises the threshold to 
higher numbers. That was described in the House Democratic summary of 
reconciliation. They put it this way:

       CBO is wrong in its forecast of the premium inflation rate 
     between now and 2018.

  Maine is a high-cost State, regrettably, because it is not a 
competitive market. We have high-cost plans, along with 16 other 
States. But given that the bill already provides for thresholds as high 
as $13,900 for individuals and $36,450 excluding vision and dental 
benefits before triggering the excise tax, those thresholds are 
significantly higher than those that were passed in the Senate-passed 
bill yesterday. Now they will be raised even higher under the pending 
reconciliation.
  The question is, Why exactly would we still require a medical 
inflation adjusted for 2018, 8 years from now, that raises those 
thresholds even higher? What does that say about the performance 
confidence in reining in medical costs as a result of this legislation 
that was signed into law and the pending reconciliation? It says they 
simply do not know. The fail-safe automatic increase in the threshold 
clearly assumes this legislation still may not address runaway costs.
  The PRESIDING OFFICER (Mrs. Hagan). The time of the Senator has 
expired.
  Ms. SNOWE. I ask unanimous consent for 1 additional minute.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Ms. SNOWE. Madam President, these are the thresholds. Eight years 
from now--the legislation suggests that because of inflation for 
medical costs that outpaces inflation two to three times, they are 
saying that 8 years from now, we will not have controlled medical costs 
even with the passage of this legislation having taken effect as a 
result of yesterday. It is precisely because of this uncertainty that I 
will be offering amendments to address these very issues.
  Somehow, the high worth of legislating, of deliberating, of ironing 
out our differences has been cast aside in favor of either/or 
propositions when we could have instead risen to the monumental 
challenge with the best possible solution to strengthen America's 
health care today and for generations to come. I profoundly regret that 
this process has provided far too few opportunities to forge 
legislation that would stand not just the test of our time but for all 
time. We could have done better and we should have done better.
  I yield the floor, and I ask unanimous consent to have printed in the 
Record the NSBA statement of March 19, 2010; the NFIB statement of 
November 19, 2009; and the Portland Press Herald article of March 23, 
2010.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

     [From the National Small Business Association, Mar. 19, 2010]

           NSBA Opposes Health Care Reform Bill, With Regret

       Despite the extraordinary need of small businesses for 
     health care reform, the National Small Business Association 
     cannot support the reform bill currently pending before 
     Congress. This bill will place significant new pressures on 
     small businesses to both offer and pay for employee health 
     insurance, starting in the earliest stages of reform. 
     However, the provider-level reforms that could contain costs 
     and enable small businesses to afford this commitment will 
     not be fully effective for many years--if at all. We 
     justifiably expect that small companies caught between these 
     twin pressures will see their ability to grow, prosper, and 
     create jobs greatly diminished.
       As long-time advocates of fundamental reform of the health 
     care system, we had high hopes for a reform measure that 
     could be more broadly embraced and that we could support. 
     Indeed, the current bill has many positive features that NSBA 
     supports: repair of the dysfunctional individual and small 
     group insurance markets; focus on individual needs and 
     responsibilities, rather than all-encompassing employer 
     mandates; and a start on transforming the delivery system 
     incentives that have driven health care costs to 
     unsustainable levels.
       The shortcomings, though, also are significant.
       Small business health premiums will continue to increase 
     sharply, as even the Congressional Budget Office has 
     determined.
       The legislation does nothing to encourage cost-conscious 
     consumer behavior, aside from the unnecessarily blunt 
     ``Cadillac tax,'' which will not begin to have an effect 
     until at least 2018, and which is insufficiently transparent 
     and imposes unintended administrative burdens on small 
     businesses.
       The previously mentioned delivery system reforms are 
     positive, but are too back-loaded, giving powerful vested 
     interests years to water them down or remove them entirely. 
     Even if implemented, they are not likely to have a 
     significant effect on costs for a decade or more. Malpractice 
     reform, absent from the current legislation, would make these 
     reforms much more effective.
       Though currently excluding most small companies, the large 
     increases in ``free-rider fees'' are troubling. If there was 
     once a distinction between an employer mandate and a free-
     rider provision, it seems to have been lost.
       The very large tax increases on both earned and unearned 
     income could have a significant effect on many small business 
     owners and their ability to reinvest in their companies' 
     growth. These increases are in addition to the 
     administration's current budget proposal which calls for 
     significant income tax increases on the same individuals. 
     Together, these taxes will create a steep increase in 
     marginal tax rates on the very entrepreneurs we need to be 
     investing and creating jobs.
       NSBA has stood apart from many other business groups during 
     deliberations on health care reform, preferring to be a 
     nonpartisan, thoughtful, and member-driven organization. We 
     have continued to work positively for needed changes to the 
     legislation, but it is now clear that most of those 
     recommendations have not been accepted and that the bill is 
     in its final form. We understand that it is impossible to 
     create a significant reform such as this without some 
     objections from nearly every constituency. But our objections 
     to this bill go beyond those reasonable expectations. 
     Congress can do better. A sense of urgency on cost 
     containment is the place to start.
                                  ____


                   NFIB Statement: Senate Health Bill

       Washington, DC, Nov. 19, 2009.--Susan Eckerly, senior vice 
     president of the National Federation of Independent Business, 
     the nation's leading small business association, issued the 
     following statement in reaction to the Patient Protection and 
     Affordable Care Act:
       ``Small business can't support a proposal that does not 
     address their No. 1 problem: the unsustainable cost of 
     healthcare. With unemployment at a 26-year high and small 
     business owners struggling to simply keep their doors open, 
     this kind of reform is not what we need to encourage small 
     businesses to thrive.
       ``We oppose the Patient Protection and Affordable Care Act 
     due to the amount of new taxes, the creation of new mandates, 
     and the establishment of new entitlement programs. There is 
     no doubt all these burdens will be paid for on the backs of 
     small business. It's clear to us that, at the end of the day, 
     the costs to small business more than outweigh the benefits 
     they may have realized.
       ``Small businesses have been clear about their needs in 
     health reform; they have been working for solutions for more 
     than two decades. They have a unique place in this debate 
     because of the exceptional challenges they face. They 
     experience the most volatile premium increases, are the most 
     cost-shifted market, see the most tax increases and have the 
     least competitive marketplace. For all these reasons, they 
     especially need reform, but these reforms can't add to their 
     cost of doing business. The impact from these new taxes, a 
     rich benefit package that is more costly than what they can 
     afford today, a new government entitlement program, and a 
     hard employer mandate equals disaster for small business.
       ``We are disappointed that, after so many months of 
     discussion, small business could be left with the status quo 
     or something even worse. Unless extreme measures are taken to 
     reverse the course Congress is on, small business will have 
     no choice but to hope for another chance at real reform down 
     the road.
       ``Congress is running out of opportunities to prove to 
     small business that they are serious about helping our 
     nation's job creators. We are hopeful that a robust 
     bipartisan debate will produce a bill that small businesses 
     see as a solution and not another government burden.''
                                  ____


            [From the Portland Press Herald, Mar. 23, 2010]

          Mainers Wait and Wonder: How Will Reform Affect Us?

                          (By John Richardson)

       Terri Grover of Portland watched from her home Sunday night 
     as Congress finally passed health-care reform legislation.
       She didn't realize that her 22-year-old daughter, a senior 
     at Bates College, was glued to the television, too.
       ``My daughter called from college last night at 10:45 and 
     said, `They passed it, they passed it! Does that mean I'm 
     going to get insurance?' '' Grover said.
       Grover is pretty sure the answer to that question is 
     ``yes.''
       The legislation, which still needs to be signed by 
     President Obama and then amended by the U.S. Senate, says 
     dependents will be eligible to stay on their parents' 
     policies until they turn 26.
       However, Grover is still nervous about all of the details 
     in the complex reform package, some of which have yet to be 
     finalized.

[[Page S1952]]

       Some Mainers, including Grover, said Monday that they're 
     excited about the legislation.
       Others said they fear that the added costs and regulation 
     will just make matters worse.
       All agreed, however, that there is much uncertainty and 
     confusion about how it will ultimately affect their health 
     care costs, their jobs and their businesses.
       ``We all want to know,'' Barbara Thorso of South Portland 
     said Monday afternoon between bingo games at the city's 
     community center.
       Thorso, 87, is president of the Three Score Plus Club, 
     which hosts the weekly gathering.
       ``We're the general public. This bill is going to cover 
     us,'' Thorso said. ``I would like to have an understanding of 
     what's in the package. I don't have a clue.''
       The 10-year, $938 billion bill will eventually extend 
     coverage to 32 million uninsured Americans, prohibit 
     insurance companies from denying coverage to sick people, and 
     create insurance marketplaces, called ``exchanges,'' intended 
     to make coverage more affordable.
       Other changes will be more immediate, such as subsidies to 
     help senior citizens pay for drugs and the requirement to let 
     dependent children remain on their parents' health insurance 
     plans until age 26.
       ``It's really too soon to know how all of this is going to 
     unfold. Some of the provisions of the bill don't go into 
     effect until 2014, and some after that,'' said Katherine 
     Pelletreau, director of the Maine Association of Health 
     Plans, an association of health insurance companies.
       ``In truth, I'm trying to understand it, to dissect it so 
     we can know what the impacts and (employers') 
     responsibilities are, and that's going to take some time,'' 
     said Dana Connors, president of the Maine State Chamber of 
     Commerce.
       ``The big question is . . . does it reduce costs or does it 
     add costs?''
       Parker Williams of South Portland believes that the 
     legislation will hurt businesses and cost jobs. ``Where are 
     they going to get the money to pay for it?'' said Williams. 
     ``It will take 10 years before it will start to save money.''
       Anne LaForgia of South Portland said she has more faith in 
     President Obama.
       ``Most of the people our age are very concerned,'' said 
     LaForgia, who is 84. ``I'm really hopeful . . . I don't think 
     it will hurt (seniors covered through Medicare). I'm more 
     worried about the younger people.''
       Toni Fizell and Sharon Haskell, both of South Portland, 
     could be directly affected by the legislation. Fizell, who is 
     59, has no health insurance.
       Haskell, who is 63, expects that she will be uninsured, 
     too, after her rate goes up in June.
       Both are more nervous about the bill than optimistic.
       ``It's scary to listen to (the debate),'' Fizell said. 
     ``Everybody has to have insurance. . . . How are they going 
     to enforce that?''
       The bill will eventually require people to buy insurance or 
     pay fees, and it includes subsidies to help people who can't 
     afford it.
       Haskell, who lost her job and her employer insurance last 
     year, said she doesn't expect any help from the legislation 
     before she turns 65 and is eligible for Medicare. ``I'm just 
     going to look for something part time and pray that I stay 
     healthy,'' she said.
       Grover, who celebrated on the phone with her daughter, is 
     confident that the legislation will be an improvement, 
     despite all the details.
       ``Young people will be able to search for the right career 
     for them rather than search for any job that will give them 
     health insurance,'' she said. ``I wish the whole thing went 
     into effect faster.''

  The PRESIDING OFFICER. The Senator from North Carolina.
  Mr. BURR. Madam President, how much time remains?
  The PRESIDING OFFICER. Nine minutes.
  Mr. BURR. Will the Chair please notify me when I am down to 1.
  I will also offer an amendment tonight, and the purpose is very 
clear: it is to protect the health care of our Nation's servicemembers, 
veterans, and their widows, orphans, and dependents. The problem is, 
since the debate on health care reform began, our veterans and their 
families have asked for just one thing: Protect our health care 
benefit. The President even promised. He said that ``one thing that 
reform will not change is veterans health care. No one is going to take 
away your benefits--that is the plain and simple truth.''
  Unfortunately, the Patients Protection and Affordable Care Act does 
not explicitly protect the health care of our Nation's servicemembers, 
veterans, their widows, orphans, or dependents. Let me explain why.
  Under this health care bill, it requires a minimal essential coverage 
of any health care plan. The requirements for that health care do not 
clearly include TRICARE, which is the Active-Duty family members of our 
troops; the VA's spina bifida program for children under our Agent 
Orange veterans under chapter 18 of title 38; and CHAMPVA, a program 
run out of the Veterans Administration for spouses and dependent 
children of veterans who died or are profoundly disabled as a result of 
military service; and possibly VA's vocational rehabilitation program. 
As a result, these beneficiaries could be forced to pay additional 
insurance or to pay punitive fees because the threshold of coverage 
does not meet the threshold defined in this bill.
  Apparently, the authors were so preoccupied with the sweetheart deals 
and backroom negotiations that they forgot to uphold their promises, 
they forgot about the policy part of this health care bill.
  Both the House and Senate have acknowledged the oversight I am here 
to correct. As soon as the issue was identified, the House rushed 
through on Saturday to pass a bill to put a technical correction on the 
Department of Defense piece. The bill passed with overwhelming 
support--403 to 0. The problem is, the only piece that the DOD 
technical corrections piece fixes is, in fact, TRICARE.
  It does not fix spina bifida for the children of Agent Orange 
survivors. It does not fix CHAMPVA, which is the program for spouses, 
dependent children of veterans who are profoundly disabled as a result 
of military service.
  Now, identical legislation was introduced in the Senate, and some 
claim, well, we just need to pass that. Well, you need to pass that if, 
in fact, you do not want to extend CHAMPVA and spina bifida.
  I have to commend that Secretaries Shinseki and Gates have tried to 
alleviate the concerns. I certainly appreciate their reassurances. 
However, the greatest assurance you can provide is to be unambiguous 
about the issue. We owe it to our Nation's veterans, to their families, 
to leave uncertainty outside and to spell it out in the legislation 
that these items meet the threshold. Therefore those families, those 
servicemembers, are not obligated in the future for additional 
penalties and/or fees to participate.
  It is time we started to listen to the American people, especially 
when it relates to our Nation's veterans and their families. My 
amendment maintains the integrity of the health care system of VA and 
DOD. It ensures that the authority of the Secretary of the Department 
of Defense and the Secretary of Veterans' Administration would not be 
challenged or obstructed by any provision in the Patient Protection and 
Affordability Care Act.
  My amendment will ensure that nothing in the Democrats' health care 
bill should be construed as affecting benefits provided under TRICARE 
or any VA health care program.
  Finally, my amendment ensures that the minimal essential coverage--
key words, ``minimum essential coverage''--under this Democratic health 
care bill includes TRICARE and all health care provided by the VA.
  I think it is important to remind my colleagues that over the weekend 
the veterans service organizations have expressed their deep concern, 
and more than one VSO, Veterans of Foreign Wars, said this:

       Bill language is important, and that's why the VFW remains 
     adamant to expeditiously fixing the new law. All of DOD's 
     programs should have been in the original bill, as well as 
     all of Title 38, not just one part of one chapter. This is 
     not playing politics, this is protecting the hard earned 
     health care coverage our veterans, servicemembers, and their 
     families deserve.

  Some might come to the Senate floor later and say, well, this is not 
the appropriate place to fix it. The reconciliation bill has been 
billed as ``the bill to fix everything'' that is wrong in the original 
health care bill. That is how it was sold to House Members: Vote for 
the Senate bill, and we will fix all of those things that you find as 
problems in the reconciliation bill.
  We have before us the reconciliation bill, and some will argue that 
fixing it for our Nation's veterans, their spouses, their family 
members, that this is not the appropriate place to do it. I agree. We 
should have gotten it right the first time. We should not have to have 
a fix-it bill. But when we do not bring sunlight to it, when we exclude 
people who are focused on policy, this is what we get. We get a bill 
that does not fulfill the promise the President made.
  Let me just state again exactly what they were. The President said:

       One thing that reform won't change is veterans health care.


[[Page S1953]]


  He went on to say:

       No one is going to take away your benefits, that is plain 
     and simple truth.

  Well, if it is plain and simple truth, then this body has no choice 
tonight but to take my amendment, to pass my amendment, to incorporate 
it in the health care fix bill, the reconciliation bill, and to make 
sure that when we finish our business, whether that is tomorrow or the 
next day, that, in fact, it is very clear in the health care bill who 
is covered. It is not just TRICARE for Life, it is TRICARE; it is spina 
bifida for the children of Agent Orange exposure; it is the CHAMPVA 
program, which covers spouses, children, and the severely disabled of 
those killed in action.
  My hope is that all of my colleagues will see the wisdom in 
supporting this bill, that they will not look for another avenue to do 
it in, that they will put it in the fix bill, and they will not leave 
it up to Secretaries to give us the assurance when we have set up so 
many outside panels to interpret for the American people what their 
coverage is going to be in the future.
  I think sometimes we can forget the complicated maze this bill 
creates, where we will actually have nonproviders determining whether 
your coverage is sufficient that you constructed or that your employer 
provided for you or that you went out as an independent and bought, and 
if it does not meet the standard of minimum essential coverage, then 
you could open----
  The PRESIDING OFFICER. The Senator has 1 minute remaining.

  Mr. BURR. I thank the Chair.
  Then you could be exposed to a fine because a government bureaucrat 
has determined that the coverage, the health care coverage you bought, 
that you were given, is not sufficient enough to meet the minimal 
essential coverage this bill crafted.
  Well, very simply, there are veterans around the country who know 
they have been left out--their spouses, their family members, their 
kids with disease. Tonight we can assure them they are included by, in 
the health care fix bill, actually fixing that one piece and making 
sure that we extend the coverage the President promised and that we owe 
to these veterans and their families.
  When I introduce that bill, I hope all 100 Senators support it like 
the House has. I thank the Chair.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Madam President, I think the half hour has now turned to 
our side.
  The PRESIDING OFFICER. That is correct.
  Mr. BAUCUS. I yield to the Senator from Michigan for a request.
  The PRESIDING OFFICER. The Senator from Michigan


                     Request for Committees to Meet

  Mr. LEVIN. Madam President, I make this request as chairman of the 
Senate Armed Services Committee. I would note that this unanimous 
consent request is supported by my ranking member, Senator McCain.
  We have three commanders scheduled to testify this afternoon. They 
have been scheduled for a long time. They have come a long distance. 
One of them has come from Korea; one of them has come from Hawaii. I 
would therefore ask unanimous consent that the previously scheduled, 
currently scheduled hearing of the Committee on Armed Services, be 
allowed to proceed and that we be authorized to meet during the session 
of the Senate on Wednesday, March 24, 2010, at 2:30 in open and closed 
session to receive testimony from ADM Robert Willard, U.S. Navy, 
Commander U.S. Pacific Command; from GEN Kevin P. Chilton, U.S. Air 
Force, Commander of the U.S. Strategic Command; and from GEN Walter 
Sharp, U.S. Army, Commander U.S. Forces Korea, in review of the defense 
authorization request for fiscal year 2011, and the future years 
defense programs.
  Senator McCain supports this request. I understand it is not likely 
there will be any votes on the floor until 5:30 this afternoon.
  The PRESIDING OFFICER. Is there objection?
  Mr. BURR. As a member of the committee, and I side myself with the 
chair and the ranking member that I have no personal objection to 
continuing. There is objection on our side of the aisle. Therefore, I 
would have to object.
  The PRESIDING OFFICER. Objection is heard.
  The Senator from Montana.
  Mr. BAUCUS. Madam President, I yield to the distinguished senior 
Senator from California, Mrs. Feinstein, 10 minutes.
  The PRESIDING OFFICER. The Senator from California.
  Mrs. FEINSTEIN. I thank the distinguished manager of the bill for his 
work on this which has been prodigious, long, and, I hope, not too 
exhausting.
  I want to speak rather personally about health care reform, why I 
support the bill that has been signed by the President, why I support 
the reconciliation bill, and why I will oppose any amendment no matter 
how good that amendment may appear to be.
  I am a doctor's daughter, and I am a former doctor's wife. So I have 
lived most of my life in a medical family. I have had very good health 
care. My father, who was chief of surgery at the University of 
California Medical Center, never operated on anyone he did not make a 
house call on. He was well respected by his students and a great 
surgeon.
  My husband who died was a neurosurgeon, and his practice was spent in 
stereotactic surgery with respect to people who had abnormal movements 
and could not control their movements. So I came to believe that we had 
the best medical system in the United States of America.
  It was only in the last few years that I began to see how much 
medicine had changed in America. We walked into a doctor's office, and 
it was not like one secretary in my father's office; it was a bank of 
files and pressure and lines waiting to be seen. I realized that there 
were so many people who did not have good health care, who worried 
about losing their health care, and, in fact, were losing their health 
care; that this kind of reform suddenly was open to me.
  Then I looked at some statistics because I thought, America is 
spending all of this money, spending nearly 15 percent of our GDP on 
health care, we must be getting substantial bang for the buck. And here 
is what I found instead.
  According to the World Health Organization, the top health care 
systems in the world begin with France, No. 1, Italy, and it goes on. 
The United States is ranked 37.
  So let's go on. Infant mortality: I think infant mortality is a good 
criteria of care because we know with good medical care we save babies. 
I thought surely America is going to be No. 1 in terms of infant 
mortality. No, we are No. 22. It is, in fact, Japan at the top with 3 
deaths per 1,000 births.
  So let's look a little further. Avoidable mortality rate: This is 
deaths that you can avoid with good medical care. Well, we have great 
medical institutions. You would expect that we would rank very high. 
Again, France is No. 1, and the United States is not 2, 3, 4 or 5 but 
No. 15. And the source of that is the Commonwealth Fund.
  Well, I then began to think more deeply about it and to realize that 
we have all of these people in this country growing who are uncovered. 
In fact, in California, my State, a State of nearly 40 million people, 
in the last 2 years, each year the uninsured have gained 1 million 
people. So over the past 2 years, California has lost insurance for 2 
million people, bringing the total of people up to 8 million who have 
no insurance whatsoever.
  Then you see companies, when the people get sick with HIV, with full-
blown AIDS, will just simply cancel their policies and throw them out. 
Then you learn that there is such a thing as a preexisting condition. 
We all come with certain preexisting conditions, or probably at one 
time in our life we will have one.
  We find there are companies that will not grant insurance if you have 
a preexisting condition. In my 17 years in the Senate, 18 years in the 
Senate, we have had numerous people write and say: I have been denied 
this treatment, or, I have been denied that treatment. Would you please 
try and help me? And we do. Sometimes we win, and we get a procedure 
for them that they had been denied by their insurance company. So it is 
so important to know what this bill will do; that it will essentially 
cover 32 million or 95 percent of the people of this country with some 
form of insurance.

[[Page S1954]]

  When the exchanges are functioning, they will have real choice if 
they wish it. Their insurance will not be taken away from them. Right 
away, this year, yesterday, those of us who were at the White House 
heard the President say that immediate gains will take place. For 
example, $5 billion for a high-risk pool, helping to provide coverage 
for those who are uninsured because they have been denied coverage by 
one of the big medical insurance companies.
  Also, children with preexisting conditions can no longer be 
discriminated against. So the family with the juvenile diabetic who 
cannot get insurance because the child is a juvenile diabetic will be 
able to get that insurance.
  That is important. We have learned that the notorious doughnut hole 
which takes place when you spend a certain amount on your 
pharmaceuticals--there is a hole in the middle at which point there is 
no help, and each person in that situation would receive $250 to help 
them through that time.
  A child can remain on a parent's policy until the age of 26. These 
are some of the things that happen right away.
  Now, I know people do not like this plan, some of them. But the 
question comes: Do we keep doing what we are doing, spending more and 
more of our gross domestic product and not improving our overall 
performance, not improving our infant mortality, not improving our 
longevity, the way good practical medicine should?
  I wish to talk about one thing that isn't in any bill about which I 
am very worried. A while ago, I introduced legislation for a medical 
insurance rate authority. We have about nine very large for-profit 
medical insurance companies in the United States. As a product of an 
earlier action, they are the only industry, other than major league 
baseball, that has an antitrust exemption. What they have been doing is 
merging and acquiring companies so that they can control markets. In 
Los Angeles, for example, today two of these companies control 51 
percent of all of the premiums. Once you have this market share and 
control, you can raise premiums with abandon. Earlier this year, a 
company, a subsidiary of WellPoint, sent out notices to 800,000 
Californians and said: We are raising your premiums. Premiums went up 
39 percent for those not in a group policy but who held individual 
policies. Can you imagine getting a notice that your insurance has gone 
up 40 percent? To add insult to injury, they then said: We may come 
back in the middle of the year and ask for another.
  That company came in. I asked the CEO what her salary was. Nine 
million a year. And you realize that these companies also have a 
substantial percentage that they spend on rent of your premium dollar, 
on the salaries of their executives in the millions of your premium 
dollar, on transportation, on conventions. Generally this can go to 20 
to 30 percent of the premium dollar. We begin to bring it down to 15 
percent of the premium dollar.
  What is missing and what the President put in the reconciliation bill 
was my legislation to give the Secretary of Health the ability to see 
that medical insurance premiums are reasonable and would establish a 
rate authority of people who have expertise in the arena that she could 
consult with in levying this authority. That is not in the bill.
  The PRESIDING OFFICER. The Senator has used 10 minutes.
  Mrs. FEINSTEIN. If I might conclude.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mrs. FEINSTEIN. These rate increases go into place May 1. So it is 
vital that we take some action before May 1, or all throughout the 
United States there are going to be substantial premium increases.
  I yield the floor.
  Mr. BAUCUS. Madam President, I yield 10 minutes to the Senator from 
Virginia, Mr. Webb.
  The PRESIDING OFFICER. The Senator from Virginia.
  Mr. WEBB. Madam President, being an eternal optimist, I rise to 
express my hope that once the process of voting over the next 2 days is 
completed, we can find a way to move forward with our colleagues across 
the aisle to fix other provisions in this legislation and make it truly 
the kind of bill they say they wish to see as well. I will support this 
reconciliation bill. At the same time, as my colleagues on this side of 
the aisle know well, I worked very hard to narrow and improve this 
legislation as it was passed last December, including voting, as I 
recall, eight different times with my Republican colleagues, which 
didn't make my chairman very happy, on a few occasions to make changes 
in the bill. In the end I voted in favor of this legislation despite 
serious misgivings with portions of it, because it does represent a 
true step forward in terms of quality, accessibility, and affordability 
of health care for most Americans.
  The important point for us to remember today and tomorrow, as we go 
through the process, is that the bill is now law. The question before 
us now is how best to implement that law so that the benefits can be 
put into place and the many detriments I was worried about can be 
addressed. There are a number of strong points in this bill. Many of my 
colleagues have laid them out. As we know, insurance companies will be 
prohibited from denying health care coverage to children with 
preexisting conditions. Young adults will be able to stay on their 
parents' insurance plans until they are 26. Uninsured Americans with 
preexisting conditions will have access to affordable insurance 
options. Insurance companies won't be able to drop people from coverage 
when they get sick, and they will be banned from implementing lifetime 
caps on coverage. Seniors who hit the Medicare Part D doughnut hole gap 
in coverage will get a $250 check to help with the cost of 
prescriptions and the doughnut hole will be completely closed by 2020.
  Access to insurance over the next couple years will be expanded to 95 
percent of Americans. It will implement reforms designed to slow 
skyrocketing health care costs. Working families will not have to worry 
about losing health insurance or facing bankruptcy because of a job 
loss or because of illness. Insurance companies will be required to 
spend the majority of their money on patient care.
  The law will also provide tax credits to help make health insurance 
available for individuals, expand access to Medicaid, create a 
regulated marketplace where people can shop for the health insurance 
plan that best meets their needs, and will prohibit insurance companies 
from refusing to sell or renew policies due to an individual's health 
status. These are just some of the positive points of the law.
  In fairness--and I understand and appreciate some of the frustration 
on the other side--there are serious problems in this bill. I don't 
like the dramatic cuts in Medicare this law proposes. In fact, I voted 
against them. I share the concerns by my Democratic colleague, 
Congressman Rick Boucher of southwest Virginia, regarding the potential 
negative impact these cuts could have on rural areas, particularly the 
population of southwest Virginia. This legislation proposes to cut 
approximately $450 billion from Medicare spending over the next 10 
years at a time when Medicare is already mired in debt and, as we know, 
a bow wave of baby boomers is going to start hitting the Medicare 
system immediately. Medicare Advantage, which provides better benefits 
than traditional Medicare, is a valuable tool in rural and underserved 
areas, and that may decrease. This law does little to address the 
historic disparity in Medicare funding between urban and rural areas.
  I am also concerned about the cost and spending projections of this 
legislation. There is a great deal of debate going on right now about 
the real cost of this bill. Former CBO Director Douglas Holtz-Eakin 
estimated, in an article in the New York Times recently, that the bill 
may increase the Federal deficit by $562 billion over 10 years because 
of some of these areas I discussed. The official score maintains that 
the bill would lower the deficit by $143 billion over that same period, 
but it includes a number of unlikely assumptions, Medicare being one of 
them. The system for reimbursing Medicare doctors, called the 
sustainable growth rate, is widely agreed to be broken, but we have not 
tried to fix it. That is a $250 billion ticket. Many, including myself, 
believe the Community Living Assistance Services and Supports Act, the 
CLASS Act, is structurally unsound. I voted against that as we were 
considering the bill.

[[Page S1955]]

  In addition, as my colleague Congressman Glenn Nye from the Norfolk-
Virginia Beach area pointed out, there is a great deal of concern among 
families and small businesses regarding the impact of this bill.
  Again, the point is, the bill is now law. The question is how to make 
the law a better law. The process that got us here has been ugly. It 
has diminished the trust and respect some citizens hold for our own 
government. We need to restore that trust through a genuine and 
transparent effort on both sides of the aisle to fix the problems in 
the law. We also need to start working together again across the aisle, 
on this and other issues that confront us, in a bipartisan sense and a 
sense of shared responsibility about the many problems facing the 
country. We are now preparing to begin a series of votes through the 
reconciliation process that ultimately, quite frankly, is going to mean 
little or nothing in terms of the outcome of this legislation. They are 
not going to seriously address the problems in it. I understand the 
concerns on the other side. I respect them. These votes in many cases 
are politically necessary for the other side. But I call on my 
Republican friends to begin to work with some of us over here on this 
side to address the inequities that we are concerned about, to 
implement cost controls, to work together for the good of the country 
once this next couple of days is done.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Connecticut.
  Mr. LIEBERMAN. Madam President, I gather I have at least 7 minutes 
assigned to me.
  The PRESIDING OFFICER. Ten minutes remains.
  Mr. LIEBERMAN. I ask that the Chair inform me if I am not finished 
when there is 1 minute remaining on my time.
  The PRESIDING OFFICER. The Chair will so inform.
  Mr. LIEBERMAN. Madam President, a good friend once wisely said to me 
that it is only a very short road that has no turns. The road that 
health care reform has traveled to get to the Senate has been very long 
and has had many turns. Its path to us might well be described as 
tortuous, with all that word has come to mean. As I said when I 
explained in December why I was voting for the Senate health care 
reform bill, any piece of legislation this big, this complicated, and 
this transformational is unlikely to be perfectly pleasing to anyone. 
That is true for me. In the end, each of us has to ask ourselves, do 
the positives in this legislation outweigh the negatives? Does what 
pleases us in it outweigh what worries us? Let me begin with the 
measure before us now.
  The reconciliation act that is before us preserves most but not all 
of the health care reform the Senate adopted and I voted for in 
December. I concluded then and repeat now that together these measures 
achieve real change in the three big areas in which our health care 
system needs to be changed: reforming health care delivery to put a 
brake on the skyrocketing costs of care for individuals, families, 
businesses, and our government; better regulating health insurance 
companies to protect consumers, including those with preexisting 
conditions; and helping millions of middle-income Americans who cannot 
afford health insurance now to buy it.
  For me it is particularly noteworthy that the Senate bill, plus the 
reconciliation act, achieves all that progress without a government 
takeover of health care or health insurance. That would have been a 
very costly deficit-exploding mistake and would have fundamentally and 
adversely altered the traditional American balance of power between the 
public and private sectors that has worked so well over our history to 
create economic growth and opportunity and to build the American middle 
class. That is why I opposed the so-called public option so strenuously 
and why I am so grateful it is not in the reconciliation act the House 
has sent us. Those are the big and good things I appreciate in this 
health care reform package.
  What worries me about it? First, the size of this proposal concerns 
me, particularly at this time of national fiscal indebtedness and 
economic stress. I wish we had chosen to achieve health care reform 
step by step, beginning with delivery reforms that would lower health 
costs and then moving on to expand middle-class access to affordable 
health insurance and then more aggressively regulating health insurance 
companies. But there was never enough bipartisan support for such step-
by-step reform. I know because I tried to find it. So now, along with 
each of my colleagues, I must vote on the proposal before us, not on 
one I wish we had before us.

  My biggest concerns about this proposal are its prospective fiscal 
consequences. I worry that the savings this bill achieves in Medicare 
and the revenue it raises from new Medicare taxes to help pay for 
health care reform will soon be urgently needed to save Medicare itself 
from running out of money it needs to pay the bills for seniors' health 
care. Most of all, I worry that the bottom line consequences of this 
health care reform will be to increase our already ominous national 
debt.
  I am, of course, greatly encouraged by the conclusion of the 
independent, nonpartisan Congressional Budget Office that this health 
care reform legislation will not only not increase the debt but 
actually decrease it by more than a trillion dollars over the next two 
decades, and that its savings in Medicare will not only pay for part of 
health care reform but actually extend the solvency of the Medicare 
Hospital Trust Fund.
  According to the Chief Actuary at the Centers for Medicare and 
Medicaid Services, the solvency of the trust fund will be extended by 
10 years as a result of the Senate health care reform bill that is now 
law.
  However, for those good and significant things to happen, future 
Congresses will have to be very disciplined and keep the promises that 
are made in this legislation to reform health care delivery to cut 
costs. Most of those reforms will over time be opposed by providers and 
beneficiaries. The record of Congress in resisting such pressure to 
stick with the costly status quo is not encouraging.
  So in the end, I have weighed the pluses and minuses, and I have 
decided to vote for this health care reform package, choosing its real 
change over the broken status quo, raising my hopes above my fears, and 
adding, if I may, a personal prayer that future Congresses and 
Presidents do not weaken the reforms in this bill that will stop the 
constant increases in health care and health insurance costs and help 
reduce our national debt.
  That will happen best if we can achieve the bipartisanship in 
overseeing the implementation of this historic health care reform 
legislation that we, unfortunately, were not able to achieve in its 
passage.
  I thank the Chair.
  I thank the distinguished chairman of the Finance Committee for his 
extraordinary effort that produced this admirable result.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Madam President, first, I thank the Senator from 
Connecticut for his very thoughtful endorsement of this legislation. He 
is one of the more thoughtful Members of this Chamber, and I want to 
very much compliment him on his process and his conclusion.
  Mr. LIEBERMAN. I thank the Senator.
  Mr. BAUCUS. Madam President, I do not think I have much time 
remaining--3 minutes. Thank you very much.
  The Senator from Maine raised the issue of Medicare solvency. I want 
to remind my colleagues that health care reform extends the solvency of 
the Medicare trust fund. Whether it is 9 years or 10 years, I am not 
sure exactly, but the Medicare trust fund is extended for at least that 
period of time, which I am sure gives great comfort to seniors and near 
seniors. Health care reform is exactly what the doctor ordered for 
Medicare's long-term health.
  The Senator also mentioned a letter from an outside group raising 
concerns with health care reform. Let me add for the record three of 
the many letters of endorsement that health care reform has received. 
The first is from the American Medical Association. I will read one 
sentence:

       After careful review and consideration, the Board of 
     Trustees of the American Medical Association supports passage 
     of the health

[[Page S1956]]

     system reform legislation under consideration . . . as a step 
     forward in the journey to provide health care for all 
     Americans.

  In addition, I have a letter from the Federation of American 
Hospitals:

       On behalf of the Federation of American Hospitals and our 
     more than 1,000 hospitals throughout the United States, I 
     express our strong support for health reform and the 
     Reconciliation Act of 2010. This legislation is long overdue, 
     and we urge all Senators to seize this historic opportunity. 
     . . .

  It is signed by Charles Kahn of the Federation of American Hospitals.
  I also have a statement here from the AARP, the association of 
retired folks. Basically it states:

       After a thorough analysis of the reform package, we believe 
     this legislation brings us so much closer to helping millions 
     of older Americans get quality, affordable health care.

  Again, that is from the AARP.
  So there are many letters of endorsement, and I ask unanimous consent 
that these three letters be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                 American Medical Association,

                                      Chicago, IL, March 19, 2010.
     Hon. Nancy Pelosi,
     Speaker, House of Representatives,
     Washington, DC.
       Dear Speaker Pelosi: After careful review and 
     consideration, the Board of Trustees of the American Medical 
     Association (AMA) supports passage of the health system 
     reform legislation under consideration in the House as a step 
     forward in the journey to provide health care coverage for 
     all Americans.
       When H.R. 3590 was being considered in the Senate, the AMA 
     supported its passage while expressing opposition to certain 
     provisions that we believed could be resolved in the 
     conference committee process. Working with the 
     Administration, congressional leaders and their very 
     dedicated staff, significant progress was made toward 
     resolving many of our most serious concerns. Unfortunately, 
     there are issues in H.R. 3590 that cannot be addressed 
     through the current reconciliation process and so will still 
     need to be addressed by Congress and the Administration.
       This forced us to weigh very carefully whether the 
     legislation, on balance, will enhance patient care and the 
     fundamental patient-physician relationship. By extending 
     coverage to the vast majority of the uninsured, improving 
     competition and choice in the insurance marketplace, 
     promoting prevention and wellness, reducing administrative 
     burdens, and promoting clinical comparative effectiveness 
     research, we believe that H.R. 3590 does, in fact, improve 
     the ability of patients and their physicians to achieve 
     better health outcomes.
       The pending bill is an imperfect product. Congress needs to 
     act very soon to preserve access to care for seniors and 
     military families by permanently repealing the Medicare 
     sustainable growth rate formula that will trigger physician 
     payment cuts of over 21 percent next month. House and Senate 
     leaders must also move immediately to correct problems with 
     the proposed Independent Payment Advisory Board. Other 
     provisions that must be promptly addressed in a subsequent 
     corrections bill include the cost-quality value index and 
     safeguards for data release and public reporting activities. 
     The health care system will be further improved by reining in 
     unnecessary costs through enactment of effective medical 
     liability reforms.
       The AMA will be relentless in our pursuit of these 
     important policy adjustments.
       Passage of H.R. 3590 marks an important step toward 
     improving the health of the American people, but our work 
     here is far from done. Additional congressional action is 
     needed to address outstanding issues. We look forward to 
     working with you on the next steps to strengthen our health 
     care system.
           Sincerely,
                                                  J. James Rohack,
     President.
                                  ____



                             Federation of American Hospitals,

                                   Washington, DC, March 22, 2010.
     Hon. Harry Reid,
     Majority Leader,
     U.S. Senate,
     Washington, DC.
       Dear Majority Leader Reid: On behalf of the Federation of 
     American Hospitals (FAH) and our more than 1,000 hospitals 
     throughout the United States, I express our strong support 
     for health reform and the Reconciliation Act of 2010. This 
     legislation is long overdue, and we urge all Senators to 
     seize this historic opportunity by supporting the 
     reconciliation package as it was reported out of the House of 
     Representatives.
       The hundreds of thousands of Americans who treat patients 
     in our hospitals understand the plight of the uninsured and 
     the need to provide health security for all Americans. The 
     Reconciliation Act of 2010, together with the recently 
     enacted Patient Protection and Affordable Care Act, advance 
     this shared goal by expanding health care coverage to 32 
     million Americans.
       Equally vital, they provide a framework for health care 
     delivery reform that will improve health care for Americans, 
     and, by extension, strengthen our economy and global 
     competitiveness by reducing costs and increasing efficiency.
       That is why hospitals will forgo $155 billion in Medicare 
     and Medicaid payments over 10 years as part of a shared 
     sacrifice to bring about the benefits that health reform will 
     deliver to all Americans.
       It is no exaggeration to say this is the last opportunity 
     in our generation to bring about durable reform that will 
     make a real difference in the lives of all of us. The time 
     for action has come, and the FAH urges all Senators to 
     support the budget reconciliation package without amendment.
       Thank you for your strong and unwavering leadership.
           Sincerely,
                                              Charles N. Kahn III,
     President.
                                  ____


              (From the AARP Press Center, Mar. 19, 2010)

       AARP Statement on Historic Health Insurance Reform Package

       Washington.--Today, AARP Board Chair Bonnie M. Cramer, 
     M.S.W., announced the Association's support for health 
     insurance reform legislation containing key reform provisions 
     that will improve health care for older Americans and their 
     families. For more than two years, AARP has fought for health 
     insurance reform that helps Americans 50-plus get the care 
     and medications they need at a price they can afford. 
     Cramer's statement follows:
       ``After a thorough analysis of the reform package, we 
     believe this legislation brings us so much closer to helping 
     millions of older Americans get quality, affordable health 
     care. For too long, our members and others have faced 
     spiraling prescription drug costs, discriminatory practices 
     by insurance companies and a Medicare system awash in fraud, 
     waste and abuse.
       ``The legislative package cracks down on insurance company 
     abuses and protects and strengthens guaranteed benefits in 
     Medicare, the program millions of our members depend on and 
     in which millions more will soon enroll. It closes the 
     dreaded Medicare Part D `doughnut hole,' a gap in 
     prescription drug coverage that is life threatening for many. 
     The package stops insurance companies from pricing people out 
     of coverage because they have an existing health problem or 
     arbitrarily limiting the amount of care someone can receive. 
     It also limits insurance companies' ability to charge higher 
     premiums based solely on age. And it improves efforts to 
     crack down on fraud and waste in Medicare, strengthening the 
     program for today's seniors and future generations.
       ``For every American who has struggled without access to 
     health insurance--and for all those at risk of losing their 
     current coverage with the next job loss, illness or premium 
     hike--this package presents the best hope to offer health 
     security for them and their families. We understand that 
     significant work remains even after this package becomes law, 
     but we cannot lose the opportunity looking for a `next time' 
     that is doomed to be `too late.'
       ``We urge Congress to seize this opportunity to improve 
     health care so older Americans and their families get the 
     care they need.''
       Also today, AARP CEO A. Barry Rand sent a letter to every 
     member of the House of Representatives, urging them to put 
     the health of Americans age 50-plus first and vote ``yes'' on 
     the legislative package.
       AARP members can see how their representatives voted on the 
     health insurance reform package by going to www.aarp.org/
 governmentwatch. AARP's Government Watch is a one-stop online 
     portal that will be tracking and publicizing every designated 
     key vote on issues facing Americans age 50-plus. A ``Key Vote 
     Summary'' highlighting votes on these issues will be 
     published at the end of each congressional session.
       AARP is a nonprofit, nonpartisan membership organization 
     that helps people 50+ have independence, choice and control 
     in ways that are beneficial and affordable to them and 
     society as a whole. AARP does not endorse candidates for 
     public office or make contributions to either political 
     campaigns or candidates. We produce AARP The Magazine, the 
     definitive voice for 50+ Americans and the world's largest-
     circulation magazine with over 35.7 million readers; AARP 
     Bulletin, the go-to news source for AARP's millions of 
     members and Americans 50+; AARP Segunda Juventud, the only 
     bilingual U.S. publication dedicated exclusively to the 50+ 
     Hispanic community; and our website, AARP.org. AARP 
     Foundation is an affiliated charity that provides security, 
     protection, and empowerment to older persons in need with 
     support from thousands of volunteers, donors, and sponsors. 
     We have staffed offices in all 50 states, the District of 
     Columbia, Puerto Rico, and the U.S. Virgin Islands.

  Mr. BAUCUS. Madam President, I now ask for 1 hour of debate evenly 
divided, a half hour on the Republican side and a half hour on the 
majority side. I ask unanimous consent that we proceed in that respect.
  I note that the next half hour will be under the control of the 
Republicans and, as I said earlier, the next half hour is to be 
controlled by the majority. I note that thereafter the Republicans will 
be due an amount of time greater than half an hour, and I propose that 
we balance that out in the next consent.

[[Page S1957]]

  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  The Senator from Maine.


                           Amendment No. 3638

  Ms. COLLINS. Madam President, I ask unanimous consent to temporarily 
set aside the pending motions and amendments so that I may offer an 
amendment which is at the desk.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Maine [Ms. Collins] proposes an amendment 
     numbered 3638.

  Ms. COLLINS. Madam President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To improve the bill by waiving the $40,000 penalty on hiring 
                   previously unemployed individuals)

       At the end of section 1003, add the following:
       (e) Unemployed Individual Not Taken Into Account.--
     Paragraph (5) of section 4980H(d) of the Internal Revenue 
     Code of 1986, as added by the Patient Protection and 
     Affordable Care Act, is amended by adding at the end the 
     following new subparagraph:
       ``(C) Exception for previously unemployed individuals.--
       ``(i) In general.--The term `full-time employee' shall not 
     include any individual who certifies by signed affidavit, 
     under penalties of perjury, that such individual has not been 
     employed from more than 40 hours during the 60-day period 
     ending on the date such individual begins such employment.
       ``(ii) Exception for replacement workers.--Clause (i) shall 
     not apply to an individual who is employed by the employer to 
     replace another employee of such employer unless such other 
     employee separated from employment voluntarily or for 
     cause.''.

  Ms. COLLINS. Madam President, I rise to speak on behalf of the 
amendment I have offered which would waive the job-killing fines in the 
reconciliation bill in cases where an employer hires an unemployed 
worker.
  I think these penalties will come as a surprise to most Americans. 
With unemployment at 9.7 percent, and a real concern that we may be on 
the brink of a double-dip recession, most Americans will be shocked to 
learn that Washington wants to slap fines on small businesses that 
choose to hire more workers. But the new health care law does exactly 
that.
  Incredibly, this reconciliation package makes this problem even 
worse. Here is how. In the reconciliation package, small businesses 
that cannot afford to provide health insurance to their employees would 
be fined $2,000 for each worker on their payroll. The way the formula 
works, the fines kick in at $40,000 when a small business reaches 50 
employees. After that, they go up at a rate of $2,000 for each new 
worker.
  Imagine what this will do to job growth. Our country relies on small 
businesses to create new jobs. In fact, time and time again, you will 
hear on the Senate floor that small businesses are the engine of the 
American economy. I certainly agree with that. But this reconciliation 
bill creates a wall--40,000 dollars high--around any small business 
that wants to grow past 49 workers.
  Think what these job-killing penalties will mean to the unemployed. 
More than 8 million Americans have lost their jobs since 2007. More 
than 6 million have been unemployed longer than 27 weeks. But beyond 
even these grim statistics, the true picture of unemployment in this 
country is actually far worse. Broader measures of unemployment show 
that 16 percent of the American people are without jobs or cannot find 
full-time work.
  I recognize some in this body will argue we should not be bothered 
with these penalties now because they do not become effective right 
away. But those who would say such a thing simply do not understand how 
small businesses work. We are not talking about big multinational 
conglomerates here. We are talking about Main Street businesses that 
are already struggling. Many of them are family-owned enterprises. They 
do not look at their employees as interchangeable parts, and they do 
not make hiring decisions to ``get rich quick.'' When they bring a new 
employee on board, they are choosing someone who they know will become 
part of their team and the face of their business to the community they 
serve.
  Having these fines on the books will discourage job growth now, no 
matter when they become effective, because small businesses will not 
hire and train workers today just to fire them tomorrow when these 
penalties go into effect.
  Ironically, less than a week ago, the President signed into law the 
so-called HIRE Act. It contains a provision authored by Senators 
Schumer and Hatch to provide a temporary tax credit to encourage 
companies to hire unemployed workers. That is a creative idea, and I 
supported it. But for the life of me, I do not understand how a week 
later we could vote for a bill that imposes fines that will hit small 
businesses when they hire new workers.
  This makes no sense to me, and it is completely contrary to the 
policy we passed a week ago when we gave tax credits to encourage 
businesses to hire workers who are unemployed. With this bill, we are 
going to fine them if they hire workers who are unemployed if they 
cannot afford to provide them with health insurance. That is why I am 
offering this commonsense amendment. It would waive the fines, the 
onerous fines that are in the reconciliation bill when small businesses 
and medium-size businesses hire workers who were previously unemployed.
  The mechanism to determine which workers qualify is exactly the same 
one we adopted in the jobs bill passed by this body last week. It is 
the height of irony that we would even consider imposing penalties and 
fines on businesses that are hiring more workers, particularly during 
this difficult economic time.
  I encourage my colleagues to support this commonsense amendment.
  Thank you, Madam President.
  The PRESIDING OFFICER. The Senator from South Dakota.


                           Amendment No. 3639

  Mr. THUNE. Madam President, I ask unanimous consent to temporarily 
set aside the pending motions and amendments to offer an amendment 
which is at the desk.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from South Dakota [Mr. Thune] proposes an 
     amendment numbered 3639.

  Mr. THUNE. Madam President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

   (Purpose: To ensure that no State experiences a net job loss as a 
               result of the enactment of the SAFRA Act)

       Beginning on page 123, strike line 10 and all that follows 
     through page 124, line 10, and insert the following:

     SEC. 2201. TERMINATION OF FEDERAL FAMILY EDUCATION LOAN 
                   APPROPRIATIONS.

       Section 421 (20 U.S.C. 1071) is amended--
       (1) in subsection (b), in the first sentence of the matter 
     following paragraph (6), by inserting ``, except that no sums 
     may be expended after June 30, 2010, with respect to loans 
     under this part for which the first disbursement is after 
     such date if the Secretary certifies that no State will 
     experience a net job loss as a result of the enactment of the 
     SAFRA Act'' after ``expended''; and
       (2) by adding at the end the following new subsection:
       ``(d) Termination of Authority To Make or Insure New 
     Loans.--Notwithstanding paragraphs (1) through (6) of 
     subsection (b) or any other provision of law--
       ``(1) no new loans (including consolidation loans) may be 
     made or insured under this part after June 30, 2010 if the 
     Secretary certifies that no State will experience a net job 
     loss as a result of the enactment of the SAFRA Act; and
       ``(2) no funds are authorized to be appropriated, or may be 
     expended, under this Act or any other Act to make or insure 
     loans under this part (including consolidation loans) for 
     which the first disbursement is after June 30, 2010 if the 
     Secretary certifies that no State will experience a net job 
     loss as a result of the enactment of the SAFRA Act,

     except as expressly authorized by an Act of Congress enacted 
     after the date of enactment of the SAFRA Act.''.


                           Amendment No. 3640

  Mr. THUNE. Madam President, I have another amendment and I ask 
unanimous consent to temporarily set aside the pending motions and 
amendments so that I may offer another amendment which is also at the 
desk.
  The PRESIDING OFFICER. Without objection, it is so ordered.

[[Page S1958]]

  The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from South Dakota [Mr. Thune], for himself, Mr. 
     Coburn, and Mr. Crapo, proposes an amendment numbered 3640.

  Mr. THUNE. Madam President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

                   (Purpose: To repeal the CLASS Act)

       At the end of subtitle B of title II, add the following:

     SEC. 2304. REPEAL OF THE CLASS ACT.

       Title VIII of the Patient Protection and Affordable Care 
     Act and the amendments made by that title are repealed.

  Mr. BAUCUS addressed the Chair.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Madam President, might I ask the Senator from South 
Dakota if he could identify his two amendments for the sake of clarity?
  Mr. THUNE. Sure. I would ask the Chair, is there a number on those 
amendments?
  The PRESIDING OFFICER. Yes, 3639 and 3640.
  Mr. THUNE. Madam President, 3639 and 3640--one dealing with student 
loans, the other dealing with striking the CLASS Act from the 
underlying bill.

  Mr. BAUCUS. I thank the Senator.
  Mr. THUNE. Madam President, in speaking to both these amendments 
today, I wish to make a couple of observations about the reconciliation 
bill that is before the Senate. Of course, it does make amendments and 
modifications to the Senate-passed health care bill that went through 
the House last week and the House adopted many of these changes. I 
think the thing that perhaps didn't get discussed as much as it should 
have throughout the course of the debate is the impact this is going to 
have down the road on future generations.
  Obviously, the other side, of course, talked about the additional 
expansions of coverage that are in the bill. Folks on our side talked 
about the impact it is going to have in the form of higher taxes on 
small businesses, the Medicare cuts that are going to impact seniors 
across this country, the higher premiums many Americans are going to be 
faced with. Those are all still fundamental features of this bill. In 
fact, many have gotten worse through this reconciliation process 
because the tax increases are now $50 billion higher than they were 
before. So now we are raising taxes even $50 billion more than we were 
previously, which is $\1/2\ trillion. The Medicare cuts have now gone 
from $465 billion over the 10 years in the bill that left the Senate in 
December, and the Medicare cuts now have been increased by $66 billion. 
So we are raising taxes more, cutting Medicare even deeper, and at the 
same time adding gimmicks that I think understate the true cost of this 
bill.
  We have all talked about this throughout the course of this debate. 
The other side has said it is $1 trillion or $900-some billion over 10 
years, but when you look at the way it is scored, there are 10 years of 
revenues, 10 years of tax increases, and only 6 years of spending, so 
that understates the cost over 10 years.
  We have a number of other budget gimmicks, some of which I will speak 
to in a few moments. But when you look at it when it is fully 
implemented--and I think that is the number the American people need to 
focus on--when this is fully implemented, it is $2.5 trillion of 
expansion of health care in this country, and it is going to be greater 
intervention than we have ever seen before by the Federal Government in 
the delivery of health care in this country.
  I wish to speak for a moment--because one of my amendments deals with 
this issue--on how the cost of this is being understated because of the 
various gimmicks and tricks being used. The CLASS Act is a program that 
is created in the bill. It is a program where there is an assumption 
that there is $70 billion available in the CLASS Act to pay for this 
new health care entitlement. What it does is it creates a new 
entitlement. As if the existing entitlement programs we have that are 
already on the way to bankruptcy aren't enough, we now have to add 
another one to it. So the CLASS Act is a long-term care entitlement 
program, which in and of itself perhaps isn't a bad idea if it were 
structured correctly and if the premiums that are going to be paid by 
people for long-term care insurance were actually going to go into the 
payment of benefits.
  What this does is it assumes $70 billion from this new CLASS Act 
program, the proceeds from which would be used to pay for this new 
health care entitlement program. So it overstates the amount of revenue 
that is coming in by $70 billion. Here is why. At some point, if you 
are an elderly person or perhaps even a younger person today who wants 
to buy into this new CLASS Act long-term care program, you would pay 
premiums. Those premiums, allegedly, would go into a fund that would 
then be available to pay benefits when the time came to pay benefits. 
That is not going to happen because you are taking that $70 billion and 
you are spending it on this new health care entitlement. So at some 
point in the future, when those people who have gone into this program 
thinking they are paying these premiums so they can derive a benefit at 
some time in the future if they need to, when the time comes to pay out 
that benefit, there will not be any money. So what happens? It is 
borrowed. It is added to the debt. So you have another $70 billion that 
goes on the backs of our children and grandchildren to pay for this new 
entitlement program, which, again, understates the cost of this bill.
  That is the CLASS Act bill, and my amendment would strike that from 
the underlying bill. By the way, I offered that during the debate on 
the Senate floor during the health care discussion we had the first 
time around, and I got 51 votes for it. There were 12 Democrats who 
voted with me in support of taking the CLASS Act out of the bill. One 
of the reasons I think there is so much bipartisan opposition to it is 
because everybody recognizes what a sham this is. The chairman of the 
Budget Committee, Senator Conrad from North Dakota, said: This is a 
Ponzi scheme of the highest order, something that Bernie Madoff would 
be proud of. That is what he said about the CLASS Act. Even the 
Washington Post went so far as to make the statement that the CLASS Act 
is a gimmick designed to pretend that health care is fully paid for. 
That is what the Washington Post editorialized about the CLASS Act--a 
gimmick designed to pretend that health care is fully paid for.
  So you take that $70 billion off the overall revenues that come in 
under the bill and you are already creating a $70 billion hole. You add 
to that the $29 billion in Social Security payroll taxes that are 
assumed are going to come in as people who get hit--the employers that 
get hit with the high-end Cadillac tax, currently paying out to their 
employees in the form of health care benefits that are tax free, start 
shifting to cash compensation which would be taxable; therefore, 
payroll taxes would apply. That would generate another $29 billion in 
Social Security payroll taxes. But, there again, those are payroll 
taxes that at some point are going to have to pay benefits, but we 
don't assume that here. We assume it is going to go on to fund this new 
health care entitlement program. So it is another $29 billion that at 
some point in the future, when somebody decides: I want to draw my 
Social Security benefits, they are not going to be there. Therefore, we 
put it back on the debt. More borrowing.
  So we have $79 billion, $29 billion, and then we have the 
implementation cost of this, which CBO has not fully given us because 
they don't know what it is going to cost in the outyears. But based 
upon what they have given us of what it is going to cost in the near 
term, we have extrapolated that it will cost about $114 billion to 
implement this new health care extravaganza run out of Washington, DC. 
When you add that onto the cost, none of which is accounted for in the 
underlying bill, you have another $114 billion in cost of this thing 
not paid for.
  Then, we take the Medicare double counting, which is interesting, 
because you have these cuts that are going to occur in Medicare; you 
have these payroll tax increases that are supposed to occur in Medicare 
that are going to generate, collectively, $529 billion in additional 
revenue. But, here again, what is wrong with this picture? The 
assumption is, these are Medicare payroll taxes that are going to go 
into a

[[Page S1959]]

Medicare fund that, at some point in the future, will pay Medicare 
benefits. Yet, at the same time, we are saying these Medicare revenues 
are going to be used to finance this new health care expansion.
  So what are you doing? You are double counting. You cannot spend that 
money twice. We are taking $529 billion in Medicare cuts, in Medicare 
payroll tax increases that supposedly would go into a Medicare trust 
fund to pay benefits at some point in the future to beneficiaries, 
recipients of those funds, but, no, we are going to spend that on this 
new health care entitlement.
  What happens then? Someday in the future that Medicare recipient is 
going to say: OK, it is time to pay out these Medicare benefits. I have 
reached the appropriate age, I am eligible, and I want to get into the 
Medicare Program, and all that money that was supposed to have been in 
the program to pay for those benefits isn't there. Why? Because it was 
spent on this new health care entitlement program. So what happens? To 
pay those benefits, the Federal Government will then have to borrow--
more debt that goes on the backs of our children and grandchildren--
another $529 billion.
  So the last point I will make is--because I have another amendment 
that addresses this issue--this reconciliation bill did something that 
obviously was not included in the health care bill that passed the 
Senate the first time; that is, this takeover of the student loan 
program in this country. It is something that has been proposed around 
here for some time. The way student loans are distributed across the 
country today is we have 2,000 lenders out there who make these loans. 
Students can go there and get these loans. What this will do is 
eliminate that model, will draw all these student loans into 
Washington, DC. There will be four Federal call centers where students 
will go to get their loans. What does that do? Well, first off, it 
kills a lot of jobs. I have 1,200 jobs in South Dakota that are related 
to the student lending business, and those are all now going to be 
bureaucratic jobs in Washington, DC. There are 31,000 jobs across the 
country where you have people who are working in the student loan 
business. Those jobs are in jeopardy because that is all going to be 
drawn into Washington DC. I don't think the American people have 
effectively focused on what is being done in this reconciliation bill 
above and beyond the bad stuff that is related to health care.
  So we have this student loan program which is coming back into the 
Federal Government and a lot of the revenues now are being earmarked 
for other things. They are being earmarked for the health care bill: $9 
billion is being used to pay for the health care expansion; $10 billion 
is going toward ``deficit reduction,'' but we have another $19 billion 
coming out of the student loan program. Who is going to pay for that? 
Students are. Students are going to pay for it in the form of higher 
interest rates on their loans. Essentially, we are now not only taxing 
small businesses, cutting Medicare recipients, but we are also taxing 
students to pay for this expansion of health care.
  We have another $19 billion which, at some point in the future--of 
course, this is all going to have to be paid for again by our children 
and grandchildren, but we have all this double counting that is going 
on and all these gimmicks that are being used to understate the cost of 
this bill. When you add it all up, $143 billion so-called budget 
savings ends up in a $618 billion cost. In other words, instead of 
running, as the other side has said, a $143 billion budget surplus 
because of this health care expansion, if you take out all the 
gimmicks--the CLASS Act, the revenues, the Social Security payroll tax 
revenues which are double counting, the Medicare double counting, and 
the student loan program--we have a real deficit of $618 billion in the 
first 10 years. If you extrapolate that out into the second 10 years, 
it is $1.8 trillion that will have to be borrowed under this bill to 
pay for the costs of it. That is the cost that we know today. That is 
all going to be passed on to future generations, to our children and 
grandchildren.
  The dirty little story that hasn't been told in this whole debate is 
how much this is going to cost future generations because of the 
enormous debt we are piling up and all the games and the gimmicks and 
the tricks and the chicanery that are being used to understate the true 
cost of this: $183 billion ``savings'' in this bill. When you take out 
all the double counting, all the gimmicks, we end up with a $618 
billion deficit in the first 10 years. That is tragic.

  That is why I am offering this amendment to strike this CLASS Act. We 
shouldn't be creating another new entitlement program when we can't pay 
for the entitlement programs we have. They are all going bankrupt, and 
we are going to create yet another one, which is going to lay more debt 
on the backs of our children and grandchildren.
  The other thing I wish to mention just briefly in closing speaks to 
the other amendment. The other amendment, as I said, because of this 
takeover of the student loan business in this country, there are lots 
of States that are going to lose significant numbers of jobs. My State 
has over 1,200 jobs related to student lending; Minnesota, 675; Iowa, 
526; Nebraska, 891. There are lots of places around this country where 
student lending creates jobs, private sector jobs. We are going to do 
away with those and bring all those jobs back to Washington, DC, and 
make students come to Washington to get their student loans, as it 
turns out, at a higher cost because we are using some of the proceeds 
of that program to pay for the cost of a new health care program.
  What my amendment essentially would do is say the Department of 
Education has to certify that there will be no jobs lost across the 
country associated with this takeover of the student lending business 
and bringing all that power and consolidating it all in Washington, DC.
  So those are the two amendments I offer. I hope my colleagues will 
vote for those. This is bad policy in so many ways, but in taking over 
yet another industry in this country that is creating a lot of jobs and 
therefore killing a lot of jobs is the wrong way to move forward when 
you are trying to pull an economy out of a recession.
  I yield the remainder of my time.
  The PRESIDING OFFICER. The Senator from Texas.


                            Motion to Commit

  Mr. CORNYN. Madam President, I ask unanimous consent to temporarily 
set aside the pending motions and amendments so I may offer a motion to 
commit, which is at the desk.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  The clerk will report the motion.
  The assistant legislative clerk read as follows:

       The Senator from Texas [Mr. Cornyn] moves to commit the 
     bill H.R. 4872 to the Committee on Finance with instructions 
     to report the same back to the Senate within 3 days with 
     changes to strike the 3.8 percent tax on net investment 
     income.

  Mr. CORNYN. Madam President, my amendment is a motion to commit the 
reconciliation bill back to the Finance Committee to report the bill 
back without a brandnew tax on savings and investment for certain 
taxpayers. This is an additional 3.8-percent tax on savings, which 
includes dividends, capital gains, ordinary savings for many consumers, 
many Americans who have not had to pay before but which this bill 
imposes. This is a $123 billion tax hike on those categories of income.
  This is a mistake for a lot of reasons. One, it will discourage the 
very thing we need to be doing more of, which is saving. It will reduce 
productivity, and it depresses wages and the standard of living for 
millions of Americans. Simply put, increasing taxes, particularly 
during a recession, on the very sectors of the economy that we want to 
invest and to create jobs is a terrible mistake.
  According to forecasts by the Institute for Research on the Economics 
of Taxation, a 2.9-percent tax increase--not 3.8 percent but a 2.9-
percent previously proposed--would depress economic growth by 1.3 
percent and reduce capital formation by 3.4 percent.
  The damage to jobs and economic growth during a recession when 
unemployment is at 9.7 percent would be even greater under the current 
proposal because we are talking about a 3.8-percent tax, not a 2.9-
percent tax, which was the subject of a Wall Street Journal article and 
this report from the Institute for Research on the Economics of 
Taxation.

[[Page S1960]]

  Not only will this motion protect jobs and the investment security of 
taxpayers, it will also make sure the reconciliation bill does not 
break yet another one of President Obama's promises. This is just 
another one of the President's promises that have been broken by this 
bill when he said, talking about this bill:

       Everyone in America--everyone--will pay lower taxes than 
     they would under the rates Bill Clinton had in the 1990s.

  But the truth is, this additional tax on savings and investment will 
make taxes higher than they were even back in the 1990s when Bill 
Clinton was President of the United States.
  I ask my colleagues to support my motion to commit this bill to the 
Finance Committee.
  I also ask unanimous consent to have printed in the Record at the 
conclusion of my remarks two articles--a March 17 Wall Street Journal 
article entitled ``ObamaCare's Worst Tax Hike'' and the report I 
referred to a moment ago from the Institute for Research on the 
Economics of Taxation.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (See exhibit 1.)
  Mr. CORNYN. Madam President, this is not the only job-killing 
provision in this bill, this brandnew 3.8 percent tax increase that 
will attack savings and investment. Other examples of job-killing 
proposals in this bill include increasing the hospital insurance 
payroll tax. This tax is increased to 3.8 percent. It will hit 
thousands of small businesses that file as subchapter S corporations 
and pay taxes at individual rates. In addition, this revenue will not 
be used to pay for Medicare but will be used to fund a brandnew 
entitlement.
  Another job-killing proposal in this bill includes new taxes and fees 
on health care consumers. That is right, the very people for whom we 
are trying to lower costs and trying to make health care more 
affordable, many will have to pay additional taxes and fees to the tune 
of $100 billion which both the Congressional Budget Office and the 
Joint Tax Committee have confirmed will inevitably be passed down to 
consumers.
  Then there are the higher premiums for individuals who do not get 
their health coverage from their employer but have to go into the group 
market. We are talking about a lot of small businesses, individuals, 
partnerships, sole proprietors, and the like. One consulting firm 
concluded that premiums in the group market could go up as much as 20 
percent because of the mandated, government-approved insurance that has 
to be sold under this bill. CBO said they concluded a somewhat lower 
level--between 10 and 13 percent. But still, if the purpose of health 
care reform is to make health care more affordable, this bill simply 
goes in the wrong direction.
  Then there is the employer mandate. I met this morning with 
representatives of the Hispanic Chamber of Commerce. The Hispanic 
Chamber told me something I knew before but reiterated--the important 
role of small businesses in terms of job creation--and pointed out to 
me how many Hispanics and minority business owners are engaged in the 
very kind of job creation we should be encouraging, not discouraging. 
This employer mandate will kill jobs because the additional cost of 
health insurance will be passed along to workers in the form of lower 
wages or result in reduced hours or layoffs. In a July 2009 report 
entitled ``Effects of Changes to the Health Care Insurance System on 
Labor Markets,'' the CBO concluded that the employer mandate is 
``likely to reduce employment.''
  At a time when unemployment is at 9.7 percent, people are losing 
their jobs, and they cannot pay their mortgages, so they are being 
kicked out of their homes due to foreclosure, we are making things 
worse with this bill, not better.
  All told, this bill that has been signed into law by the President 
and the bill before the Senate, this reconciliation bill, include more 
than $500 billion in tax increases. It makes no sense, except in the 
rarefied air under this dome, for Congress to even consider raising 
taxes, imposing new mandates on employers and individuals at a time 
when unemployment is so high and when that is the most pressing issue 
confronting the Nation today. Congress is making this worse, not 
better. Why Congress would pass a new tax on investment that will act 
like a wet blanket on the economy to further exacerbate unemployment 
and make recovery harder is, frankly, beyond me.
  Madam President, I yield the floor.

                               Exhibit 1

             [From the Wall Street Journal, Mar. 17, 2010]

                       ObamaCare's Worst Tax Hike

       The forced march to pass ObamaCare continues, and all that 
     matters now is raw politics. But opponents should go down 
     swinging, and that means exposing such policy debacles as 
     President Obama's 11th-hour decision to apply the 2.9% 
     Medicare payroll tax to ``unearned income.''
       That's what savings and investment income are called in 
     Washington, and this destructive tax wasn't in either the 
     House or Senate bills, though it may now become law with 
     almost no scrutiny.
       For the first time, the combined employer-worker 2.9% 
     Medicare rate would be extended beyond wages to interest, 
     dividends, capital gains, annuities, royalties and rents for 
     individuals with adjusted gross income above $200,000 and 
     joint filers over $250,000.
       That would lift the top capital-gains rate to 22.9% as the 
     regular rate bounces back to 20% from 15% when the Bush tax 
     cuts expire at the end of this year. The top rate for 
     dividends would rise to 42.5% when the Bush income-tax rates 
     expire. The White House plan also raises the ordinary 
     Medicare payroll tax by 0.9 percentage points for the same 
     filers, bringing it to 3.8%.
       Preliminary estimates from the Joint Committee on Taxation 
     peg the revenue from these changes at $183.6 billion over 10 
     years. The Tax Policy Center of the Urban Institute and 
     Brookings Institution estimates that 86% of the revenue from 
     the investment tax would come from people making more than 
     $624,000, or about 1.2 million taxpayers. This has led many 
     liberals to claim that it won't matter to investors or harm 
     the economy.
       Yet these static analyses ignore the incentive effects 
     forecast by the Institute for Research on the Economics of 
     Taxation. Stephen Entin and colleagues estimates that the 
     investment tax would depress GDP by about 1.3% and reduce 
     capital formation by 3.4%, and thus reduce the after-tax 
     incomes of everyone not paying the tax directly in the 
     neighborhood of 1.1% to 1.2%. Labor productivity and wages 
     would fall across the board, while the lost government 
     revenues from the more-sluggish economy would offset the 
     expected receipts.
       Senate Democrats rejected Nancy Pelosi's favored 5.4-
     percentage-point ``surcharge'' on modified adjusted gross 
     income above $1 million as too radical. But they seem to be 
     fine with its 2.9-percentage-point alter ego, although the 
     Tax Policy Center concludes (on paper) that they'll soak more 
     or less the same people for more or less the same amount.
       Earning even a single dollar more than $200,000 in adjusted 
     gross income will slap the 2.9% tax on every dollar of a 
     taxpayer's investment income, creating a huge marginal-rate 
     spike that will most hurt middle-class earners, as opposed to 
     the superrich.
       This two-tier tax also fundamentally and probably 
     irrevocably alters the social insurance model that has 
     governed Medicare for more than a half-century. Medicare is 
     supposed to be a universal entitlement with at least some 
     connection between the taxes paid on wages in return for 
     benefits. The investment tax, and the apparatus of ObamaCare 
     financing more generally, severs this link by redirecting 
     Medicare's ``dedicated'' revenues toward a new entitlement. 
     Even Bill Clinton didn't cross this policy threshold in the 
     health debate of the early 1990s, proposing to fund 
     HillaryCare entirely through new corporate taxes and 
     preserving Medicare as its own discrete program.
       Mr. Obama gave a preview of the fiscal confusion this 
     creates at a Wednesday campaign stop in St. Charles. Shortly 
     after accusing his critics of being ``just plain wrong'' 
     about everything, he went on to boast that ``we're going to 
     be able to help ensure Medicare's solvency for an additional 
     decade'' and also ``reduce the deficit by a trillion 
     dollars.''
       Yet his claims are just plain wrong, as already exposed by 
     the Congressional Budget Office. The government can't spend 
     the same Medicare dollar twice: Either it can reduce the 
     deficit or extend the life of Medicare, but not both. This 
     may seem an arcane point, but the White House obviously knows 
     better and yet continues to peddle this falsehood.
       The White House has embraced this investment tax because 
     Big Labor opposed its preferred excise tax on high-cost 
     health plans. So the White House decided to delay the excise 
     tax, which meant losing $116.2 billion in revenue over the 
     first 10 years. Voila, out came the 2.9% investment tax.
       So for reasons of political expediency, Democrats will now 
     impose a destructive tax that will permanently skew the 
     incentives to work, save and create jobs. Come to think of 
     it, that sums up this entire exercise.
                                  ____


[From the Institute for Research on the Economics of Taxation, Mar. 1, 
                                 2010]

 The Obama Administration's Proposed 2.9% ``HI'' Surtax Would Harm the 
                        Economy and Lose Revenue

       President Obama has recommended imposing a 2.9% ``HI'' 
     surtax on ``passive income'' (income from saving and 
     investment) to help

[[Page S1961]]

     fund his health insurance overhaul. Social Security taxes for 
     retirement and medical programs for the elderly taxes have 
     always been levied on wages, as a form of social insurance. 
     Extending the Hospital Insurance tax to income from savings 
     would be a sharp departure from previous practice and very 
     bad economics.


              Economic consequences of the 2.9% rate hike

       On a static basis, our preliminary estimate is that the 
     Obama plan's 2.9% surtax on the capital gains, dividends, 
     interest, and certain other income of upper-middle class and 
     wealthy taxpayers would:
       Raise approximately $39 billion yearly (at 2009 income 
     levels);
       Affect only a small number of upper-income individuals.
       In reality, on a dynamic basis, the 2.9% surtax would, 
     after the economy has adjusted to it:
       Depress GDP by about 1.3%;
       Reduce private-sector capital formation by about 3.4%;
       Cut the wage rate by about 1.1%, and hours worked by about 
     0.2%;
       Reduce the after-tax incomes of the people in the income 
     ranges supposedly not touched by the proposed 2.9% surtax by 
     1.1%-1.2%;
       Lose about 70% of its anticipated income tax revenue gain 
     due to lower GDP and incomes across-the-board;
       Decrease other federal tax revenues, causing total federal 
     receipts actually to fall by about $5 billion yearly (at 2009 
     income levels).


                               Discussion

       Capital formation is very sensitive to taxes on capital 
     income, and reduced capital formation reduces labor 
     productivity and wages across the board. We estimate that the 
     proposed surtax will depress capital formation, GDP, and 
     wages. The resulting loss of income, payroll, corporate, 
     excise, and other taxes will offset the assumed revenue 
     gains. The wage depression will affect all income levels, and 
     the tax burden will not be confined to the top income 
     earners.
       The 2.9% passive income surtax (equal to the Medicare Part 
     A--or Hospital Insurance--payroll tax rate) would be imposed 
     on dividends, interest, capital gains, rents, royalties, and 
     other income from saving and investing. The tax would hit 
     couples with more than $250,000 in adjusted gross income 
     ($200,000 trigger for singles and heads of households). The 
     tax would be triggered by earning even a single dollar above 
     the thresholds, after which all of the taxpayers' passive 
     income would be immediately subject to the tax. This creates 
     a huge tax rate spike or ``cliff' at the thresholds. It would 
     be imposed on AGI instead of taxable income, taking no 
     consideration of itemized deductions and the differing 
     circumstances of families which the deductions reveal.
       The surtax would depress capital formation and wages, and 
     fail to bring in the expected revenue. The numbers below are 
     for the 2.9% rate hike in isolation. The Administration's 
     proposal to raise the top tax rates on capital gains and 
     dividends would produce additional losses. Further losses 
     would result from the Administration's proposal that the Bush 
     tax cuts expire for upper-income taxpayers, which would 
     increase the top two tax rates on interest income and other 
     ``passive'' income to 36% and 39.6%. The return of the 
     itemized deduction limitation and the personal exemption 
     phase-out would raise upper-income individuals' marginal 
     rates even higher and add more economic damage. (The rise in 
     the top two rates would also apply to labor income, and the 
     Administration's health care proposal, taking a page from the 
     health care bill that the Senate passed on Christmas Eve, 
     would pile on a 0.9% surtax on wages and self-employment 
     income.)
       The House health bill has a 5.4% surtax on AGI. The Senate 
     considered that but dropped it as ill-advised and instead 
     opted for a 0.9% surtax on wage and self-employment income 
     only, building on the existing payroll tax. Any surtax is 
     undesirable, but a surtax on capital income would be 
     especially damaging, and the ``cliff' in the Obama 
     Administration's plan would compound the harm and is 
     especially inept.

  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Madam President, has the time on the Republican side 
expired?
  The PRESIDING OFFICER. There are 25 seconds remaining.
  Mr. BAUCUS. I assume they do not want to use those 25 seconds, 
hearing no objection.
  Madam President, we have several speakers. We are waiting for Senator 
Shaheen, Senator Feingold, Senator Sanders, Senator Nelson, and Senator 
McCaskill. I do not see any of them right now.
  While we are waiting, I wish to make a point about CBO's analysis 
with respect to premiums.
  The Congressional Budget Office says that the health care reform bill 
will lower premiums for all--millions--Americans--all. The 
Congressional Budget Office said health insurance premiums would fall 
by 14 to 20 percent for the same plan in the individual market and the 
small group market, up to 2 percent lower. Let me repeat that. The 
individual market for the same plan, the Congressional Budget Office 
says premiums will fall under this legislation. They will be lower, 
they will be less by 14 to 20 percent than the same plan in the 
individual market, as people buy insurance individually, and premiums 
for the small group market--that is roughly small business--would be up 
to 2 percent lower than currently.
  Why is all that? It is basically because there are savings. The 
savings come from lower administrative costs, increased competition, 
and from better pooling of risk.
  The analogy I like to refer to is Orbitz and Travelocity. Today with 
Orbitz, you shop online for an airline ticket. You look for fares and 
you look for times. The same type of operation would occur with respect 
to insurance--you get on the exchange and shop for insurance.
  I see the Senator from New Hampshire is now on the floor. I yield 4 
minutes to the Senator from New Hampshire.
  The PRESIDING OFFICER. The Senator from New Hampshire.
  Mrs. SHAHEEN. Madam President, I thank Senator Baucus.
  I am pleased to be here to join in this effort to talk about the 
importance of what we are doing with health care reform. We have waited 
so long for health care reform, and yesterday it became a reality. 
Today, we celebrate a reformed health care system that President Obama 
has signed into law. With this historic step, we have ensured that more 
Americans have the health care security and stability they need. We 
have ensured that families will have choices for coverage even if their 
jobs do not provide it. We have ended denials for preexisting 
conditions, and we have a guarantee that no one has to pay more for 
health insurance if they get sick and that the insurance coverage 
cannot be taken away. We no longer allow insurance companies to put 
lifetime limits on the amounts of benefits they will cover.
  But insurance reforms are not the only thing we have done. We have 
made health care more affordable for those who need it most and made it 
easier for small businesses to provide coverage for their employees. We 
made important steps to encourage everyone to take advantage of 
preventive care, and we have created incentives for people to enroll in 
wellness programs and encourage communities to address the public 
health of their citizens. Finally, we are changing the way doctors 
provide care, making it better coordinated and more patient-centered.
  I am pleased we are here building on the success of the health care 
reform legislation that was just signed into law. Our resolve is 
strong, make no mistake about that. We must continue our work in making 
a good bill even better.
  The legislation we are now considering makes great strides to 
strengthen the new law. It will provide more tax relief to families to 
help them afford health care and more help for seniors to pay for 
prescription drugs.
  I have talked with seniors throughout New Hampshire who struggle with 
the high cost of prescription drugs. The Medicare doughnut hole, as it 
is known, causes great stress in family budgets when seniors have to 
pay full price for the drugs they need, people such as Sue Quinlan from 
Portsmouth, who recently wrote me about her experience with the 
doughnut hole. She wrote:

       This year, because of my illness, my drug costs have 
     doubled, and in September I experienced the ``donut hole.'' 
     This meant that when my Total Drug Cost reached $2,400 for 
     the year, I was on my own.

  She went on to say:

       You know you are in the donut hole when a drug you have 
     been paying $90 for is now $364.47. You know you are in the 
     donut hole when the mail order prescription company calls to 
     warn you that your order is going to cost $720.82 and wants 
     to confirm that you really do want them to send it, and you 
     have no choice except to send it unless you want to stop 
     taking the medications. You know you are in the donut hole 
     when the pharmacist gives you a sympathetic smile when they 
     hand you your order.

  Under this bill, seniors such as Sue no longer need to worry. They 
will get a discount on medicine critical to their health, and we will 
begin to close the doughnut hole. Seniors will now have access to 
affordable drugs on which they depend. We have all heard the

[[Page S1962]]

story of seniors breaking their pills in half or skipping their daily 
doses because of the cost. Under this bill, a senior with high 
cholesterol and heart disease who relies on Lipitor and 
antihypertension medication to stay healthy now can take these drugs 
with peace of mind and less financial stress.
  This bill will expand affordable coverage to 32 million Americans. 
The bill will provide the same Medicaid deals for every State so that 
the Federal Government will help share in the burden the States face in 
providing coverage for new populations. The bill also builds on the 
previous bill to attack waste, fraud, and abuse in our health care 
system.
  This is a historic time. Today, we build on that historic legislation 
with improvements to make it stronger and even better for American 
families and seniors.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Madam President, I yield 6\1/2\ minutes to the Senator 
from Wisconsin.
  The PRESIDING OFFICER. The Senator from Wisconsin.
  Mr. FEINGOLD. Madam President, for far too long, my constituents have 
been at the mercy of the health insurance industry which has dictated 
how and whether they get health care coverage. Wisconsinites have been 
denied coverage because of preexisting conditions, dropped from 
coverage because they made too many claims, or simply forced to pay 
through the nose for skyrocketing premiums. Those days are now coming 
to an end thanks to the Patient Protection and Affordable Care Act.
  We have taken an important step with the enactment of that bill, but 
as you know, our work is not done. The Patient Protection and 
Affordable Care Act is not perfect, and Congress must be committed to 
strengthening and adjusting this law as necessary in the years to come. 
The first step, of course, is for the Senate to pass the Health Care 
Education Reconciliation Act of 2010, which the Senate is now debating. 
This bill will strengthen our health care reform law to ensure that 
health insurance is even more affordable for working families and that 
seniors actually pay less for prescription drug coverage.
  Taken together with the Patient Protection and Affordable Care Act, 
this bill would help Wisconsinites purchase good, affordable health 
insurance and health care. As a result, this year children will no 
longer be denied coverage for preexisting conditions, insurance 
companies will no longer drop Americans because they are sick, young 
Americans can remain on their parents' coverage longer, and the 
Medicare doughnut hole that shortchanges seniors will begin to be 
filled. Then, over the next 4 years, States will prepare to set up 
health insurance exchanges for individuals and small businesses to 
purchase more affordable health insurance. As a result, an estimated 
541,000 Wisconsinites who are uninsured and 320,000 Wisconsinites who 
have individual market insurance will gain access to affordable 
coverage. As many as 358,000 Wisconsinites are expected to qualify for 
premium tax credits to help them purchase health care coverage. Experts 
believe this reform effort will lower premiums in the nongroup market 
by 14 to 20 percent for the same benefits--premium savings of $1,540 to 
$2,200 for a family in Wisconsin. Now, this is real savings.

  According to the nonpartisan experts at CBO, over the next 10 years, 
our national deficit will decrease by $143 billion and up to $1.2 
trillion in the following 10 years. Those savings come from a number of 
cost containment provisions, including one which I strongly support 
that will begin to reimburse physicians based on the quality of care 
they provide rather than on the quantity of care. This movement toward 
value-based health care purchasing is one that is already seeing great 
success in hospitals and medical groups around my State of Wisconsin. I 
was so pleased to work with our nationally recognized medical centers 
around Wisconsin on these successful efforts.
  Health reform also means more choice, more affordability, and more 
protections for Wisconsin businesses. Over 77,400 small businesses 
throughout the State of Wisconsin are eligible now for tax credits 
starting this year to help purchase health insurance for business 
owners and their employees. No longer will small businesses be 
vulnerable to insurance practices of raising rates on a year-to-year 
basis due to an employee falling ill.
  I visit all 72 counties in Wisconsin every year, and I always hear 
about the burden of health care costs on small businesses. So many 
Wisconsinites are discouraged from striking out on their own to start a 
small business or to expand it because they can't afford or couldn't 
get health insurance on their own. This bill will help those 
Wisconsinites start businesses and create jobs by providing the 
affordability and protections of the large insurance group market to 
small business owners.
  Reform also means better and more affordable health care for 
Wisconsin's seniors. The bill we are debating will build upon 
improvements made by the Patient Protection and Affordable Care Act by 
closing the Medicare Part D prescription drug doughnut hole by 2020. 
Beginning this year already seniors who reach the doughnut hole will 
receive a $250 rebate, with more and more assistance available each 
year until the doughnut hole is ultimately closed. Seniors will also be 
guaranteed an annual wellness visit and no cost sharing on preventive 
care visits to their physician.
  Of course, we know this reconciliation bill is not just about health 
care. It also ends unjustified subsidies for private banks and lenders 
to issue Federal student loans. By transferring the authority to make 
all Federal student loans over to the existing Federal Direct Loan 
Program effective July 1 of this year, we will save approximately $61 
billion over 10 years. The savings will in part be used to help ensure 
that students do not see a reduction in their Pell grant awards next 
year, providing much needed assistance to Wisconsin's low-income and 
middle-income students when they need it the most.
  Historic health care reform is now the law of the land. But we have 
to do more, and passing this bill is the next step.
  The ACTING PRESIDENT pro tempore. The Senator's time has expired.
  Mr. FEINGOLD. I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I yield 7 minutes to the Senator from 
Florida, a very valued member of the Finance Committee.
  Mr. NELSON of Florida. I thank the Presiding Officer and the 
chairman.
  For the first time as a nation, we are recognizing that people have a 
right to not be destroyed by sickness. Under the Senate bill passed by 
the House and signed into law yesterday by the President, folks are no 
longer going to have to choose between their health and their 
pocketbooks. Parents will no longer have to worry about whether they 
can afford to get their kids to the doctor. Seniors will not have to 
wonder if Medicare will still be there for them several years down the 
road.
  Health care reform doesn't mean people would not have to continue 
taking responsibility for themselves. The bill we passed, and even the 
one we are now debating, improves health care affordability and access 
for all, but it still requires folks to do their part. Families who can 
afford to will be asked to contribute to the cost of their coverage. 
People are expected to get regular primary care so they do not end up 
in the emergency room with something that could have been treated 
easily and cheaply if it had been addressed sooner.
  But, very importantly, we are also going to hold the insurance 
companies accountable. We are finally telling them: You can't drop 
someone just because they get sick; you can't cap someone's benefits 
just because you are tired of paying for their care; and you can't 
decide not to offer someone coverage because they have a preexisting 
condition. We are telling them: No more, no more, no more.
  We are also saying to our seniors that we, as a nation, remain 
unwavering in our commitment to protecting and preserving Medicare for 
today, tomorrow, and the next millennium.
  There has been an awful lot of misinformation going around about 
Medicare and something called Medicare Advantage. The fact is, the 
original Senate bill proposed an unfair way to fix overpayments to 
these private Medicare HMO insurance plans. The fix

[[Page S1963]]

would have come at the expense of seniors living in areas with high 
medical costs, such as my State of Florida. I was able to pass an 
amendment in committee that fixed that problem fairly.
  Under this reconciliation bill, the President has proposed another 
way to rein in those Medicare Advantage insurance companies, and this, 
upon close inspection, also treats seniors fairly. It puts companies on 
the hook for their performance. If they do not provide quality service, 
their reimbursements are cut. Their enrollees--the seniors--are going 
to demand that they provide quality service. I appreciate the 
President's leadership on this issue and the fact that he heard the 
concerns expressed by a number of us, including Senator Schumer and 
Senator Wyden.
  But having said all this, we have left something undone in this 
Senate bill that is now law and even in this reconciliation package. I 
am not happy this legislation lets the drug companies pretty much off 
the hook. You all know that over the past few years I have been voicing 
the concerns and fears of residents in my State about what is happening 
to their drug prices. I also hear from the folks who can't afford their 
medications when they hit the prescription drug coverage gap known as 
the doughnut hole. They skimp on food or split their pills or stop 
taking them altogether. While this bill offers a discount to seniors in 
the doughnut hole, there is nothing to keep drug companies from 
continuing to jack up the prices until that discount is meaningless.
  I also hear from folks who are frustrated that in other countries 
folks are getting the very same drugs for much less than we pay here. I 
had an amendment that would have required the drug industry to pay its 
fair share of the tab for health care reform. It required the drug 
manufacturers to give the government price breaks on drugs for a lot of 
our low-income seniors, and that would have saved us $106 billion of 
taxpayer money, which was more than enough to fill the doughnut hole 
altogether and then make a dent in offsetting the Federal deficit.
  So I intend to come back and revisit this. In the meantime, I want to 
say this reconciliation bill deepens and extends the promise of the 
health care reform bill that was signed into law just yesterday. I 
stood with the President when he put pen to paper yesterday. I think it 
is great we have begun the process of health care reform.
  It has been said by many folks in many different ways that we are not 
put on Earth for ourselves, but we are placed here for each other. 
Well, here we are, and here we are debating legislation that stands to 
improve the lives of tens of millions of Americans. So despite its 
flaws, I will vote to pass this legislation.
  Mr. President, I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I thank the Senator from Florida for his 
very considered and thoughtful conclusion in deciding to vote for this 
legislation. I deeply appreciate that very much. He is a wonderful 
member of the committee.
  Mr. President, I yield 7 minutes to the Senator from Vermont.
  The ACTING PRESIDENT pro tempore. The Senator from Vermont is 
recognized.
  Mr. SANDERS. I thank the Senator from Montana for yielding.
  Mr. President, my Republican colleagues have reached the conclusion 
that this is not a perfect bill. Well, they are right. While my 
problems with this bill are very different than theirs, I do hope that 
in the weeks and months to come, after we pass this reconciliation 
package, we will improve it. But I would ask my Republican colleagues 
to tell me something: When they controlled the White House and they 
controlled the Senate and they controlled the House, when President 
Bush was our President--during that period--7 million more Americans 
lost their health insurance and health care costs soared. Where were 
they then in talking about health care? Did they have one substantive 
idea during that period about how we were going to lower the cost of 
health care for Americans and provide health insurance for all of our 
people?
  I do hope that after we pass reconciliation we are going to improve 
this bill. In that regard I want to thank Majority Leader Reid who has 
promised us--Senator Merkley, myself and others--that we will have the 
chance to vote on a public option provision. I think millions of 
Americans understand that public option is a choice that people should 
have--the right to go outside of the private insurance companies for 
their health insurance. That public option will provide competitive 
pressure on the insurance industry to control soaring health care 
costs. So I very much appreciate Senator Reid telling us that we are 
going to have a vote on that issue within a couple of months.
  This bill is a strong step forward. It is no small thing that we are 
providing health insurance to 32 million more Americans. It is no small 
thing that we are moving to eliminate preexisting conditions as a 
grounds for rejecting someone for health care. It is no small thing 
that we are going to begin to fill that doughnut hole so that seniors 
will be able to get the prescription drugs they need in an affordable 
way. Those are, among other achievements, quite significant.
  But having said that, after the passage of this legislation, we still 
have to deal with the reality that we will continue to spend far more 
per capita on health care than any other major country.
  A few days ago, we had the Ambassador from Denmark visiting Vermont. 
In that country, they provide quality care for all of their people, and 
they do it spending about 50 percent of what we do because they have 
eliminated private insurance companies and all of the administrative 
and profiteering costs associated with private insurance companies. I 
hope we will one day at least allow States the option to move forward 
with a single-payer, Medicare-for-all program, which I think ultimately 
is the way we are going to go as a nation if we are going to solve the 
need for comprehensive universal and cost-effective health care for all 
of our people.
  I do want to say a word on one aspect, one provision of this bill 
which I think is enormously important, and I am very excited it is 
included in this bill. Again, I thank Senator Reid for his help in 
making sure it remained in and is amply funded. That is that in this 
legislation we are going to take a giant step forward in providing 
primary health care to the people of this country through a major 
expansion of Community Health Centers and the National Health Service 
Corps. This legislation provides enough funding so that we are going to 
create, over the next 5 years, 8,000 new health center sites, more than 
doubling the number that now exists. We are going to increase access 
for primary health care, dental care, mental health counseling, and 
low-cost prescription drugs by doubling the number of Americans with 
access to community health centers from 20 million to 40 million in 
every State, and in every region of this country. That is a huge step 
forward in providing basic health care to millions of Americans who 
today cannot access that care.

  While we do that, we are also going to significantly expand the 
number of doctors, the number of nurse practitioners and dentists that 
we desperately need in order to provide primary health care to our 
people.
  This legislation--over a 5-year period--triples the amount of money 
going into the National Health Service Corps, a program which provides 
debt forgiveness and scholarships for those doctors and dentists who 
will be serving in underserved areas throughout this country.
  Through the National Health Service Corps, we are going to support an 
additional 17,000 new primary health care doctors, dentists, nurse 
practitioners, and mental health professionals. What this means is that 
if somebody has no health insurance, if somebody has Medicaid, if 
somebody has Medicare, if somebody has private health insurance, that 
individual is going to be able to walk into a community health center 
and get the high quality care they need. The incredible thing, and this 
is quite remarkable, is that by doing this we are going to actually 
save taxpayers money because we are going to keep people out of the 
emergency room, which is the most expensive form of primary health 
care; we are going to prevent people from becoming sicker than they 
should and ending up in the

[[Page S1964]]

hospital at great expense. Based on a study by the Geiger-Gibson 
Program at George Washington University, it is conservatively estimated 
that, by investing $12.5 billion in health centers and the National 
Health Service Corps, we will save Medicaid alone over $17 billion over 
the next 5 years.
  This legislation is going to be very significant in providing the 
primary health care that we need as a nation, and I am very 
appreciative it is part of the bill.
  Mr. President, as I conclude, I ask unanimous consent to have printed 
in the Record the findings of the study by the Geiger-Gibson/RCHN 
Community Health Foundation Research Collaborative, George Washington 
University, dated October 14, 2009.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                Findings

       Since health centers are non-profit entities that operate 
     subject to comprehensive federal standards, our models assume 
     that health centers will serve as many patients as their 
     revenues permit. As a result, the number of patients served 
     at health centers depends on the revenue available to health 
     centers and the distribution of insurance coverage among 
     health center patients. The Senate provisions increase health 
     center revenues in three key ways: (1) by increasing federal 
     health center grants; (2) by increasing Medicaid revenues as 
     a result of expanded Medicaid coverage; and (3) by assuring 
     higher private insurance revenues as a result of the 
     extension of the Prospective Payment System (PPS) to health 
     center patients insured through a health exchange. By 
     lowering the number of uninsured patients, health reform thus 
     will allow health centers to use their grant funds to reach 
     additional uninsured patients, thereby increasing the number 
     of patients who can be served.
       It is important to note that federal health center grants 
     and payments under Medicaid and private health insurance 
     represent only a portion of total health center revenue. 
     Other important sources include other federal, state, local 
     and private grants or contracts. As in our prior report, we 
     conservatively assume that these other funding sources will 
     grow by only five percent annually.
       We estimate that by 2019, these combined policy changes 
     would roughly triple the number of patients receiving care at 
     health centers. The number of patients would rise from an 
     estimated 19.0 million in 2009 to 44.2 million in 2015 and to 
     60.4 million by 2019. In order to expand to serve this many 
     patients, we assume that the number of health center grantees 
     and the number of health center delivery sites (i.e., 
     clinics) would grow substantially, permitting a major 
     expansion of health centers and clinics into more medically 
     underserved rural, suburban and urban communities.
       In our prior paper, we analyzed data from the 2006 Medical 
     Expenditure Panel Survey to compare the medical expenditures 
     of people who receive the majority of ambulatory care at 
     health centers and those who do not. We found that, after 
     adjusting for health status, age, gender, race/ethnicity, and 
     health insurance coverage, the average patient receiving care 
     at a community health center had annual medical expenditures 
     $1,093 lower than an average patient who did not use health 
     centers. This estimated savings includes both reduced 
     ambulatory costs as a result of health center efficiencies as 
     well as reduced inpatient medical expenses, which may be due 
     to the prevention of more severe health problems requiring 
     hospitalization. These findings are consistent with numerous 
     prior studies showing that health centers are efficient 
     providers of quality primary care and that more effective use 
     of primary care can reduce hospital and specialty care costs.
       Using the estimate of $1,093 savings per health center 
     patient in 2006, we applied the estimates of the increased 
     number of health center patients and adjusted savings to 
     account for health care inflation to estimate total medical 
     savings associated with the expansion of services at health 
     centers over the next ten years. These are summarized in 
     Table 1.

 TABLE 1--ESTIMATED INCREASE IN HEALTH CENTER PATIENTS, TOTAL MEDICAL SAVINGS AND FEDERAL MEDICAID SAVINGS UNDER
                                       THE SENATE PROVISIONS, 2010 TO 2019
----------------------------------------------------------------------------------------------------------------
                                                         2009        2015        2019      2010-2015   2010-2019
----------------------------------------------------------------------------------------------------------------
Total Number of Patients (mil)......................        19.0        44.2        60.4  ..........  ..........
Increase Over 2009 Patients (mil)...................  ..........        25.2        41.4  ..........  ..........
Est. Total Med Savings Per Person...................      $1,262      $1,551      $1,780  ..........  ..........
Est. Total Medical Savings (bil)....................          --       $39.0       $73.7      $129.1      $369.2
Est. Federal Medicaid Savings (bil).................          --       $11.0       $22.5       $34.2     $105.0
----------------------------------------------------------------------------------------------------------------
Source: Authors' estimates.

       As seen in Table 1, in 2019, we estimate that the number of 
     patients receiving primary care services at health centers 
     will rise by 41.4 million over the 2009 level of 19.0 
     million, to 60.4 million total patients. This growing use of 
     health centers to serve an additional 41.4 million patients 
     times the medical savings of $1,780 per patient yields an 
     overall medical savings estimate of $73.7 billion in 2019 
     alone. Over the 2010-2019 period, we estimate that an 
     increase in the number of patients who receive their health 
     care through health centers will lead to $369 billion in 
     total medical savings. (Following the approach used by the 
     Congressional Budget Office, we estimate only the additional 
     savings due to increases in the number of patients served at 
     health centers. We estimate that the 19 million patients 
     already served in 2009 create medical savings of $24 billion 
     in that year alone; savings from the existing 19 million 
     patients are not included in the estimates shown in Table 1 
     above.)
       This estimate includes all medical savings, whether public 
     or private. From the federal perspective, the critical 
     question is federal savings. We estimate savings attributable 
     to federal spending by focusing on federal Medicaid savings, 
     accounting both for the increased volume of Medicaid patients 
     and the effective increases in federal matching shares for 
     Medicaid. (There are also state Medicaid savings not included 
     in the estimate of federal savings.) This calculation yields 
     an estimated federal Medicaid savings of $22.5 billion in 
     2019 and $105 billion between 2010 and 2019. This is a 
     conservative estimate of federal savings, since there would 
     also be savings under Medicare as well as in the federal 
     subsidies spent to purchase health insurance through 
     exchanges.

  The ACTING PRESIDENT pro tempore. The time of the Senator has 
expired.
  Mr. BAUCUS. Mr. President, how much time remains on our half hour?
  The ACTING PRESIDENT pro tempore. There remains 2 minutes 40 seconds.
  Mr. BAUCUS. I yield 2 minutes 40 seconds to the Senator from 
Missouri.
  The ACTING PRESIDENT pro tempore. The Senator from Missouri is 
recognized.
  Mrs. McCASKILL. Mr. President, we have had a lot of that childhood 
story we all learned of ``Chicken Little.'' We have had a lot of 
Chicken Little around this building in the last few months: The sky is 
falling, the sky is falling. You know, I woke up this morning, I looked 
up and the sky was not falling. Every day that goes by in America 
people are going to realize the sky is not falling. In fact, as time 
goes on that sky is going to get bluer and brighter because people in 
America are going to realize this bill is not full of booby traps, it 
is full of good things that will reform health care.
  I rise this afternoon to take a couple of minutes to talk about a new 
low of obstructionism, taking game playing to a whole new level. In 10 
minutes I was supposed to convene a hearing on the contracts for police 
training in Afghanistan. This is a very important part of our mission 
in Afghanistan, the training of local police departments. There was a 
witness who was going to be there from the State Department, a witness 
there from the Defense Department, the Inspectors General were going to 
be there.
  Just last week GAO wiped out a contract that had been let on police 
training because of problems in the way the contract was competed. So 
this hearing was timely and it is important. We cannot succeed in 
Afghanistan if we do not have effective police training. These 
contracts are problematic. The State Department is supposed to be 
overseeing them. We have hundreds of millions of dollars not accounted 
for.
  So what do I find out this morning? The Republican party is not going 
to let us have the hearing. What in the world? Why in the world are we 
not being allowed to work this afternoon? Why in the world are we not 
able to ask questions at a hearing in a few minutes as to why the 
police training is not going well in Afghanistan and how we can do 
better?
  Our men and women are over there and they are at risk if we do not 
get this right. I don't get it. I don't get what the purpose of saying 
no is. I don't get what we accomplish. We are sent here to work. We are 
paid by the people of this country to work. The idea that I had to call 
these witnesses and say go home because the Republicans will not let us 
have a hearing--

[[Page S1965]]

somebody has to explain this to me. Disagree with us, debate, vote no--
but let us work. I implore you: Let us work.
  The ACTING PRESIDENT pro tempore. The Senator's time has expired.
  The Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, I have one unanimous consent request that 
we continue altering sides of the debate. I ask consent we continuing 
alternating back and forth, and the next half hour be on the Republican 
side.
  I ask unanimous consent the next half hour be controlled by the 
Republicans and the half hour thereafter be controlled by the majority, 
and the half hour after that be controlled by Republicans.
  The ACTING PRESIDENT pro tempore. Is there objection?
  Without objection, it is so ordered.
  Mr. BAUCUS. Mr. President, for the information of Senators, the final 
block of time is reserved to be under the control of the chairman for 
concluding remarks; that is, prior to a series of votes. I make that 
statement for the information of Senators.
  The ACTING PRESIDENT pro tempore. The Senator from Kansas is 
recognized.


                           Amendment No. 3579

  Mr. ROBERTS. I ask consent to call up Roberts-Inhofe-Brown amendment 
No. 3579, and I ask unanimous consent Senator Crapo be added as 
cosponsor.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  The clerk will report.
  The bill clerk read as follows:

       The Senator from Kansas [Mr. ROBERTS], for himself, Mr. 
     Inhofe, Mr. Brown of Massachusetts, and Mr. Crapo, proposes 
     an amendment numbered 3579.

  Mr. ROBERTS. I ask unanimous consent the reading of the amendment be 
dispensed with.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  The amendment is as follows:

              (Purpose: To strike the medical device tax)

       Strike section 1405 and insert the following:

     SEC. 1405. REPEAL OF MEDICAL DEVICE FEE.

       (a) In General.--Section 9009 of the Patient Protection and 
     Affordable Care Act, as amended by section 10904 of such Act, 
     is repealed effective as of the date of the enactment of that 
     Act.
       (b) Expansion of Affordability Exception to Individual 
     Mandate.--Section 5000A(e)(1)(A) of the Internal Revenue Code 
     of 1986, as added by section 1501(b) of the Patient 
     Protection and Affordable Care Act and amended by section 
     10106 of such Act, is amended by striking ``8 percent'' and 
     inserting ``5 percent''.
       (c) Application of Provision.--The amendment made by 
     subsection (b) shall apply as if included in the Patient 
     Protection and Affordable Care Act.

  Mr. ROBERTS. Mr. President, included in the half trillion dollars in 
new taxes in this health reform bill is a tax hike of $20 billion on 
medical devices, a $20 billion excise tax on lifesaving medical 
devices. The nonpartisan Congressional Budget Office and Joint 
Committee on Taxation have both confirmed that these excise taxes will 
not be borne by the medical device industry if in fact that is what the 
other side wanted to do. Instead, the tax will be passed on to patients 
in the form of higher prices and higher insurance premiums. My 
colleagues are going to speak in greater detail about this tax, but let 
me take a moment to talk about some of the people who will bear the 
burden, and what types of devices will be taxed.
  People with disabilities, diabetics, amputees, people with cancer and 
people with Alzheimer's are just some of the folks who will see their 
tax costs go up because of this tax. My amendment prevents this new tax 
from raising the already high cost for these groups by striking the tax 
on medical devices.
  This is a tax on innovative devices as well, a device such as the 
cyberknife. The cyberknife is a noninvasive alternative to surgery for 
the treatment of both cancerous and noncancerous tumors anywhere in the 
body. Yet under this bill, such cutting-edge devices will be taxed. 
Those who need the treatment offered by the cyberknife will see the 
cost of that treatment go up. When innovative and lifesaving 
technologies such as the cyberknife are taxed, when the costs of many 
tests increase because the devices used in the tests are taxed, when 
the new devices are not developed and when fewer manufacturers are able 
to survive in the anticompetitive environment this tax will create, 
consumers of health care will suffer for it.
  I urge my colleagues to support this amendment, and yield the 
remainder of my time to the distinguished Senator from Massachusetts, 
Mr. Brown.
  The ACTING PRESIDENT pro tempore. The Senator from Massachusetts is 
recognized.
  Mr. BROWN of Massachusetts. Mr. President, I thank Senator Roberts 
for bringing this very important issue to the forefront. Many of you 
know I live in Massachusetts. We have over 225 medical device companies 
there. Before I got here, I visited many of them and the message was 
very clear, that if in fact that 3-percent medical device tax goes into 
effect, it is virtually all of their profit for many of these young 
companies and established companies.
  Placing a tax on medical devices, in my opinion and their opinion, 
will dramatically affect jobs, not only in Massachusetts but throughout 
the country.
  Unemployment in my State is hovering near 10 percent and we should be 
doing everything we can at this point to create jobs and stimulate the 
economy. I am hopeful that in the effort I made in the beginning for a 
bipartisan effort to start jobs with the first jobs bill that we can 
look at the areas we are trying to focus on to make this bill better. I 
am hopeful once again, through the Senator's leadership and that of 
Senator Roberts and others who sponsored it, we will look twice at what 
we are trying to do here in order to pay for the so-called health care 
bill.
  As we are in the middle of a 2-year recession, taxing companies, 
especially vibrant companies throughout my State and throughout the 
country, I am fearful they will leave and go to other countries to do 
their business.
  I yield the remainder of my time.
  The ACTING PRESIDENT pro tempore. The Senator from Oklahoma is 
recognized.


                           Amendment No. 3588

  Mr. INHOFE. Mr. President, I call up amendment No. 3588 and make it 
pending.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered. The clerk will report.
  The bill clerk read as follows:

       The Senator from Oklahoma [Mr. INHOFE] proposes an 
     amendment numbered 3588.

  Mr. INHOFE. I ask unanimous consent we dispense with the reading of 
the amendment.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  The amendment is as follows:

  (Purpose: To exclude pediatric devices and devices for persons with 
               disabilities from the medical device tax)

       On page 99, between lines 9 and 10, insert the following:
       (e) Exclusion of Medical Devices for Pediatric Use and 
     Persons With Disabilities.--
       (1) In general.--For purposes of section 4191(b)(1) of the 
     Internal Revenue Code of 1986, as added by subsection (a), 
     the term ``taxable medical device'' shall not include any 
     device which is primarily designed--
       (A) to be used by or for pediatric patients, or
       (B) to assist persons with disabilities with tasks of daily 
     life.
       (2) Expansion of affordability exception to individual 
     mandate.--Section 5000A(e)(1)(A) of the Internal Revenue Code 
     of 1986, as added by section 1501(b) of the Patient 
     Protection and Affordable Care Act and amended by section 
     10106 of such Act, is amended by striking ``8 percent'' and 
     inserting ``5 percent''.
       (3) Application of provision.--The amendment made by 
     paragraph (2) shall apply as if included in the Patient 
     Protection and Affordable Care Act.

  Mr. INHOFE. Mr. President, President Obama repeatedly promised during 
the campaign that no one making under $250,000 per year would see their 
taxes increase. However, the Democrats claim to spend $2.6 trillion in 
new health care at a time when the country cannot afford the promises 
they have already made and we have a record 1-year budget deficit, $1.4 
trillion.
  We hear President Obama always talking about what he inherited from 
George W. Bush. What he inherited was nothing like what he did. He 
actually raised the deficit $1.4 trillion in 1 year. That is more than 
President Bush did in his last 5 years.
  The HELP bill, which recently passed the House, represents an 
unprecedented

[[Page S1966]]

expansion of government control and increases taxes on Americans during 
a difficult economic time. But the Democrats did not stop with one 
expensive health care bill. Now the Senate is debating a fix-it bill 
which increases taxes an additional $50 billion on the American people.
  Reading through the legislation, I am struck by a myriad of ways this 
raises taxes on American citizens, from job-creating small businesses 
to middle-income families--over a half trillion dollars of new taxes.
  If you happen to need a medical device--that is what we are talking 
about right now--you get taxed under the bill. Section 9009 of the 
recently passed health care bill imposes a new tax on assistive 
devices, which includes items such as pacemakers, ventilators, and 
prosthetics, and incubators for premature babies. The fix-it bill--I 
call this the payoff bill because as you all know the Speaker of the 
House had to pay off all these individuals. We understand how that 
works. That is what this bill is all about right now. That is why it 
needs to be amended. This is what we are currently debating. It 
actually expands to include more medical devices such as tongue 
depressors, elastic bandages, most hand-held dental instruments, and 
examination gloves.
  I am joining with my Republican colleagues to propose an amendment 
striking the tax on medical devices.
  Additionally, I have filed amendment No. 3588--that is what we are 
talking about now--that will strike this expansion of taxes on 
assistive devices for two of the most vulnerable populations, children 
and individuals with disabilities.
  I have previously spoken on the floor about this new tax and how it 
hurts Americans. Let me remind you of a couple of examples.
  My son-in-law Brad Swan installs pacemakers and defibrillators. I 
know this is true because he lives right across the street from us. At 
1 o'clock in the morning he was called to an emergency involving a 
young 8-year-old boy with no heartbeat whatsoever.
  He was born with congenital heart disease, was able to have a 
pacemaker put in that morning, right after he was called, and now he 
has a full, healthy life ahead of him. My older sister Marilyn faced a 
similar situation and is alive and healthy today. Additionally, Dr. 
Stanley DeFehr, a cardiologist in Bartlesville, OK, explained to me 
that:

       The cost of a pacemaker [we are talking about $5,000; it is 
     something that lasts 10 years] pales in comparison to the 
     cost of a stroke or multiple fractures.

  Now with this tax, we are making these medical devices more expensive 
for families, which may prevent others from accessing the device they 
need in order to enhance or even save their lives.
  I have never been through anything like this in the 20 years I have 
been here. We look at the tax increase in this bill of $569 billion; 
now it is going to be more than that.
  Additionally, I was talking this morning in Chickasha, OK, on a radio 
show, and the person intervening me was talking about his 94-year-old 
mother and how she depends on Medicare. I explained that there is $523 
billion in Medicare cuts in this bill.
  So, you know, the White House was celebrating. You could hear the 
champagne corks popping all night long. Yes, they successfully 
increased taxes by $569 billion.
  So I encourage people to vote for this amendment to at least relieve 
part of the problem that is out there. It is amendment No. 3588.
  I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Utah is 
recognized.


                           Amendment No. 3644

  Mr. HATCH. Mr. President, I ask unanimous consent that the pending 
amendment be set aside. I have an amendment at the desk.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered. The clerk will report.
  The bill clerk read as follows:

       The Senator from Utah [Mr. Hatch], for himself, Mr. Coburn, 
     and Mr. Crapo, proposes an amendment numbered 3644.

  Mr. HATCH. Mr. President, I ask unanimous consent that the reading of 
the amendment be dispensed with.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  The amendment is as follows:

      (Purpose: To protect access for America's wounded warriors)

       On page 99, between lines 9 and 10, insert the following:
       (e) Exclusion of Medical Devices Sold Under the TRICARE for 
     Life Program or Veteran's Health Care Programs.--
       (1) In general.--For purposes of section 4191(b)(1) of the 
     Internal Revenue Code of 1986, as added by subsection (a), 
     the term ``taxable medical device'' shall not include any 
     device which is sold to individuals covered under the TRICARE 
     for Life program or the veteran's health care program under 
     chapter 17 of title 38, United States Code, any portion of 
     the cost of which is paid or reimbursed under either such 
     program.
       (2) Expansion of affordability exception to individual 
     mandate.--Section 5000A(e)(1)(A) of the Internal Revenue Code 
     of 1986, as added by section 1501(b) of the Patient 
     Protection and Affordable Care Act and amended by section 
     10106 of such Act, is amended by striking ``8 percent'' and 
     inserting ``5 percent''.
       (3) Application of provision.--The amendment made by 
     paragraph (2) shall apply as if included in the Patient 
     Protection and Affordable Care Act.

  Mr. HATCH. Mr. President, before I talk about my amendment to exempt 
our Nation's wounded warriors from this new medical device tax, let me 
take a moment to talk about the enormous tax burden imposed under this 
bill.
  Republicans in Congress agree with the majority of Americans who 
believe that simply throwing more hard-earned taxpayer dollars at a 
$2.5 trillion health care system will not deliver meaningful reform. 
Simply raising more than $650 billion in new taxes at a time when our 
national unemployment rate stagnates near double digits is a really bad 
idea.
  Now, let us take a look at the claims that despite more than $650 
billion in new taxes in this bill, this big government bill will not 
raise taxes for Americans making less than $200,000 a year, a pledge 
that President Obama repeatedly mentioned both as a candidate and then 
as our President. Well, the Democratic chairman of the Finance 
Committee, and I commend him for his honesty, in his floor remarks on 
March 23, 2010, stated: One other point that I think is very important 
to make is that it is true that in certain cases, the taxes will go up 
for some Americans who might be making less than $200,000. We have 
known all along that this pledge is an illusion that will slowly but 
continuously disappear over time.
  A recent analysis by former Congressional Budget Office Director 
Douglas Holtz-Eakin based on data provided by the Joint Committee on 
Taxation revealed some startling facts on the distributional impact of 
the Senate-passed bill. Let me share these findings with you:
  Only 7 percent of Americans would qualify for the new government 
subsidy to help them pay for mandatory health insurance. 93 percent of 
all Americans will not be eligible for a tax benefit under this bill.
  Twenty-five percent of Americans earning less than $200,000 a year 
would see their taxes rise.
  So what does this all mean? For every one family that receives the 
government subsidy, three middle-class families will pay higher taxes.
  Simply put, we will continue our march towards the Europeanization of 
America as fewer and fewer Americans continue to bear the burden of 
supporting the needs of a growing majority.
  By the way, the figures I just discussed, do not take into account 
all the tax increases in this bill signed by the President yesterday, 
including hundreds of billions in new taxes on employers who do not 
provide coverage to insurance premiums, prescription drugs and medical 
devices.
  Representatives from both the Congressional Budget Office and the 
Joint Committee on Taxation testified before the Finance Committee that 
these taxes will be passed on to the consumers. So even though the bill 
tries to hide these taxes as fees, average Americans who purchase 
health plans, use prescription drugs and buy medical devices will end 
up footing the bill. Every American knows that there is no such thing 
as a free lunch in this town.
  Included in the $650 billion of new taxes in this health bill is a 
tax hike of $20 billion on medical devices. Of the few exemptions 
included in the reconciliation bill, there is no mention of

[[Page S1967]]

the brave men and women in the military and our veterans who have 
sustained injuries defending this country during the wars.
  My amendment would prevent this new tax from raising costs or hurting 
access for American soldiers and veterans by exempting medical devices 
used by the TRICARE program and the Veterans health care program. We 
must protect our wounded warriors who rely on these life-saving and 
life-enhancing medical devices.
  I urge my colleagues to stand up for our brave warriors and support 
this amendment.
  Let me tell you, I hope my colleagues on both sides will stand up for 
the wounded warriors. I hope they will stand up and realize that these 
folks should not be hammered with higher costs on medical devices. We 
owe them a debt of gratitude not more taxes.
  The ACTING PRESIDENT pro tempore. The Senator from Iowa.
  Mr. GRASSLEY. I wish to speak in support of Senator Inhofe's 
amendment No. 3588, which would be to exclude medical devices for 
children and persons with disabilities from a medical device tax.
  I know that when you talk about a medical device tax and if it is on 
the manufacturers, you are going to say: Well, what should I be 
concerned about that for because some manufacturer is going to pay it. 
Well, don't fool yourself. You know, corporations do not pay taxes, 
only people pay taxes, and there are three categories of people who pay 
taxes: stockholders or employees or consumers. And I will bet in most 
cases consumers end up paying for that.
  So this provision in this bill is much broader than the Inhofe 
amendment would apply to, but I think Senator Inhofe has picked out a 
very important aspect of adding taxes, the extent to which surely the 
vulnerable people whom you call children and persons with disabilities 
are consumers who shouldn't be paying for a tax to pay for a bill that 
59 percent of the people in this country say they are against. But 
because the majority party and the President want to make history, just 
make history, don't worry about the people at the grassroots of 
America, what they think.
  So there are all these taxes and all of these fees in here, and I 
compliment Senator Inhofe for his leadership in at least trying to 
reduce this burden on people who are very vulnerable, people with 
disabilities.
  Of the many taxes in this bill, I am especially worried about the tax 
on medical devices. What will happen when the Democrats impose a new 
tax hike on $20 billion of these innovative medical devices? During the 
markup of the Finance Committee bill, I asked the question to the 
nonpartisan Congressional Budget Office and the nonpartisan Joint 
Committee on Taxation.
  For people who might not understand the emphasis of ``nonpartisan'' 
about the Congressional Budget Office and the Joint Committee on 
Taxation, I would like to say it is very important that you understand 
that because everybody thinks everything connected with Congress is 
totally political. Well, these are professionals who are around here a 
lot longer than a lot of Senators and Representatives, and then their 
job is, in a professional way, to look at what things cost and how much 
money certain taxes will raise. So they are kind of like God around 
here. They are believed. If you want to overrule them, you know, it 
takes 60 votes. That is a lot of power when you have to have 60 votes 
to overrule something on a point of order.
  So explaining what nonpartisanship is with the Congressional Budget 
Office and our constituents understanding that so they understand we 
are not quoting a Republican or a Democrat, we are quoting 
professionals, I think is very basic to understanding the points we 
individually make so that they are accepted as intellectually honest.
  In this particular case where these two offices--both of them said 
these excise taxes will be passed on to consumers in the form of higher 
prices and higher insurance premiums. When I began my remarks, I said 
that is what is going to happen. Well, Chuck Grassley said that, but I 
want you to know that is what these professionals in the Joint 
Committee on Taxation and the Congressional Budget Office backed me up 
in saying.
  Who are the consumers of these devices? I have the exact language 
here of how these things are going to be passed on to consumers so that 
you know, you see the document right here.
  Who are these consumers of these devices who will bear the burden of 
the new medical device excise tax? I would like to tell the story of 
the Tillman family, a family who would bear the burden of this new 
medical device tax.
  At only 5 months old, Tiana Tillman had her life saved by a medical 
device.
  This story has received a lot of attention because Tiana's father is 
a professional football player for the Chicago Bears. However, 
lifesaving stories like this happen all across the country.
  When Charles Tillman reported to training camp in 2008, it was not 
long before his coach told him his 5-month-old daughter Tiana had been 
rushed to the hospital. When Charles got to the hospital, Tiana's heart 
rate was over 200 beats per minute. The doctor told Charles and his 
wife Jackie that Tiana may not make it through the night.
  Tiana survived the night, and after a series of tests, she was 
diagnosed with cardiomyopathy, that is, an enlarged heart that is 
unable to function properly. Her condition was critical, and without a 
heart transplant, she would not survive. But finding pediatric donors 
is very difficult, and many children do not survive that long wait 
time.
  Tiana was immediately put on ECMO, a device that would help the 
functions of the heart while Tiana waited for a transplant. However, 
ECMO is an old device that has many shortcomings.
  The Tillmans waited for one of two outcomes: either Tiana would 
receive the transplant or she would die waiting on ECMO.
  If you want to know, ECMO is E-C-M-O, an acronym.
  But then doctors told them about the new pediatric medical device 
called the Berlin Heart--the Berlin Heart is an external device that 
performs the function of the heart and lungs--the Tillmans decided to 
move forward with the Berlin Heart. After 13 days of being on ECMO 
without any movement, Tiana underwent surgery to connect the Berlin 
Heart. After the operation, you can see Tiana in that photo. It pumped 
her blood through her body--a job her heart could not perform on its 
own. Doctors said the Berlin Heart helped Tiana regain her strength 
because she was off the paralytic medication and finally moving.
  Not long after Tiana connected to the Berlin Heart, a donor was found 
and Tiana underwent an 8-hour transplant surgery. The risky surgery was 
a success, thank God. Usually it takes some time for a new heart to 
start working, but doctors said that due to Tiana's strength, her new 
heart started working immediately.
  So you see here Tiana today. She probably loves that football just 
like her dad loved the football. She is a happy and healthy 2-year-old 
girl. She enjoys playing on her swing and watching her dad play 
football.
  Without the Berlin Heart to keep her alive and help her to gain 
strength, she might not, in fact, be alive. Democrats would increase 
costs for families such as the Tillmans with this tax, particularly. 
But it will be relieved somewhat if we adopt the Inhofe amendment. In 
fact, the Democratic bill would tax most pediatric medical devices. I 
wish to make clear that any vote against the Inhofe amendment is an 
endorsement of the tax on devices such as the Berlin Heart and many 
others children across this country rely upon. Not only that, it would 
also probably have a great impact upon research that brings about some 
of these miracle medical devices that make a difference. Taking money 
away from research at businesses is going to delay the miracle things 
that come along, whether they are pharmaceuticals or medical devices.
  We should not be discouraging that. In the rest of the world, there 
has not been as much research done in the rest of the world as is done 
in the United States. Maybe go back 50 years ago and you had Germany 
and other European countries very much involved. But their government 
taking over everything and their high rates of taxation are drying up 
resources used for research. So the United States has been the 
beneficiary of that. Our pharmaceutical industry and medical device

[[Page S1968]]

industry have taken advantage of it. So much new development around the 
world in the enhancement of these devices as well as pharmaceuticals 
have come because of the research we do. This tremendous tax burden 
that the American consumer is going to feel from the massive money 
coming in to fund this bill, which isn't going to drive down health 
care costs, is going to stymie a lot of innovation we should not want 
to stymie.
  May I ask the Chair how many minutes my side has remaining?
  The ACTING PRESIDENT pro tempore. The Senator has 3\1/2\ minutes 
remaining.
  Mr. GRASSLEY. I will take that 3\1/2\ minutes to comment on another 
aspect of the bill. This is not on the Inhofe amendment, at this point. 
It is something unrelated to health care, but in a sense it is related 
to health care. This is the nationalization of the student loan 
program. For a long time, colleges on behalf of their students have had 
the benefit of going with a direct student loan from the government or 
getting it through the banks. They have voted by their feet, by the 
overwhelming amount of them going to the banks to get their student 
loans. Now this reconciliation is going to nationalize student loans, 
have just direct loans. There are about 31,000 people around the 
country who have something to do with student loans. Those people are 
going to be out of work at a time when we are all talking about jobs. 
We need to do something for jobs. So we're going to nationalize 
education loans and have that unemployment and then take four call 
centers around the country to take its place. Do you think college 
students are going to get the service they get when they have to deal 
with the Federal bureaucracy redtape? I don't believe so. But there's 
supposedly a certain amount of savings in this. I don't know whether it 
is real savings, but the CBO, which I say is God around here, scored it 
as a certain amount of savings, even considering the fact that the 
government is going to have to borrow $\1/2\ trillion to get this 
program underway. They are going to use those supposed savings from the 
student loan program to fund this bill, the health care bill.
  We are in a situation that is just something that common sense 
Americans in the Midwest are not going to understand. But it is 
something, I suppose, you would expect to happen in Washington, DC, 
which is an island surrounded by reality, that you are going to have 
college students who are going to pay 6.75 percent interest on their 
loans to the Federal Government that the government only pays 2.75 
percent to borrow, that you are going to be taxing college students to 
pay for health care. It doesn't add up, at the very same time that too 
many of us in this body are complaining about the increased cost of 
education.
  I hope the college students will speak up in this particular instance 
about what is being done, that college students should not be taxed to 
provide health insurance. But this whole health care bill taxes 
everything. It just seems like everything.
  How many minutes are remaining?
  The ACTING PRESIDENT pro tempore. The time of the Senator has 
expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, I yield 5 minutes to the Senator from New 
Jersey, Mr. Lautenberg.
  The ACTING PRESIDENT pro tempore. The Senator from New Jersey is 
recognized.
  Mr. LAUTENBERG. Mr. President, I thank Senator Baucus for his 
leadership on this health care reform effort that is underway.
  This is the most astounding thing. For all these weeks, our friends 
on the other side have said no, no, no to health care. Not one good 
word. Not one of them stood and said: Yes, we should cover 32 million 
people who don't have coverage; yes, we should cover young people who 
want to join their parents' health insurance policy. They said no to 
small businesses that need help in providing affordable health coverage 
to their employees.
  Many know that recently I was stricken with an illness. Five weeks 
ago this time, I was in an ambulance on my way to the hospital, 
bleeding profusely, very sick. I was lucky. I had health care coverage. 
The doctors were there waiting for me. They were there to give me 
transfusions. They were there to give me intravenous fluids. They were 
there to care for me. I had nursing care, and I came through a crisis, 
as my children stood by, my four children stood by with their fingers 
crossed, pleading for my health to return. It was because I had health 
care coverage that I am standing here today on my way to a full cure--
less hair but still willing to fight the fight for the people I 
represent, for the people across this country who are being denied 
coverage in any way they can do it.
  What we see is obstructionism at its worst. I have yet to hear them 
say: Let our conscience come out here and say we ought to cover these 
people, that we ought to make sure health care is affordable.
  The night I was brought into the hospital and was so fortunate enough 
to have the health care coverage I had, during the days of recovery I 
thought: What would happen if I was 40 years younger, had two or three 
kids, had no health care coverage, and I came in, in this kind of 
critical condition? The chances of my walking out of that hospital 
would have been very low.
  So I say to my friends on the other side, they are not bad people, 
they are just totally wrong. They don't want to say that a young person 
can join their family's affordable health care insurance. They don't 
want to encourage people to find insurance that is affordable through 
the exchanges that are provided. They don't want to permit people who 
are there without coverage, who would force their way into an emergency 
room, perhaps, and say: Look, I am very ill. I have no pep. I feel 
terrible. Take care of me. Yes? Take a number like you do in a 
supermarket. You are No. 32. We will get to you. Don't worry about it.
  Well, I worry about it because I know a different kind of America. I 
know an America that was there for me when I needed an education. I 
know an America that is there for people. I get letters from them all 
the time that say thank you for helping us to be able to afford a 
better education. Thank you for the things you can do.
  I say to my colleagues on the other side: Open up. Tell the truth. If 
you don't want to give those people affordable coverage, then throw in 
the coverage you have. Throw in your policy. When you say no to the 32 
million people, say: I mean it when I say no. I am giving up my 
coverage similar to those people out there. Tell the truth about how 
you feel about the people who stand there without coverage, worrying 
every day whether an illness is going to rob them of their jobs, of 
their opportunity to perform their parental duties or any duties. That 
is what ought to happen. Stand. Vote no, vote no against anything that 
improves or might improve this insurance and say: No, I mean it when I 
say no. I mean it. I am willing to give up the coverage I and my family 
have.
  I am talking to the Senators on the other side. Say no and mean no. 
But mean it for yourselves as well as the people outside who are 
begging for the coverage.
  I thank the Chair.
  Mr. BAUCUS. Mr. President, I thank my good friend from New Jersey. I 
am reminded how he led the fight years ago to stop cigarette smoking in 
airlines. I was so pleased when he did that. I know many millions of 
Americans who are still pleased. It was he who did it.
  I yield 10 minutes to the Senator from Oregon, a big leader in health 
care reform. He has been working health care reform as long as I can 
remember. I thank the Senator from Oregon.
  The ACTING PRESIDENT pro tempore. The Senator from Oregon is 
recognized for 10 minutes.
  Mr. WYDEN. Before he leaves the floor, let me echo the praise for our 
friend from New Jersey, who has prosecuted the case against cigarettes 
for so many years. We are thankful to him. What a strong advocate he 
is.
  I thank the chairman as well for all his efforts. I wish to highlight 
a couple provisions he and I worked on together that speak to the 
headlines we are seeing in this morning's newspaper; in particular, the 
provision he and I partnered on that allows States to innovate and take 
their own fresh approaches in terms of addressing health care 
challenges. We all read today about how roughly a dozen States are

[[Page S1969]]

already challenging the important, recently-signed health care law on 
the grounds that the individual mandate is unconstitutional. He and I 
worked very closely together to ensure that States could have a waiver 
to, in effect, go out and set up their own approach. In fact, counsel 
to the Senate Finance Committee specifically said, in response to our 
questions during the markup of health reform, that if a State could 
meet the general framework of our legislation, it did not have to do it 
with an individual mandate.
  I thank the chairman for stepping up and empowering the States. I 
want the country to know that under the legislation Chairman Baucus 
worked on with me, every State does not have to litigate. They can 
innovate. They can go out and look at fresh approaches to address our 
health care challenges. That would include doing health reform without 
an individual mandate. I have followed the discussion on the floor over 
the last couple days about how somehow reform would Europeanize the 
health care system. On the contrary, what Chairman Baucus has done, 
with Section 1332 of the health reform bill, similar to what I sought 
to do in the legislation I drafted that had bipartisan support, is to 
send a message to all the States all across the country that we invite 
them to come up with the kind of fresh, creative ideas that are going 
to help us hold health care costs down. In fact, the chairman and I 
spent a lot of time trying to make sure States could tailor their own 
health insurance exchanges, which would be fresh marketplaces, so that, 
for example, an approach in Montana or Oregon that folks there thought 
made sense, could be entirely different than a strategy New York would 
try on its own. Not only is section 1332 a provision that allows for 
State innovation, but, as the chairman knows, there is also another 
approach that our colleague Senator Cantwell came up with that advances 
similar State innovation, allowing States to set up a basic health care 
plan.

  So my message to these States talking about litigating right now is, 
why would you say at this point you are going to go out and go to court 
and sue everybody in sight when, in fact, what the President signed 
yesterday gives the States the authority to come up with their own 
approach? Senate Finance Committee counsel is on record as saying that 
States could pursue their own approach without an individual mandate. I 
hope--given the amount of attention that is being paid this afternoon 
to the question of States filing these lawsuits, alleging the law is 
unconstitutional because of the individual mandate--I hope some of 
those States will take a look at section 1332 that, in my view, ought 
to be attractive to elected officials all across the political spectrum 
who share the view Chairman Baucus and I share; which is, we would like 
to empower the States.
  Another area where innovation is encouraged to occur is the Medicare 
Advantage provision in our legislation. We have had a lot of discussion 
on the floor about Medicare Advantage. Having been involved with this 
program for a number of years, and its predecessors during the days 
when I was codirector of the Gray Panthers, I wish to offer up to 
colleagues that not all Medicare Advantage is created equal. Two years 
ago, we heard testimony in the Senate Finance Committee about some 
Medicare Advantage products that, as far as I am concerned, are so 
shoddy and so devoid of consumer protection the people who sold them 
ought to be in jail. We have taken steps to add consumer protection to 
the Medicare Advantage Program.
  On the other hand, there are very good Medicare Advantage Programs in 
our part of the country that have been able to win recognition from the 
Federal Government as high quality plans. In fact, under this 
legislation, plans that have earned a high quality rating from the 
Federal Government on the basis of, for example, how they manage 
chronic conditions, the kinds of screenings they do of a preventive 
nature, and their responsiveness to member complaints, when they get a 
high rating from the Federal Government on the basis of such criteria 
and earn those extra stars, they will get bonus payments. This was an 
idea the Chairman worked closely with me on when the legislation was 
advanced by the Finance Committee.
  We will probably have further discussions on the floor about Medicare 
Advantage, but I only come to the floor today to say--for those who are 
interested in promoting quality; for those who believe that no matter 
how much you do to contain costs, you also have to beef up quality--
take a look at the work that was done with respect to Medicare 
Advantage. It acknowledges that not all Medicare Advantage is created 
equal.
  (Mr. MERKLEY assumed the Chair.)
  Mr. WYDEN. The Presiding Officer in the Senate, who has just joined 
us, knows that our home State has the largest percentage of folks in 
Medicare Advantage than any other State in the United States: over 40 
percent. They happen to be in good plans with those high ratings I 
mentioned from the Federal Government. So clearly, our States with high 
quality are going to be appreciative of this. But so will all the other 
programs across the land that have similar ratings, and we will have 
created an incentive for all of those other Medicare Advantage Programs 
in the years ahead to meet our standards.
  I come to the floor briefly this afternoon to point out these two 
provisions in the bill that promote quality and innovation. First, I 
hope States will use the provision that creates incentives for them to 
innovate. Our message ought to be innovate rather than litigate. I hope 
attorneys general will remember that in the days and weeks ahead.
  Second, I hope colleagues will look at the new incentives in this 
legislation to promote quality in the Medicare Advantage program and 
beyond because I believe those two provisions in this legislation--that 
encourage State innovation, that promote quality in the Medicare 
Program--ought to be widely supported by colleagues on both sides of 
the aisle in the days ahead.
  That is, in my view, the kind of approach that can bring the American 
people together and help us implement this law in a fashion that is in 
line with what Americans want: good quality, affordable care, and 
reform that works for them.
  Mr. Chairman, I thank you for this time and particularly for your 
help on those two provisions that I think ought to appeal to both 
Republicans and Democrats in the days ahead.
  Mr. BAUCUS. I thank the Senator very much.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Might I inquire, Mr. President, how much time remains on 
this side for this block?
  The PRESIDING OFFICER. Fifteen minutes.
  Mr. BAUCUS. I thank the Chair.
  Mr. President, I yield 10 minutes--5 minutes--to the Senator from 
Colorado.
  The PRESIDING OFFICER. The Senator from Colorado.
  Mr. BENNET. Thank you, Mr. President. I say thank you to the Senator 
from Montana for his generosity. I will not take 10 minutes. I know the 
Senator from Pennsylvania is here.
  Mr. President, I stand here today for the millions of Coloradans and 
American families who are sick and tired of the name calling, the 
bickering, and the partisanship in Washington.
  I am here today for over 800,000 uninsured Coloradans who will now 
have a fighting chance to get the health care they need.
  I am here for the 1.2 million Coloradan children who will never again 
be at risk of being denied coverage because they have a preexisting 
condition.
  I am here for the 70,000 small businesses that will get a tax cut to 
provide health insurance, so they do not have to make the terrible 
choice between providing health care coverage for their employees and 
keeping their doors open.
  I am here for the hundreds of thousands of seniors who depend on 
Medicare and expect us to protect and preserve it for generations to 
come.
  We have passed a bill that makes our country more competitive, ends 
insurance company abuses, gives people more coverage, and starts 
putting our country on a more sound fiscal footing for the next 20 
years.
  I join those on this side of the aisle and on the other side of the 
aisle who have said this is not a perfect piece of legislation. No 
piece of legislation is perfect. But it is a great first step for the 
reasons I said.

[[Page S1970]]

  The nonpartisan Congressional Budget Office has confirmed a $143 
billion reduction in the Federal deficit over 10 years, as a 
consequence of our passing this legislation, and a $1.2 trillion 
reduction in the first 20 years.
  Now we need to pass this reconciliation bill--a bill that gets rid of 
the special deals I spoke out against at the end of the year, a bill 
that makes sure our seniors can afford the prescription drugs they 
need, a bill that covers more people in my State of Colorado.
  But the insurance companies and the special interests have not given 
up. The defenders of the status quo are still at it. Put simply, to 
amend the bill is to kill this bill. The only reason we are going 
through this process is because opponents of health care reform want to 
kill the bill. Now is not the time to play games with the lives of 
thousands of Coloradans and millions of Americans, and I will not do 
it.
  There are also some who are well intentioned and want to amend this 
bill to include a public option. I am and have been a strong proponent 
of a public option and, like a lot of people, have taken a lot of heat 
for it. I am not sure why because everywhere I went in Colorado people 
said to me: Michael, if you are going to require us to have insurance, 
we want as many choices as possible for our family. Please don't force 
us into this private insurance if there are other options out there.

  A lot of us did all we could to convince the House to include it in 
this bill, and we were disappointed when they did not. We are going to 
continue to fight for it until we get a vote. We will have our vote on 
a public option. But I will not risk the well-being of Coloradans to do 
it, and I will not play into the hands of those who want to kill the 
bill.
  So today I stand with many of my colleagues, with the American 
Diabetes Association, the American Hospice Foundation, the Autism 
Society, Doctors for America, Easter Seals, and the National Alliance 
on Mental Illness, along with over 150 organizations that want us to 
pass this bill as well. I stand with AARP which knows that changing 
this bill now will put seniors at risk.
  But more important than all of that, I stand with the people of 
Colorado who expect more from their government and who want more for 
their children and grandchildren than politics and name calling.
  I urge all of my colleagues to pass reconciliation and send this bill 
to the President's desk.
  I yield the floor.
  Thank you, Mr. President.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I yield the remainder of the time to the 
Senator from Pennsylvania, Mr. Casey.
  The PRESIDING OFFICER. The Senator from Pennsylvania.
  Mr. CASEY. Mr. President, I am grateful for this opportunity to speak 
about health care. I commend our chairman, Senator Baucus, for his 
great leadership in the Finance Committee and on so many other 
important issues we have been wrestling with with regard to health 
care.
  We have had a chance over many months now--and even as we speak 
today--to talk about a lot of the policy of the bill the President 
signed into law, our health care bill we passed here in the Senate, 
and, of course, the policy contained in the bill we are considering 
now. But sometimes it is important for us to step back and talk about 
some--not all--but a few examples of some of the real people out there 
on whom this legislation will have an impact.
  I have spoken a number of times about Trisha Urban from Berks County, 
PA--all the problems she and her family had with their health care: 
denied coverage because of a preexisting condition, running into 
problems when the insurance company dropped coverage. Her husband died 
in the process. And the same day he died, her daughter was born. I have 
told that story a number of times, and I will tell it again.
  I also want to highlight what has happened to another family, the 
Ritter family from Manheim, PA, Lancaster County. The family has two 
young girls whom I have met. I met them in 2009. As children, these two 
little girls, Hannah and Madeline Ritter, hit their lifetime cap on 
their cancer treatment before they completed their course of treatment. 
When they hit this cap, they were 4 years old, these two Ritter twins. 
If that is not proof that comprehensive health reform is needed now, I 
do not know what more we can say.
  We are very happy the President signed into law the bill we passed in 
December. Now the health care reform is the law of the land. The Ritter 
twins--Hannah and Madeline Ritter--will not have to worry about how to 
get or keep health insurance coverage throughout their lives because, 
in 2010, strong consumer protections will go into effect. Not only will 
these protections ensure that these two little girls--Hannah and 
Madeline--not only will it ensure they can have access to the medical 
care they need to grow up healthy, but also they will be able to reap 
the benefits of other parts of this bill.
  This bill will also help hard-working insured Americans from having 
to declare bankruptcy due to medical bills, as the Ritter family of 
Manheim, PA, had to do at one point. I do not have the time in this 
segment to be able to tell their whole story, but suffice it to say, in 
addition to the nightmare their daughters lived through, the family had 
to declare bankruptcy.
  But some highlights of what this bill means to real families: Health 
insurance reform puts American families and small business owners--not 
their insurance companies--in control of their own health care.
  Secondly, this bill makes health insurance affordable for middle-
class families and small businesses--one of the largest tax cuts in 
history--reducing premiums and out-of-pocket costs.
  Third, it holds insurance companies accountable, at long last, to 
keep premiums down and prevent denial of care and coverage, including 
for preexisting conditions.
  No. 4, this legislation improves Medicare benefits with lower 
prescription drug costs for those in the doughnut hole, better chronic 
care, free prevention care, and nearly a decade more of solvency for 
Medicare.
  Finally, No. 5--and this is not a comprehensive summary but one more 
point--this legislation reduces the deficit, according to the 
Congressional Budget Office, by $143 billion over the next 10 years. If 
you look at the 10 years after that, 20 years in total, it is well over 
$1 trillion.
  So this is a bill, and this is legislation, whose time has come. At a 
time when our State--in Pennsylvania, where we have 577,000 people out 
of work, almost a record number of people out of work in Pennsylvania--
we have to make sure that one of the things we put in place is a more 
secure health care system for workers and their families.
  We all have heard the list of provisions that will go into effect 
right away. Small businesses will have access to--have the eligibility, 
I should say--for tax credits. Some companies will get credits up to 35 
percent of the dollars they spend on premiums. The Federal Government 
will be investing in community health centers even in greater amounts 
than the Federal Government does now. Older citizens would not be 
affected by the doughnut hole problem where they have to pay the whole 
freight for prescription drug costs for several thousands of dollars' 
worth of care. They are going to get relief from that. In 3 months' 
time--3 months from yesterday--people with preexisting conditions will 
be able to get help from a high-risk pool, a special fund to help them 
in that crisis.
  As we know, in 6 months--in September--children will have the full 
legal protection in new insurance plans for denials of coverage--or I 
should say against denials of coverage--for a preexisting condition.
  So for all of those reasons and more, whether we are thinking about 
the problem that Trisha Urban and her family had before and certainly 
after her husband's death, or the Ritter twins, Hannah and Madeline 
Ritter, we hope more families have the benefit of the protections in 
this bill. We know one thing. We know small businesses across the 
country are starting to get a sense now of what this will mean in terms 
of helping them with the tax credit, helping their employees with the 
critically important issue of health care.
  Mr. President, I yield the floor and note the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.

[[Page S1971]]

  The assistant legislative clerk proceeded to call the roll.
  Mr. GREGG. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. GREGG. Mr. President, I believe the Senator from Tennessee is 
here and ready to speak.
  The PRESIDING OFFICER. The Senator from Tennessee.
  Mr. CORKER. Mr. President, I might meditate for about 60 seconds and 
step back up. I now notice the absence of a quorum, unless I should 
give it to the other side.
  Mr. GREGG. No. If the Senator is not ready to speak, I will speak.
  The PRESIDING OFFICER. The Senator from New Hampshire.
  Mr. GREGG. The Senator from Tennessee is going to offer an amendment 
in a second, and I will follow him with an amendment. I wish to 
highlight what my amendment will do as we are waiting.
  One of the extraordinary shell games that is played under this bill 
in the ``Alice in Wonderland'' claim that this bill is paid for is the 
fact that the doctors will receive a $285 billion cut in their 
reimbursements if this bill goes forward in its present form. We all 
know that is not going to happen. So at some point there is going to 
have to be a doctors fix, which means $285 billion not accounted for in 
this bill will have to be spent over the next 10 years. Of course, if 
they had included this in the bill--this fact that doctors are being 
underreimbursed and that we are going to correct this; this is called 
the doctor fix, and we do it every year on an annual basis--if they had 
included it in the bill, as they should have because this is, after 
all, called health care reform, then the bill would have been in 
deficit even under the gamesmanship played by the Democratic Party on 
this bill.
  Remember, the way they got a surplus in this bill in the first 10 
years was they took 10 years of spending cuts, 10 years of revenues, 
and matched them against 6 years--6 years--of programmatic 
expenditures. So they were able to get a surplus, and CBO has to score 
what is given to them. If you are given phony ideas, you have to score 
them. In any event, what CBO was not asked to score as part of this 
health care, because there was no attempt to correct it, and even 
though it is the essence of health care, is how do you correct the 
reimbursed doctors.
  So after the Senator from Tennessee proceeds, and I think he may be 
ready to proceed at this time, I am going to offer an amendment for a 
doctors fix so that this bill will address that issue which is, 
obviously, one of the core issues on the question of health care reform 
around here.
  So I will reserve now on that issue and turn to the Senator from 
Tennessee who I see is ready to proceed.
  The PRESIDING OFFICER. The Senator from Tennessee.
  Mr. CORKER. Mr. President, I wish to thank the Senator from New 
Hampshire who I think has offered extraordinary leadership on this 
issue and on the issues regarding our country's huge amount of 
indebtedness. As does Senator Gregg, I find it hard to believe that we 
are taking over $500 billion in savings from Medicare, as he just 
mentioned, to leverage a new entitlement when we know that Medicare 
itself has a $37 trillion unfunded liability. As he mentioned, we go 
further by not even dealing with this doc fix which he was just 
discussing.
  I look forward to his amendment, I look forward to supporting it, and 
I thank him for his leadership.
  I wish to speak today about unfunded liabilities. I was the mayor of 
a city. I know the Presiding Officer served in the general assembly in 
the State from where he comes. I was the commissioner of finance for 
our State where we dealt with all of our financial issues for the State 
of Tennessee. I know Senator Gregg was a Governor.
  One of the things that I think bothered all of us who used to serve 
at the city and State levels was unfunded mandates. It is an incredible 
thing where Washington will pass a piece of legislation and, by the 
way, have a major signing ceremony where everybody is patting each 
other on the back and celebrating that they just passed something, and 
the part that is left out is that the States across this country are 
left with a huge unfunded mandate.
  We have a very good Governor in our State. His name is Phil Bredesen. 
He is a Democrat. He has spent a lifetime in health care. He has 
handled our State's finances very well. He called me on Friday with a 
sense of tremendous concern in his voice talking about the fact that 
this bill was going to cause the State of Tennessee, which is already 
experiencing huge tuition increases--we have all kinds of services 
there that we are having difficulties dealing with--and this bill is 
going to create a $1.1 billion unfunded liability for the State of 
Tennessee. I just find it hard to believe that, again, knowing the 
stress our States around this country are dealing with, we are passing 
legislation that puts in place a $1.1 billion unfunded mandate on the 
State of Tennessee.
  But let me go a step further. This bill also violates something we 
thought was sacrosanct around here and that was the Unfunded Mandates 
Reform Act, which basically said that we acknowledge--most of us have 
come from other places, served in local and State governments, and we 
acknowledge that we should not be passing legislation that creates 
unfunded mandates. We shouldn't be patting ourselves on the back, 
passing legislation that we say is good for the people back home, and 
then sending the tab there.
  So this bill violates that. I think everybody in this body knows it 
violates that. So it is just kind of, yes, we said we didn't want to 
deal inappropriately with States, but we decided we wanted to pass 
health care reform, and we are going to do it.
  Let me come to the one that I find most fascinating. Senator Gregg 
was just talking about the fact that we have this 21-percent cut coming 
for physicians who treat Medicare recipients, and instead of taking the 
Medicare savings that we found in this bill and using that to make sure 
these physicians are paid, we are not going to do that. So in a short 
time, without us taking, again, emergency action--$200 billion or so--
these physicians are going to have a cut.
  Let me tell my colleagues what we are doing in this bill, and I think 
the Presiding Officer may already know this, but in addition to 
creating in our State a $1.1 billion unfunded mandate, we are going to 
pay physicians who treat Medicaid recipients at the same level as, if 
you are a primary care physician, as Medicare reimbursements are today, 
but we are going to do that for 2 years.
  Now, this is like the worst joke ever that we can play on our States. 
What we are saying is, we are going to mandate to the States that the 
primary care physicians who treat Medicaid recipients, their rate has 
to be jacked up, and we are going to provide the money for that for 2 
years, but then that drops off. So not only do we have this issue of 
the unfunded mandate, we are creating that exact cliff issue for States 
in this bill, which means that after this 2-year period ends--after 
this 2-year period ends and we have given them the money to pay these 
physicians at Medicare rates instead of Medicaid, which is much lower--
we are going to cut off the funding.
  So the State is going to be in the position, obviously, of having to 
keep that up. It is like the worst joke ever.
  I don't know how we can come up with legislation such as this and 
call it reform. I said this before. Half the people who are going to be 
receiving health insurance after this bill passes are going on a 
Medicaid Program.

  There was a bill in the Senate that Senators Wyden and Bennett worked 
on together. It had some flaws. It would have been an interesting 
starting place, though, and that bill did away with Medicaid and caused 
Medicaid recipients to have the same kind of health care that you and I 
have. What we have done in this bill instead of that--instead of 
focusing on cost--we are going to put half of the new recipients in a 
program that none of us--none of us--would want to be in, and we are 
calling that health care reform.
  So I do plan later to offer an amendment to deal with this issue of 
unfunded mandates. I think it is wrong for us as a country to have 
people in Federal office who push their desires off on people and then 
call them to pick up the tab. I was a mayor. I was a commissioner of 
finance. The Presiding Officer served in the general assembly. Senator 
Gregg served as a Governor.

[[Page S1972]]

We know that is wrong. I don't know why we are doing it. I plan to 
offer an amendment to correct it.
  Mr. President, I thank you for the time, and I note the absence of a 
quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. GREGG. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                           Amendment No. 3651

  Mr. GREGG. The States don't have the elasticity the Federal 
Government has, which we will not have much longer, by the way, as a 
result of passing this bill specifically because our debt is growing so 
fast that it is going to be very hard for us 5 or 6 years from now to 
be able to sell our debt at a reasonable price, in my opinion, and we 
are going to find that maybe some people don't even want to buy our 
debt.
  There was a very significant event this week when it was determined 
that the debt issued by Warren Buffett was going out at a lower cost 
than the debt issued by the United States of America. That is the first 
time that anybody can remember something like that, and that is a very 
clear statement by the markets that they are getting very worried about 
how much deficit and debt this government is running up.
  Now we pass this bill which adds $2.6 trillion to the spending of the 
U.S. Government and alleges it is paid for, but we know it is not going 
to be, and creates new entitlement programs which we know would not be 
fully funded. Even if it were paid for, it takes resources which should 
be used to reduce the debt, especially in the area of making Medicare 
more solvent, and uses them to expand new programs.
  This event, as I have described it, is an astroid of debt headed at 
our country. The simple fact is, it is going to have an effect. The 
effect will be that we will have more difficulty selling our debt, the 
deficits and debt we pass on to our children will be extraordinary, and 
their ability to have a higher standard of living will be reduced as a 
result of that.
  But the point, of course, is this bill, on top of all of the other 
egregious things it does in the area of fiscal policy--of running up 
debt and creating a massive government that we can't afford, being 
intrusive in everybody's health care delivery system, undermining the 
ability of small businesses to offer insurance, raising premiums, 
raising taxes on people not only earning more than $200,000 but earning 
less than $200,000, replete with special deals--on top of all of that, 
this bill, as Senator Corker said, puts pressure on the States and 
local communities.
  It asks them to spend money which they did not want to spend and 
which is not reimbursed. That is not fair. It is called unfunded 
mandates. It is inappropriate. We actually have a law around here that 
this bill basically runs over that says we will not do that.
  As I said earlier, another thing this bill does, which I find 
extraordinary, is it does not address one of the elephants in the room 
relative to the cost of health care in this country, which is the fact 
that we are not adequately reimbursing our doctors; that our doctors 
are going to receive a $285 billion cut over the next 10 years, a $65 
billion cut over the next 3 years unless we correct that. This is from 
basically a freeze level of reimbursement.
  Every year we adjust that payment so doctors do get their money they 
deserve or at least some portion of it in that we do not keep up with 
inflation. But this bill, which is supposed to be a comprehensive 
resolution of health care, leaves the doctors out in the cold. It means 
every year they are going to have to come hat in hand, one more time, 
asking for something they should not have to ask for, which is a fair 
reimbursement for their services.
  We will every year, hopefully, address it. But it is not right that 
we have a bill that does not even account for that.
  Why was it not put in? It was not put in because if it had been put 
in, this bill could not meet the budgetary rules that give it the 
special protection that allows it to come to the floor of the Senate, 
and it would have been in deficit, at least over the first 10 years, by 
$100 billion, even using the gamesmanship scoring the other side of the 
aisle has used relative to the big bill.
  This is not fair to the doctors. The doctors deserve better than 
this. We should correct this right now as part of this process. This 
trailer bill has the title ``fix-it bill'' on it. One thing we should 
definitely fix is the fact the doctors are getting shortchanged. So 
let's fix it. That is what my amendment does.
  My amendment says: OK, this bill alleges it generates a surplus. 
Let's use part of that surplus to make the doctors whole for the next 3 
years. It is a paid-for amendment. I cannot imagine anybody would want 
to oppose this amendment. After all, after we complete this bill--
immediately after we complete this bill--we are going to do, I believe 
it is a 1-month extension to try to correct the doctor problem. How 
inconsistent, how fundamentally hypocritical is it for us to pass a 
major health care reform bill, and then in the next breath--literally 
the next breath--within the next 24 hours, this body will take up a 
bill to give a 1-month extension to the doctors fix. I think it is 1 
month. That is not right. Let's do it now. Let's do it in this bill. 
Let's do the doctors fix. I have come up with a proposal that will take 
care of the doctors in a fair and forthright manner for 3 years.
  That is my amendment. I am not sure if it is at the desk or whether I 
have to send it to the desk.
  I send my amendment to the desk.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from New Hampshire [Mr. Gregg] proposes an 
     amendment numbered 3651.

  Mr. GREGG. Mr. President, I ask unanimous consent that the reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

 (Purpose: To provide for a long-term fix to the Medicare sustainable 
      growth rate formula in order to improve access for Medicare 
                             beneficiaries)

       On page 61, between lines 3 and 4, insert the following:

     SEC. __. INCREASE IN THE MEDICARE PHYSICIAN PAYMENT UPDATE 
                   FOR THE LAST 9 MONTHS OF 2010 AND ALL OF 2011 
                   THROUGH 2013.

       Paragraph (1) of section 1848(d) of the Social Security 
     Act, as added by section 1011(a) of the Department of Defense 
     Appropriations Act, 2010 (Public Law 111-118) and as amended 
     by section 5 of the Temporary Extension Act of 2010 (Public 
     Law 111-144), is amended to read as follows:
       ``(10) Update for 2010 through 2013.--
       ``(A) In general.--Subject to paragraphs (7)(B), (8)(B), 
     and (9)(B), in lieu of the update to the single conversion 
     factor established in paragraph (1)(C) that would otherwise 
     apply for each of 2010, 2011, 2012, and 2013, the update to 
     the single conversion factor shall be 0 percent for such 
     years.
       ``(B) No effect on computation of conversion factor for 
     2014 and subsequent years.--The conversion factor under this 
     subsection shall be computed under paragraph (1)(A) for 2014 
     and subsequent years as if subparagraph (A) had never 
     applied.''.

  Mr. GREGG. Mr. President, let me summarize it again. We know the 
doctors are being shortchanged. They deserve fair treatment. It is 
pretty obvious that if we are going to do a health care reform bill, 
the proper place to correct the doctor issue of reimbursement is in 
that bill, not the next day in a short-term extension.
  This is a forthright and fully paid-for attempt--and if it is passed 
it will occur--to reimburse the doctors at a fair rate for the next 3 
years and correct what is known as the SGR problem relative to doctor 
reimbursement.
  I cannot understand why we would not want to do something such as 
this.
  I see the Senator from North Carolina. I will be happy to yield to 
him for any thoughts he may have on this amendment or the Senator from 
Oklahoma.
  The PRESIDING OFFICER. The Senator from North Carolina.
  Mr. BURR. Mr. President, I wish to reiterate the fact that this 
should be part of health care reform. It is not. It is shocking that we 
would have something of this magnitude that is not fixed in a reform 
bill. We have an opportunity in a bill that has now come before us, 
which is to fix the things they missed in the health care bill, to 
provide a 3-year comfort on the part of physicians around the country 
that their reimbursements are not going to

[[Page S1973]]

be cut. They are targeted for 21 percent. It expires March 31. There is 
not a more appropriate time than right now.
  What a lot of us have said is: Let's pay for it. Let's simply pay for 
it. Enough is enough on spending money we do not have. Here is an 
excellent opportunity, where we have savings from the health care 
reform bill that we can now pump back in to pay for the fix to the 
sustainable growth rate about which the doctors have been under the 
gun.
  We have extended it every 30 days for some time without paying for 
it. Here is a real opportunity in a bill that is designed specifically 
to fix things that were missed in the health care bill.
  I thank my colleague, Senator Gregg, for understanding the importance 
of this issue and working up an amendment but, more importantly, saying 
to every physician in America: We can finally fix this, we can do it 
with money that is paid for and, more importantly, we can take you out 
of the box of this horror story of wondering what your reimbursement 
for services is going to be at any given point in time in the future.
  Let's seize this opportunity in this bill and fix this sustainable 
growth rate.
  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. COBURN. Mr. President, what needs to be fixed in this bill is a 
whole lot more than that, but this is a great attempt to try to solve a 
problem.
  Let me describe a scenario, what is getting ready to happen. Every 
State is cutting Medicaid reimbursement. We are going to add 16 million 
people to Medicaid. We cannot get them all seen now. Then we have a 
doctor cut that is coming to 21 percent for people who are under 
Medicare. What is going to happen? What do you think the average 
physician in this country is going to do? I can tell you that they are 
going to do three things: Fewer will see Medicaid patients so there 
will be fewer doctors taking Medicaid at the time we increase the 
enrollment by 50 percent. That is No. 1.
  No. 2, fewer doctors are going to take Medicare as we have this 
ballooning increase of baby boomers going into Medicare.
  No. 3--and this is probably more important than anything--we are 
going to see a large percentage of doctors, with this bill passed with 
no continuity as to how they are ever going to get funded under 
Medicare, quit. They are going to quit. They can take their training, 
their effort, their education and knowledge and apply it in some other 
field of endeavor and not have to live with the hassle of a 21-percent 
cut hanging over their head.
  Even if we fix it for 3 years, 3 years from now the same problem is 
going to come up, except it is going to be worse. So there is no fix in 
it. There is an unrecognized $300 billion to get doctors even, let 
alone take away the cut--no increase--with this amendment. My hope 
would be we would fix this situation for 3 years.
  Mr. GREGG. Mr. President, I ask unanimous consent that we be able to 
participate in a colloquy on our side of the aisle.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. GREGG. Mr. President, I wish to ask the Senator from Oklahoma, 
who is obviously a physician and has an indepth knowledge of this 
issue, I heard the other side of the aisle say: There are no cuts to 
the benefits of people on Medicare. If you reduce doctor payments under 
Medicare 21 percent, don't you think that is going to affect what they 
receive? Technically, there will be no cut because they will still have 
the right to see a doctor. Is it not going to be hard to see a doctor 
because doctors will stop seeing them?
  Mr. COBURN. They are not going to find a doctor, and that is the 
whole problem. Whatever we see in the urban areas now, multiply it 
tenfold in the rural areas. We are going to increase eligibility for 
Medicaid to 133 percent of the poverty level, we are going to add 16 
million people to a system that is not handling the people who are in 
it today, so we are going to promise them: Here is your Medicaid.
  Now where is the care? It is not going to be there. There is not the 
available physicians in this country to care for 16 million new 
Medicaid patients.
  If we, in fact, do not fix long term the SGR, physicians are going to 
do one of two things. They are either going to completely quit seeing 
Medicaid and Medicare patients or they are going to retire. Quite 
frankly, physicians my age who are still practicing are not doing it 
for the money; they are doing it because they love the patients. But 
they are going to be forced to quit because they will not even be able 
to pay their overhead to care for those patients.
  Mr. BURR. If I may add to Dr. Coburn's comments and say, when you 
double the size of the Medicaid population, you are already forcing 
more doctors to say: I am not going to see Medicaid patients. But you 
are changing the payer mix. Every provider, every practice, every 
hospital is going to see more patients whose reimbursement is less. 
That is automatically going to affect Medicare right there because 
people are going to have to try to bring in more private pay, private 
insurance.
  Mr. COBURN. Will the Senator yield for a second?
  Mr. BURR. Absolutely.
  Mr. COBURN. What it is going to do is exacerbate the cost shifting 
going on with Medicare and Medicaid right now, which means insurance 
rates for everybody else in the country are going to go up.
  Mr. GREGG. I thought we were told insurance rates were not going to 
go up.
  Mr. COBURN. All I will tell you is, the best guess of CBO--wonderful 
people, but they can only make decisions within the parameters they are 
given. There is no question private insurance, individual and family 
insurance, is going to go up, but everybody else's is because we are 
going to increase the trend of cost shifting from government programs 
to the private sector.
  You are going to end up with three taxes. You will pay income taxes, 
you will pay a Medicare tax, and then you will pay a tax on your 
insurance--actually, you will pay four--and then you are going to pay 
higher health insurance premiums because the government does not cover 
the cost.

  Mr. GREGG. I assume that is not just going to be people with incomes 
over $200,000.
  Mr. COBURN. That is everybody in this country who has private 
insurance, either through their employer or the individual market.
  Mr. GREGG. Isn't it equally likely that a large number of small 
employers will get frustrated with the rate increases they are getting 
in order to support people on Medicaid that they will simply drop that 
and push their membership, their employees over into this new exchange?
  Mr. COBURN. Yes, they will pay the fee. They will pay the tax and say 
it is easier. Consequently, the young people in our country, because we 
do not have a big enough payment under the ``individual mandate,'' are 
going to say it is smarter for me to save my money, pay the fine, and 
not get insurance because when I get sick, I can get it. You are going 
to get what is called adverse selection, which is even going to drive 
the rates up further. Anybody 40 or older, watch out, your health 
insurance rates are getting ready to bloom.
  Mr. GREGG. We have basically a multiplier effect----
  Mr. COBURN. That is correct.
  Mr. GREGG. In the area of costs being driven up as a result of this 
new policy of adding a huge number of people to an uninsured system 
that cannot afford it right now, Medicaid. The costs are going to 
multiply on people in the private sector. The effect will be higher 
premiums, less opportunity for your employer to give you insurance and, 
in the end, a higher tax rate for you, Americans who are just working 
Americans, not people with high incomes.
  Mr. COBURN. And people who are not necessarily getting a subsidy.
  Mr. GREGG. Then they do not even take care of the doctors. They cut 
the doctors 21 percent on top of all this.
  Mr. COBURN. What happens to all this? What is the ultimate? The 
ultimate is failure of the insurance market.
  Mr. GREGG. That is the goal, isn't it?
  Mr. COBURN. That is the goal, so the government can control it all. I 
yield back.
  Mr. BURR. Let me add, if I may, to my good friend, Senator Gregg, 
even though some would choose not to have coverage and pay the fine, we 
have an

[[Page S1974]]

emergency room system that is obligated to see those individuals when 
they have traumatic care. For those who claim we have sorted out the 
system where the high-cost delivery of care does not exist, no, we have 
again exacerbated the problem.
  I think Senator Coburn hit on the key. As you try to handle the 
health care of individuals by limiting the reimbursement, whether that 
is the way we are limited in the problem you are trying to fix, whether 
we do it by shoving them into Medicaid, you have now cost shifted more 
money to the side causing greater inflation for the health care in this 
country.
  Mr. GREGG. The Senator is absolutely right. Isn't it true one of the 
ultimate cost shifts is to claim that the health care bill is fiscally 
responsible when it ignores the fact that the doctors are being cut by 
21 percent and does not even attempt to address that huge problem which 
represents $65 billion over 3 years?
  Mr. BURR. I have learned throughout this whole process to never try 
to figure out what promises have been made. But I know the promise we 
have made to physicians--to reimburse them fairly for the services they 
provide--and anything less than that jeopardizes the pool of health 
care professionals we have and eventually will affect the quality of 
care simply because if the pool is not big enough to handle the 
patients, the quality will suffer.
  Mr. GREGG. So I guess I would get on to the next question because it 
is pretty obvious we have to correct this problem with the physicians. 
In fact, as I understand it, the next bill immediately that we will 
consider will correct it for 30 days. Why wouldn't we correct it right 
now for 3 years, get that 3-year consistency in the system so 
physicians can have some confidence in their reimbursement rates, fully 
paid for? What possible, conceivable reason would there be not to vote 
for this type of amendment?
  Mr. BURR. Because the Senator from New Hampshire remembers this body 
did pass a bill that partially paid for an extension of this through 
September of this year. The problem was, when they passed the health 
care bill, they used the pay-fors out of that extension bill to be 
included in this health care bill. Now they have gone to a point that 
they just seek the 30-day renewals and claim it is an emergency. One, I 
don't think that passes the threshold of emergency. I think it should 
be paid for. And there is a legitimate way to pay for it and extend it 
for 3 years, where this Congress can fully understand the implications 
of the current health care bill as it is implemented and put back the 
comfort of physicians around this country and their trust back in the 
system.
  Mr. GREGG. Well, I think the Senator is absolutely right, but I would 
also suggest that maybe there is another reason they haven't paid for 
it in this bill or put the correction in this bill, which is that if 
they did that, the bill would fall because it would be out of 
compliance with the budget because it is a $285 billion cost over 10 
years. Therefore, aren't they sort of trying to pull the wool over 
somebody's eyes here? Aren't they trying to act as if this bill that we 
know exists for our doctors, that we are never going to pay for it? We 
are not going to pay; we are just going to act as if it doesn't exist? 
We know as soon as this bill is over, we will have to do something 
about it, at least for the next 30 days.
  Mr. BURR. You are absolutely right, it will be the first order of 
business when this bill is finished if we miss the opportunity to fix 
it in this bill and fix it for 3 years and actually fix it in a way 
that it is paid for.
  Mr. GREGG. I see the Senator from Arizona has arrived.
  Mr. McCAIN. Mr. President, I ask unanimous consent to be included in 
the colloquy.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. McCAIN. I would say to the Senator from New Hampshire that there 
is some recent information that I find hard to believe, but apparently 
it may be the case. As we go through this 2,733-page piece of 
legislation, the IRS may need up to $10 billion to administer the new 
health care program this decade, and it may need to hire as many as 
16,500 additional auditors, agents, and other employees to investigate 
and collect billions of new taxes from Americans. Is that possible, in 
this legislation, I would ask the Senator from New Hampshire?
  Mr. GREGG. The Senator is absolutely correct, and that does call into 
question the representation that this bill is not a tax increase on 
Americans that we need 16,000 new IRS agents to enforce it.
  Mr. McCAIN. At $10 billion to administer. That is probably 
believable, given what is in 2,733 pages.
  Mr. GREGG. Well, you are going to need one IRS person for everybody 
in America who doesn't have insurance, I guess, or however the ratio 
works out. Everybody has to buy insurance under this bill, and your 
local IRS agent is going to show up at your door to tell you that you 
better do it or else you will have to answer to the IRS.
  We know there are no new taxes in this bill because that has been 
represented to us a number of times.
  Mr. BURR. If I could add, it also adds some insight into how many 
people will choose not to have insurance and make themselves 
susceptible to the fine. The anticipation is the IRS is going to chase 
a lot of people to recover the fine.
  Mr. McCAIN. I would also finally add that perhaps we could get some 
indication--I think we should before we vote on passage of this bill--
as to how many new bureaucrats and bureaucracies there are going to be 
with 193 new boards and commissions and other layers of bureaucracy. I 
think the American people are owed at least a round figure as to how 
many new bureaucrats there are going to be to administer this program.
  I see the Senator from Montana, and I don't want to impede on what 
has been the agreed-upon rule here, but I did want to continue and say 
to my friends very quickly that I think there are several myths here 
that have to be refuted by the facts.
  One is that this legislation will result in a tax cut for the 
American people. I would say to my friend from New Hampshire, we have 
to rebut that in the next hour.
  The next myth is that the health care bill won't increase taxes on 
individuals with incomes under $250,000. The fact is, millions of 
Americans with incomes below $250,000 will pay higher taxes.
  Another myth: The legislation will reduce the growth of health 
costs--President Obama's stated goal for health reform--and premiums 
will go down. The fact is, national health expenditures and premiums 
will increase.
  Another myth: The legislation is deficit neutral. The fact is, 
commitment to health care spending under existing obligations increases 
the deficit.
  Myth: ``If you like the plan you have, you can keep it.'' Fact: 
Millions of Americans with coverage will lose their current coverage, 
including 330,000 citizens of my State who have the Medicare Advantage 
Program.
  Finally, the myth is that the law will provide immediate coverage for 
children with preexisting conditions. The fact is, children are not 
necessarily protected against discrimination for preexisting 
conditions.
  So I hope we have a chance, I would say to my friend from New 
Hampshire, to address the allegations about this legislation, and 
perhaps the first one is that legislation will result in a tax cut for 
the American people when the fact is that taxes will increase for 
millions of Americans.
  I would yield to my colleague from New Hampshire.
  Mr. GREGG. I thank the Senator from Arizona, who has been one of the 
most cogent and thoughtful speakers on the issue of what this bill 
really does. He has hit the nail on the head time and time again with 
his points. They are all absolutely accurate.
  Has the Senator completed his statement?
  Mr. McCAIN. Well, I just wanted to throw in here that perhaps one of 
the most egregious statements, and it is worth repeating, is this so-
called doc fix. They are using an assumption that we will cut 
physicians' fees by 21 percent sometime this fall in order to make up--
and please correct me if I am wrong--some $281 billion over 10 years, 
which we know is not going to happen. And the reason it is not going to 
happen is because doctors would refuse to take Medicare patients if 
they cut their reimbursement by some 21 percent.

[[Page S1975]]

  So this is one of the fundamental assumptions they are selling this 
on, is that it is deficit neutral when it is not.
  Mr. COBURN. If I may, I would like to add one other thing here. Think 
about it. We are talking about the cuts that are set to go. But since 
there is no tort reform in this bill, we spend $250 billion on 
defensive medicine and liability costs continue to rise. You could 
bring them back whole, but if you give them no increase, they are still 
going to quit seeing Medicare patients.
  One other point I would like to make is with the student loan program 
being totally taken over by the government, 31,800 people in this 
country this July will lose their jobs. So we are going to lose 31,800 
jobs in the private sector, but we will add 16,500 jobs at the IRS. I 
don't think anybody in America would like to see that happen.
  Mr. McCAIN. The CEO of Caterpillar wrote a letter saying that the 
taxes for Caterpillar would go up by $100 million next year. What does 
that do to Caterpillar? It obviously makes them either not hire or lay 
off individuals as they pay an additional $100 million. And I might 
point out, as we all know, Caterpillar's headquarters is in Peoria, IL.
  So, again, I would ask the Senator from New Hampshire, is this 
legislation deficit neutral?
  Mr. GREGG. No, it is not deficit neutral if you actually score the 
number of years of income against the number of years of expenditures 
or you include the doctors fix. Either one would throw this into a 
deficit-negative situation.
  Mr. McCAIN. Isn't that another of the great scams, that for 4 years 
the benefits are cut and the taxes are increased, and for most--not all 
but most--of this bill, none of the benefits really kick in until after 
4 years?
  Mr. GREGG. That is right.
  Mr. McCAIN. So when you score it, that is the way you make it deficit 
neutral over 10 years?
  Mr. GREGG. That is correct. And it is a bit of a scam, as you say.
  I am going to have to reserve the remainder of our time here for a 
moment, but I understand the Senator from North Carolina wants to bring 
up an amendment.


                           Amendment No. 3652

  Mr. BURR. Mr. President, I ask unanimous consent to temporarily set 
aside the pending motions and amendments so that I may offer an 
amendment that is at the desk.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The clerk will report.
  The bill clerk read as follows:

       The Senator from North Carolina [Mr. Burr] proposes an 
     amendment numbered 3652.

  Mr. BURR. Mr. President, I ask unanimous consent that the amendment 
be considered as read.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

 (Purpose: To protect the integrity of Department of Veterans Affairs 
  and Department of Defense health care programs for veterans, active-
duty service members, their families, widows and widowers, and orphans 
             who have sacrificed in defense of our Nation)

       At the end of subtitle F of title I, insert the following:

     SEC. 1__. TREATMENT OF DEPARTMENT OF VETERANS AFFAIRS AND 
                   DEPARTMENT OF DEFENSE HEALTH PROGRAMS.

       Subtitle G of title I of the Patient Protection and 
     Affordable Care Act is amended by adding at the end the 
     following new section:

     ``SEC. 1564. DEPARTMENT OF VETERANS AFFAIRS AND DEPARTMENT OF 
                   DEFENSE HEALTH PROGRAMS.

       ``(a) Clarifications With Respect to Certain Programs and 
     Authorities.--Nothing in this Act or in the amendments made 
     by this Act shall be construed as affecting any of the 
     following:
       ``(1) Any authority under title 38, United States Code.
       ``(2) Any authority under chapter 55 of title 10, United 
     States Code.
       ``(3) Any health care or health care benefit provided under 
     the TRICARE program under chapter 55 of title 10, United 
     States Code, or by the Secretary of Veterans Affairs under 
     the laws administered by such Secretary.
       ``(b) Clarification With Respect to Minimum Essential 
     Coverage.--For purposes of this Act and the amendments made 
     by this Act, the term `minimum essential coverage' includes 
     the following:
       ``(1) Coverage provided under chapter 55 of title 10, 
     United States Code.
       ``(2) Eligibility for health care provided by the Secretary 
     of Veterans Affairs under title 38, United States Code.''.

  Mr. BURR. Mr. President, I yield the floor, and I protect the 
remainder of the time.
  The PRESIDING OFFICER. Who yields time?
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, the debate on this bill is winding to a 
close, so let me return to the nonpartisan Congressional Budget Office.
  The Congressional Budget Office is the referee we all turn to as an 
impartial judge of whether we are accomplishing what we set out to do, 
so I will take a moment and quote from the Congressional Budget Office. 
It is very appropriate as it relates to the prior conversation on the 
other side. Let me read excerpts from the most recent Congressional 
Budget Office statement on deficits, debt, and coverage and whether 
this is deficit neutral. This was released Saturday. This is a 
statement by the Congressional Budget Office and the Joint Committee on 
Taxation. They are our scorekeepers. They determine how much we are 
spending and how much revenue we are taking in on legislation and what 
the net result is.
  Here are the highlights of the letter:

       Enacting both pieces of legislation--H.R. 3590--

  That is basically our Senate bill that passed the House and the 
President signed--

     --and the reconciliation proposal--would produce a net 
     reduction in Federal deficits of $143 billion over the 2010-
     2019 period.

  That is a direct quote from the CBO.
  Further quoting:

       Enacting H.R. 3590 by itself would yield a net reduction in 
     Federal deficits of $118 billion over the 2010-2019 period.

  Further quoting:

       The incremental effect of enacting the reconciliation 
     proposal would be an estimated net reduction in Federal 
     deficits of $25 billion during the 2010-2019 period over and 
     above the savings from enacting H.R. 3590 by itself.

  Further quoting CBO:

       The combined effect of enacting H.R. 3590 and the 
     reconciliation proposal would be to reduce the number of 
     nonelderly people who are uninsured by about 32 million 
     people. The share of legal nonelderly residents with 
     insurance coverage would rise from about 83 percent currently 
     to about 94 percent.

  CBO said of the new health care law:

       Enacting H.R. 3590 would reduce Federal budget deficits 
     over the ensuing decade--

  That is the next decade, the second decade--

     with a total effect during that decade in a broad range 
     between one-quarter percent and one-half percent of gross 
     domestic product.

  But what is more, CBO further said:

       The combined effect of enacting H.R. 3590 and the 
     reconciliation proposal would also be to reduce Federal 
     budget deficits over the ensuing decade . . . with a total 
     effect during that decade of a broad range around one-half 
     percent of GDP.

  I might add parenthetically, that is about $1.3 trillion.
  CBO continues:

       The incremental effect of enacting the reconciliation bill 
     over and above the effect of enacting H.R. 3590 by itself 
     would thus be to further reduce Federal budget deficits in 
     that decade, with an effect in a broad range between zero and 
     one-quarter percent of GDP.

  In other words, the new health care formula would accomplish major 
deficit reduction. This is the CBO talking, not Senators. Don't take my 
word for it. Don't take anyone else's word for it. This is the 
Congressional Budget Office. This reconciliation bill itself would 
accomplish major deficit reduction, probably the greatest deficit 
reduction actually we are going to take over a long period of time--the 
preceding perhaps 8, 9, 10 years and a subsequent period of time. We 
don't know that, but this is certainly major deficit reduction. 
Together, these two bills would accomplish deficit reduction of 
historic proportions.
  Let me continue to quote the letter from the Congressional Budget 
Office.

       [T]he reconciliation proposal would probably continue--

  Get this--

     to reduce deficit budget deficits relative to those under 
     subsequent decades. . . .

  Not just this period, not next decade but subsequent decades. This is 
my edit now. This means this bill continues to reduce the deficit in 
year after year after the second decade, according to the Congressional 
Budget Office.
  Finally, CBO says:

       In subsequent years, the effects of the provisions of the 
     two bills combined that would tend to decrease the federal 
     budgetary commitment to health care would grow faster

[[Page S1976]]

     than the effects of the provision that would increase it.

  Let me get to that statement. It gets to the Federal involvement in 
health care as a result of the consequences of this bill.

       In subsequent years the effect of the provisions of the two 
     bills combined that would tend to decrease the federal 
     budgetary commitment to health care would grow faster than 
     the effects of the provisions that would increase it.

  Further quoting:

       As a result, CBO expects that enacting both proposals would 
     generate a reduction in the federal budgetary commitment to 
     health care during the decade following the 10-year budget 
     window. . . .

  Even less government in the second 10 years relative to current law. 
In other words, CBO says that after the first decade, health care 
reform will reduce--yes, reduce--the budgetary role of government in 
the health care sector.
  Whom do we trust? Whom else are we going to listen to? We all have 
opinions. Those folks at CBO have sharp pencils. They are very good at 
what they do. They are nonpartisan. Nobody has ever suggested they are 
partisan. Nobody has ever questioned their professionalism. They are 
very good. This is what CBO says.
  That is it. CBO says health care reform cuts the deficit. Let me 
pause there and let that sink in. CBO says health care reform will cut 
the deficit. CBO also says it expands coverage. More people will get 
health insurance, from 83 percent to 94 percent. Also, this legislation 
reduces the Government's budgetary role in health care. It reduces it.
  That is quite a feat--more coverage, deficit reduction, and less 
Federal involvement in health care. I think this bill is pretty well 
designed to accomplish all those purposes--cuts cost, increases 
coverage, and reforms the health insurance market, most significantly 
in the individual market and also in the small group market.
  On another matter, I think it is relevant and important--this is a 
letter from AARP, dated March 24 of this year. It says:

       Dear Senator,
       We have made enormous progress advancing historic, urgently 
     needed health care reform legislation but we are not done 
     yet.

  This is from the AARP. Continuing:

       We now urge you to promptly pass the Health Care an 
     Education Affordability Reconciliation Act of 2010--without 
     amendments.

  Let me repeat that. AARP, in a letter dated March 24, strongly 
suggests the Congress, especially Senate, pass this legislation without 
amendments. Those are their own words, ``without amendments,'' in order 
``to help make affordable, high-quality health care available to all 
Americans.''
  The letter is much longer. I just wanted to quote the more salient 
provisions, where the AARP suggests amendments not be adopted so we can 
get reconciliation passed so we can implement the law which the 
President already signed and get health care to Americans who 
desperately need it and reform of the health care industry, which is 
desperately needed, and start getting control of health care costs, 
which is desperately needed.
  I ask unanimous consent the full letter be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

         AARP--Nancy A. LeaMond, Executive Vice President, AARP 
           Social Impact Group,
                                                   March 24, 2010.

       Dear Senator: We have made enormous progress advancing 
     historic, urgently needed health care reform legislation, but 
     we are not done yet. We now urge you to promptly pass the 
     Health Care and Education Affordability Reconciliation Act of 
     2010--without amendments--to help make affordable, high 
     quality health care available to all Americans.
       The Reconciliation Act will:
       1. Close Medicare's dreaded ``doughnut hole'' drug coverage 
     gap for all beneficiaries. This is a top priority for AARP 
     because it helps older Americans afford drugs they need to 
     stay healthy and avoid costlier treatments;
       2. Make coverage more affordable for hard-working middle-
     income families who now too often are uninsured because the 
     cost of coverage is beyond their modest means. Added help is 
     vital to meet the public's demand for coverage that is truly 
     affordable for all Americans;
       3. Further strengthen our fight against fraud, waste and 
     abuse, a key component to better controlling rising costs in 
     our health care system; and
       4. Improve Medicare's fiscal health and extend the solvency 
     of the Medicare Trust. Fund.
       These provisions build on the solid foundation of the 
     Patient Protection and Affordable Care Act that the Senate 
     passed in December. These two bills together will protect and 
     strengthen Medicare's guaranteed benefits, eliminate barriers 
     to prevention, and crack down on insurance company abuses, 
     such as denying affordable coverage because of age or health 
     status and setting arbitrary caps on how much care they will 
     cover. The legislative package will also provide affordable 
     coverage options to millions of Americans and small 
     businesses, help Americans to better plan for their future 
     long-term care needs, and receive services to help them 
     remain in their own homes and stay out of costly nursing 
     facilities.
       We, like you, hear countless stories from our members who 
     were denied coverage or cannot afford their prescriptions or 
     insurance premiums. Health care remains among the most 
     important and personal economic issues for the vast majority 
     of Americans.
       Health expenditures consume roughly one sixth of our 
     economy today, and will reach 20 percent in seven years if 
     current trends continue. These skyrocketing costs strain the 
     budgets of families and businesses as well as the 
     government--crowding out other priorities--as health care 
     costs continue to grow 2-3 times faster than general 
     inflation. That is why all the major health care stakeholders 
     have come to the table to solve this unsustainable situation.
       Delay will only mean more Medicare beneficiaries will not 
     be able to afford the drugs they need. Millions of our family 
     members and neighbors will not be able to afford the coverage 
     they need. Billions of additional dollars in uncompensated 
     care costs will unfairly shift to those who do have coverage. 
     More individuals will impoverish themselves to get the health 
     care they need. Skyrocketing costs will continue to strain 
     even more family, business, and government budgets.
       AARP therefore urges all Senators to vote in favor of the 
     Health Care and Education Affordability Reconciliation Act of 
     2010. Both the economic and physical health of our members, 
     their families, and our nation are at stake,
       Because AARP members have a strong interest in how their 
     elected officials vote on key issues, we will be informing 
     them about how their Senators vote on this important issue.
           Sincerely,
                                               Addison Barry Rand.

  Mr. GREGG. What is the time situation?
  The PRESIDING OFFICER (Mr. Franken). We have 27 minutes 51 seconds on 
the majority side and 35 minutes 42 seconds on the minority side.
  Mr. GREGG. Let me make two quick points. The only way CBO gets to the 
conclusions they reach, and they had to get to those conclusions, is 
because of the facts put before them. One of those facts, they have to 
presume Medicare is going to be cut $500 billion in the first years 
before full implementation, $1 trillion in the second 10 years during 
full implementation, and $3 trillion during the first 20 years of full 
implementation--$3 trillion.
  All that money is going to be taken out of Medicare and moved over to 
start new programs, new entitlements to benefit people who are not 
senior citizens and who, for the most part, have never paid into 
Medicare. That is a serious problem.
  You can score that positively if you wish, but first off I do not 
think it will happen. I think what will end up happening is, it will 
get put on our children's backs as debt. But second, if it does happen, 
it is wrong because Medicare has to be fixed and you are taking the 
money that should be used to fix it, if you believe in these types of 
cuts in Medicare, and you are spending them on a new entitlement.
  Mr. BAUCUS. Mr. President, may I ask my colleague a friendly 
question?
  Mr. GREGG. On your time you may ask a question, including my answer, 
which may take 24 minutes.
  Mr. BAUCUS. I trust in the good faith of the Senator from New 
Hampshire not to abuse the situation.
  As I understand it, basically the Senator does not question the 
professionalism of CBO. Clearly, CBO had all the facts. All Senators 
have them, all Senators, House Members, the whole world has. CBO has 
all the facts. You are not questioning their professionalism. You do 
question their conclusions.
  Mr. GREGG. I certainly don't question their professionalism. They are 
an extraordinarily good organization with a wonderful leader who is 
fair and unbiased. I don't question their conclusions because what they 
have to score is a fact pattern that was given them and

[[Page S1977]]

the fact pattern given them by this bill is, on its face, not 
believable relative to what is going to happen in the outyears, even 
though they have to score it as believable. It is a fantasy.
  Mr. McCAIN. I ask the Senator from New Hampshire, while the Senator 
from Montana is here, maybe it is a legitimate question. Does the 
Senator from Montana believe that the assumption given to the 
Congressional Budget Office that the so-called doc fix, reimbursement 
for physicians who treat Medicare patients, will be cut by 21 percent? 
The Senator from Montana knows full well the AMA has been told in no 
uncertain terms it will be fixed between now and when it is supposed to 
take effect because the fact is, as the Senator from Montana knows, you 
can cut Medicare physician reimbursement. Then doctors will not treat 
Medicare patients. So maybe the Senator from Montana would tell us if 
that was a valid assumption given to the CBO, that there would be some 
$281 billion that would be accrued because physicians' payments would 
be reduced by some 21 percent?
  Mr. GREGG. I simply ask the time of the Senator from Arizona come off 
ours and the time of the Senator from Montana for his answer come off 
his.
  Mr. BAUCUS. Mr. President, that sounds fair.
  Let me say to my good friend from Arizona, first of all, clearly this 
body, the Senate and the Congress, is going to not let the SGR problem 
expire; that is, doctors are not going to be cut 21 percent, whatever 
the rate is the first year or more and so on. That is not going to 
happen. First, from the seniors' point of view, second from the 
doctors' point of view, that is not going to happen. I do not want to 
take too much time on the subject, but the long and short of it simply 
is we are going to have to find a way, this Congress, to address that 
problem. If I might finish, it is not part of health care reform, and 
we will find a way. A question is going to be how much will be paid 
for. That is a judgment this body is going to have to make in the 
pretty near future.
  Mr. McCAIN. I appreciate very much the acknowledgment, on the part of 
the manager of the bill, that the assumption that provides us with 
deficit neutrality is not valid. That is the point we have been trying 
to make. It is based on false assumptions. The assumption that 
doctors--I am very happy to hear the Senator from Montana state 
unequivocally what was given and assumed by the CBO when they gave us 
our numbers is not true. So we will be voting, in a short period of 
time, on a piece of legislation which is based on false assumptions. I 
think that is an unfortunate circumstance.
  Mr. GREGG. I simply note the Senator from Montana made the case for 
my amendment rather eloquently because my amendment does address the 
doctors fix and it is paid for. Therefore, I certainly hope the Senator 
might consider voting for it.
  At this point, I yield 5 minutes to the Senator from Georgia.
  Mr. CHAMBLISS. I thank the Senator, from New Hampshire. Let me 
reiterate what just came out of this dialog and colloquy between the 
Senator from Montana and the Senator from Arizona. That is this. CBO 
has said this is going to be a deficit saver, a deficit reducer, and 
the President is going around the country talking about the fact that 
this bill is going to reduce the deficit.
  What the President is not going to say but what the Senator from 
Montana just agreed to, is the fact that our physicians who are due a 
21-percent decrease in Medicare reimbursement payments are not, in 
fact, going to have that 21-percent reduction. That decrease was 
included in this bill to make it appear more deficit-neutral over the 
first 10 years. When you factor that in, this not only does not reduce 
the deficit, but it adds to the deficit an additional $281 billion 
difference in what the number of the CBO says we are going to reduce 
the deficit by.
  You know very clearly we are going to add to the deficit when we pass 
this bill because the Senator from Montana is right, we are not going 
to see that 21-percent reduction. I suspect that the $523 billion in 
Medicare cuts that are provided for in this bill, that are scheduled to 
take effect in future years, may not ever happen. If that is the case, 
then not only are we looking at an additional cost of that $523 
billion, the $281 billion for the SGR fix or the doctors fix, but we 
are looking at increasing the deficit to fund a domestic program in a 
future way.
  One thing the CBO does say is, this bill provides an additional 
$569.2 billion in new taxes, new taxes on the American people, 
particularly the small business community that is hit the hardest by 
this.
  The American people have made it very clear: They do not want these 
bills to become law. Two new polls by CBS and CNN show that only 20 
percent of Americans believe this legislation will benefit them and 
their families. Still, the majority party has chosen to push these 
unpopular proposals through.
  My constituents in Georgia have reached out in record numbers to 
register their opposition to President Obama's plan.
  Why? For starters, because this is an unprecedented government 
involvement in an industry that constitutes one-sixth of the Nation's 
economy. If we get it wrong, if we overreach, our fragile economy will 
suffer and a recovery will lag, perhaps for years.
  This bill also does something very un-American: It would penalize 
individuals for not purchasing health insurance. Today, we have seen 13 
State attorneys general file lawsuits challenging the constitutionality 
of fining Americans for not purchasing insurance.
  The bill that passed the Senate and was signed by the president is 
filled with backroom deal-making, partisan arm-twisting and special 
carve-outs for some of my wavering colleagues on the other side of the 
aisle.
  Now, instead of working together on a bill that would be more 
palatable to all Americans, my colleagues on the other side of the 
aisle have decided to push forward in the face of united opposition.
  The Governor of Georgia recently expressed concern regarding the 
unfunded mandates in this legislation. Our State faces an additional 
billion dollars or more of Medicaid spending per year.
  These new costs that will be absorbed by the State will require 
further tax hikes on Georgians or cuts to public safety, education and 
other core State government services.
  The bill that was just signed contains $518.5 billion in gross tax 
increases. It cuts Medicare by $465 billion--and, more importantly--
does nothing to bend the health care cost curve down.
  With Medicare on the verge of insolvency, this bill takes money from 
the Hospital Insurance Trust Fund to pay for unrelated entitlement 
spending.
  Under this new plan, new Federal taxes on Americans start 
immediately. But full benefits won't take effect until 2014. The bill 
raises $60 billion in taxes before any of the major benefits go into 
effect.
  Looking at the years 2013-2024, the 10-year period after the law is 
fully implemented, the overall cost is estimated to be $2.6 trillion.
  Some of these numbers are so large that its tough to get your head 
around them. But rest assured that they will detrimentally impact 
Americans and our economy.
  There is also substantial evidence that this new law will hurt small 
businesses.
  The bill imposes $493 billion in new taxes that will fall 
disproportionately on the backs of small-business owners.
  A $54 billion increase in the Medicare payroll tax will hit 
approximately one-third of the small-business owners across the 
country.
  A $60 billion tax on insurers means small businesses that manage to 
provide health insurance coverage for their employees will see this tax 
passed on to them, increasing premiums.
  The CLASS Act portion of the new law appears to make it less costly 
because, as the CBO said, ``the program would pay out far less in 
benefits than it would receive in premiums over the 10-year budget 
window,'' raising $70 billion in premiums that will fund benefits 
outside the window. Outlays in later years will increase significantly.
  And the legislation just signed into law is still filled with the 
sweetheart deals that have so angered Americans.
  That includes the Cornhusker Kickback, in which the Federal 
Government pays the entire tab of Nebraska's Medicaid expansion.
  It also includes the Louisiana Purchase, in which the Federal 
Government pays an extra $300 million in

[[Page S1978]]

Medicaid dollars to the State of Louisiana.
  And it still has the Gator Aid Florida Medicare Advantage grandfather 
clause to protect certain areas of Florida from Medicare Advantage cuts 
that all other seniors in America will face.
  Meanwhile, the 176,000 seniors in Georgia who rely on Medicare 
Advantage to supplement the gaps in traditional Medicare will see their 
benefits cut by $33 each month.
  The new law significantly raises taxes, cuts benefits for seniors, 
adds to the Federal deficit and allows the government to make decisions 
that should be between a patient and his doctor.
  The reconciliation bill--optimistically deemed a ``fix-it'' bill--is 
actually a ``make-it-worse'' bill.
  The legislation before us today raises taxes by an additional $50 
billion more than the Senate bill. That is an overall tax increase of 
$569.2 billion.
  The reconciliation bill nearly doubles the tax on health insurers 
beginning in 2014, and also raises taxes and fees on drugmakers and 
medical devices. The Congressional Budget Office has specifically 
stated that these taxes will be passed on to all Americans in the form 
of higher health costs and rising insurance premiums.
  The reconciliation bill raises another $66.1 billion from Medicare 
Advantage, bringing total Medicare cuts in both bills to $523 billion.
  And it forces an additional 1 million individuals into Medicaid on 
top of the 15 million already added to Medicaid in the Senate bill. 
That means 16 million of the 32 million newly insured individuals would 
obtain that coverage through Medicaid--a program President Obama 
admitted already suffers from serious access problems.
  It also increases penalties for businesses that don't offer health 
insurance and have at least one employee receiving a subsidy in the 
exchange from $750 per full-time employee to $2,000 per full-time 
employee.
  And, among other things, it penalizes many Americans with higher 
incomes from rent, interest, royalties and individuals by forcing an 
almost 4 percent Medicare tax on their investment income.
  According to the Congressional Budget Office, this bill is going to 
cost $940 billion over 10 years.
  We are burdening our children and grandchildren--generations of 
America's future--by creating a behemoth new government entitlement 
program.
  And in the same week of its creation, we turned around and 
immediately added to this new program almost $1 trillion more.
  The American people are asking a simple question: Where does the 
spending end?
  Also, I wish to talk about a specific provision that is going to have 
an immediate, direct impact on my taxpayers in Georgia; that is, with 
the increase in the threshold to qualify for Medicaid going from 100 
percent to 133 percent, in my State, according to our Governor--and he 
has run the numbers--that is going to cost the taxpayers of Georgia, in 
addition to their share of this $569.2 billion in additional taxes, an 
additional $1 billion per year that Georgia taxpayers are going to have 
to pay.
  We are in difficult times in my State, as all 50 States are right 
now. That is a new provision, a new tax.
  I ask unanimous consent that a statement from the Governor of 
Georgia, the Honorable Sonny Perdue, be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

            [From the Office of the Governor, Mar. 22, 2010]

Statement of Governor Sonny Perdue Regarding the Healthcare Legislation 
                  Passed by the United States Congress

       Atlanta.--Governor Sonny Perdue issued the following 
     statement today regarding the healthcare legislation passed 
     by the United States Congress:
       ``Unfortunately, the United States House of Representatives 
     last night chose politics over the will of the American 
     people. The enormous upheaval of our healthcare system was 
     pushed through the House against the wishes of the majority 
     of American families and businesses.
       Here in Georgia, this vote will force an additional billion 
     dollars or more of Medicaid spending per year, requiring 
     either a tax hike or offsetting cuts to public safety, 
     education and other core services of state government. While 
     this colossal unfunded mandate cripples our budget, I am even 
     more concerned about the debilitating impact it will have on 
     Georgia's small businesses. The extension of the Medicare tax 
     on all non-wage income means that small business owners will 
     see their top rate increased by 20 percent and investment 
     income taxes increasing 60 percent.
       What is most unfortunate is that the American people had no 
     voice at the table in Washington during the course of this 
     debate. The only glimpse citizens saw of the process were 
     closed-door meetings that resulted in backroom deals and the 
     buying of votes to ensure passage. I am today renewing my 
     December request to the Attorney General that he join other 
     states in reviewing the constitutionality of this travesty. 
     My office has already begun to review any and all legal 
     options to challenge this legislation.
       I also urge the Georgia General Assembly to continue moving 
     forward on my proposal to allow Georgians to purchase 
     insurance plans across state lines. Now that Congress is 
     mandating that every American purchase health insurance, we 
     should open the individual market to as much competition as 
     possible.
       Since this bill has such a significant impact on future 
     state budgets, it is imperative that current candidates for 
     elected office publicly state their plans to either support 
     the Obama-Pelosi legislation or fight for the people of 
     Georgia.''

  Mr. CHAMBLISS. Let me say that within the last 48 hours we have 
discovered that the agency that is going to be administering the new 
health care reform bill the President signed into law is none other 
than the Internal Revenue Service. The Internal Revenue Service has 
said that in order to review the tax returns of every taxpayer in 
America to ensure that they have complied with the law and bought 
insurance or had insurance taken out through their employer, they are 
going to have to have an additional 16,500 Internal Revenue Service 
Agents at a cost of an additional $10 billion to the taxpayers. That 
$10 billion is not factored in here in anyway.
  We are dealing with a piece of legislation that the American public 
has shown, over and over in every poll taken, whether it is by a 
Democratic pollster, Republican pollster or an independent pollster, 
that they do not want. We are going to force that bill down on the 
American people and that is wrong, that is not the way this body and 
the body across the Capitol should be working with respect to the best 
interests of the American people.
  I urge my colleagues at the appropriate time during the vote on the 
amendments this afternoon and tonight to repeal this bill and let us 
replace it with a true, meaningful health care reform bill that we can 
all agree on. There are a lot of provisions in those 2,700 pages plus, 
the length of this so-called fix-it bill that we can agree on, that we 
can replace this bill with, that will provide the American people with 
true, meaningful health care reform that they need and deserve.
  We will not see all of these huge increases in taxes, we will not see 
all of these huge reductions in Medicare benefits, and we can do the 
will of the people in the right and appropriate way.
  I yield the floor.
  Mr. GREGG. Mr. President, I yield 2\1/2\ minutes to the Senator from 
Louisiana.


                           Amendment No. 3553

  Mr. VITTER. Mr. President, at this point I ask unanimous consent to 
set aside any pending amendment and call up amendment No. 3553.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The clerk will report.
  The bill clerk read as follows:

       The Senator from Louisiana [Mr. Vitter] proposes an 
     amendment numbered 3553.

  Mr. VITTER. I ask unanimous consent that the reading of the amendment 
be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

      (Purpose: To repeal the government takeover of health care)

       Strike all after the enacting clause and insert the 
     following:

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Patient Choice Restoration 
     Act''.

     SEC. 2. REPEAL.

       The Patient Protection and Affordable Care Act, and the 
     amendments made by that Act, are repealed.

  Mr. VITTER. Mr. President, this amendment is very simple, and it goes 
to the heart of all of these arguments. This amendment would repeal 
this new ObamaCare plan.
  All of us on this side urge this action and urge us to focus instead 
on a focused step-by-step approach to solve

[[Page S1979]]

specific, real problems with specific solutions. This gargantuan plan 
which this amendment would repeal does not do that. This gargantuan 
plan has fundamental problems at its core that my colleagues have been 
talking about; truly offensive, fundamental problems such as over a 
$\1/2\ trillion cut to Medicare. The American people do not want to pay 
for anything through that. Over $\1/2\ trillion of increased taxes and 
costs. The American people do not want an approach that does that, 
increasing health ObamaCare costs, when the American people know our 
big challenge is to do the opposite.
  Nonpartisan sources such as the Congressional Budget Office confirm 
that the ObamaCare plan does not decrease health ObamaCare costs, it 
increases health ObamaCare costs from their rising rate already. It 
pushes that cost curve up and growing the bureaucracy, including 
thousands of new IRS workers, and putting them and the Federal 
Government between you and your doctor.
  These are not minor parts of the ObamaCare plan. This is the core of 
that plan. That is why we absolutely need to repeal it and take a 
fundamentally different approach, an approach that is focused like a 
laser beam on real problems and that deals with those real problems 
with real and targeted and step-by-step solutions.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. VITTER. I urge support of amendment No. 3553.
  The PRESIDING OFFICER. The Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, we are coming to a close, or a beginning, 
I am not sure which, when we start the vote on amendments. If my 
calculation is correct, the time for debate on this reconciliation bill 
will expire around 5:10, about that time, approximately.
  At that time, approximately, we will start voting on amendments. By 
my count we have 21 amendments pending, and if we vote on amendments in 
the time in which it usually takes to vote on amendments in a series, 
my experience is it roughly takes around an hour for three amendments. 
Maybe we can speed that up. With 21 amendments, that is 7 hours. That 
is the good news. There probably will be some intervening disruptions.
  But the good news is, that means the earliest we might be finished is 
around midnight. But, of course, that is not the case, because there 
will be other amendments offered.
  For the information of my colleagues, we will probably start voting 
on amendments at approximately around 5:10, thereabouts. We have 21 
amendments pending at the present time. It takes about 1 hour to vote 
on three amendments. I believe we can squeeze that time down. It is my 
hope that we can. But that is my experience around here, it takes about 
that long.
  Because there are a lot more amendments most likely to be offered, I 
inform my colleagues that we will be in very late tonight, certainly 
way past midnight, because of the number of amendments that are 
currently pending.
  The PRESIDING OFFICER. The Senator from New Hampshire.
  Mr. GREGG. What is the time situation?
  The PRESIDING OFFICER. The minority has 23 minutes 47 seconds left.
  Mr. GREGG. And the majority?
  The PRESIDING OFFICER. The majority has 24 minutes 52 seconds.
  Mr. GREGG. I yield 10 minutes to the Senator from Tennessee.
  Mr. ALEXANDER. Mr. President, could you let me know when 8 minutes 
has been consumed?
  The PRESIDING OFFICER. The Chair will advise the Senator.
  Mr. ALEXANDER. Mr. President, this has been a debate filled with 
passion and good intentions and a lot of hard work. Our political 
parties have come to vastly different conclusions. The President and 
the majority have said, this is an historic occasion. I agree.
  But I believe, as do most of us, that it is an historic mistake, and 
it is important to say why we think that. This is the fundamental 
mistake, that with the law that was passed yesterday and what the 
majority has proposed to do in this second bill, to expand a health 
ObamaCare delivery system that we all know is more expensive than we 
can afford, instead of stepping back and instead seeking to reduce the 
cost of that health ObamaCare delivery system so that more Americans 
can afford to buy health insurance. That is the mistake.
  I wish to try to say in 3 or 4 minutes what this bill means to 
Tennesseans. I was listening to the Senator from Montana and the 
Republican Senators talk about debt. We believe, I believe, that this 
bill, these two bills, will increase each Tennessean's share of the 
national debt.
  The Senator from Montana says: Well, but the Congressional Budget 
Office says it does not. Well, that would be like going to the 
Congressional Budget Office and saying: I have got a horse farm here. 
Tell me how much it costs to operate over the next 10 years. The CBO 
would say: Would you like me to tell you how to do it with the horses 
or without the horses? If you tell me how to do it without the horses, 
it is not going to cost as much. Or, if I have a gas station, would you 
like me to tell you how to operate that with the gas in it or without 
the gasoline?
  That is what we are saying here. They have gone to the Congressional 
Budget Office and said: Tell us how much this health bill costs. They 
have said to them: With the doctors or without the doctors?
  They say: Oh, no, keep the doctors out.
  Because, according to the President's own budget, that is $371 
billion over 10 years. If you put that in, then the whole bill adds to 
the deficit, so they leave it out. So that is why we say, and I would 
say, that the first thing this bill does is add to the debt, each 
Tennessean's share of the debt.
  The second thing is, it adds $8,470 in new spending for every 
Tennessean. Thirdly there are 243,000 Tennesseans enrolled in Medicare 
Advantage, which is about one out of four persons in Medicare who will 
have their benefits reduced by half, according to the Congressional 
Budget Office Director in testimony before Congress, whose veracity we 
have been hearing extolled on all sides.
  The next thing it does is about 1.4 million Tennesseans making less 
than $200,000 will pay higher taxes, based on estimates by the Joint 
Committee on Taxation. Some 300,000 Tennesseans in the individual 
health insurance market will see premium rate increases of 30 to 45 
percent based upon a Blue Cross/Blue Shield study of Tennessee and 
other analysis.
  Next, Tennessee's small businesses employing 50 or more people and 
construction companies employing 5 or more people--that is 5,000 
construction companies in Tennessee--will pay higher health ObamaCare 
costs because of new government mandates.
  Then here is the other one. This is the one that was just added over 
the weekend: 200,000 Tennessee students including--I checked--11,000 at 
the University of Tennessee-Knoxville where I was this week, will be 
overcharged by $1,700 to $1,800 over the next 10 years on their student 
loans in order to help pay for the health ObamaCare bill and other 
programs.
  Let me say that again. Over the weekend, without any debate in the 
Senate, they have stuck in this bill--they are going to overcharge 19 
million students in America, 200,000 in Tennessee, $1,700 or $1,800 
more than it costs the government to borrow the money, because the 
government is taking over the student loan program.
  They borrow the money at 2.8 percent, they loan it out at 6.8 
percent, they take the difference, they spend it, $8.7 billion of it to 
help pay for the health ObamaCare program. So that is 200,000 Tennessee 
students. These are not Wall Street financiers. This is a mom with a 
child and a job going to school to get a better job. That is 200,000 
Tennessee students. And $1.1 billion in costs will be forced on the 
Tennessee government. That is according to our State Democratic 
Governor, who said that is the cost of the Medicaid expansion and what 
happens to the State after the physicians reimbursement expires in 2 
years for Medicaid. This will force States, Tennessee for sure, and 
many other States, to raise taxes, cut services, or increase college 
tuition.

  According to an Oliver Wyman study, 30 percent of young people will 
pay up to 35 percent more in premiums as premiums go up in the 
individual market.
  Then finally, of course, the bill does add in Tennessee about 200,000 
people to our TennCare or Medicare rolls. But

[[Page S1980]]

that is not health ObamaCare reform because nationally only about half 
of doctors will see new Medicaid patients.
  So we are saying to people, we are giving you health ObamaCare, but 
it is like saying, we are giving you a bus ticket to a bus line where 
the bus only runs half the time. When you put these low-income 
Americans into this program in such large numbers, what that 
additionally does is create more opportunities for physicians, for 
hospitals, and for drugstores to say, we cannot serve Medicaid patients 
any more.
  That is why we feel this is the wrong course and an historic mistake. 
What we would do instead is replace this bill with a different bill 
that focuses on costs. We have said it over and over again. We said it 
at the health ObamaCare summit. We would start with allowing people to 
buy health care across State lines; with allowing small businesses to 
combine their resources to offer insurance to more people at lower 
costs; with reducing the number of lawsuits against doctors for 
malpractice.
  We would step up efforts against waste, fraud, and abuse, expand 
health savings accounts. All of these were proposals made before the 
Senate, basically ignored. But the fundamental mistake and the reason 
we have such a difference of opinion between that side of the aisle and 
this side of the aisle is that that side of the aisle, which has the 
majority, is expanding a health ObamaCare delivery system that we all 
know is too expensive, and we think instead what we should be doing is 
focusing on reducing health ObamaCare costs so that more Americans can 
afford to purchase health ObamaCare insurance.
  I yield back my time to the Senator from New Hampshire.
  Mr. GREGG. I would yield for 30 seconds to the Senator from Kansas to 
put in order a couple of amendments.
  The PRESIDING OFFICER. The Senator from Kansas.


                           Amendment No. 3577

  Mr. ROBERTS. I ask unanimous consent to temporarily set aside the 
pending motions and amendments so that I may offer an amendment, No. 
3577, which is at the desk.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The clerk will report.
  The bill clerk read as follows:

       The Senator from Kansas [Mr. Roberts] proposes an amendment 
     numbered 3577.

  Mr. ROBERTS. Mr. President, I ask unanimous consent that the reading 
of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

 (Purpose: To protect Medicare beneficiary access to hospital care in 
 rural areas from recommendations by the Independent Payment Advisory 
                                 Board)

       At the end of subtitle B of title I, insert the following:

     SEC. __. PROTECTING MEDICARE BENEFICIARY ACCESS TO HOSPITAL 
                   CARE IN RURAL AREAS FROM RECOMMENDATIONS BY THE 
                   INDEPENDENT PAYMENT ADVISORY BOARD.

       (a) In General.--Section 1899A(c)(2)(A) of the Social 
     Security Act, as added by section 3403 of the Patient 
     Protection and Affordable Care Act and amended by section 
     10320 of such Act, is amended by adding at the end the 
     following new clause:
       ``(vii) The proposal shall not include any recommendation 
     that would reduce payment rates for items and services 
     furnished by a critical access hospital (as defined in 
     section 1861(mm)(1)).''.
       (b) Expansion of Affordability Exception to Individual 
     Mandate.--Section 5000A(e)(1)(A) of the Internal Revenue Code 
     of 1986, as added by section 1501(b) of the Patient 
     Protection and Affordable Care Act, is amended by striking 
     ``8 percent'' and inserting ``5 percent''.


                            Motion to Commit

  Mr. ROBERTS. Mr. President, I ask unanimous consent now to 
temporarily set aside the pending motions so that I may offer a motion 
to commit, which is at the desk.
  The PRESIDING OFFICER. Without objection, it is so ordered. The clerk 
will report.
  The bill clerk read as follows:

       The Senator from Kansas [Mr. Roberts] moves to commit the 
     bill (H.R. 4872) to the Committee on Finance with 
     instructions to report the same back to the Senate within 3 
     days with changes to repeal the Patient-Centered Outcomes 
     Research Institute, the Center for Medicare and Medicaid 
     Innovation, any new functions of the United States Preventive 
     Services Task Force, and the Independent Payment Advisory 
     Board and adds an offset.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, how much time remains?
  The PRESIDING OFFICER. There is 24 minutes 40 seconds.
  Mr. BAUCUS. I yield half that time to the distinguished chairman of 
the Banking Committee, former acting chairman of the HELP Committee, 
and one of the most valuable and productive Members of this body, the 
Senator from Connecticut.
  Mr. DODD. I thank my colleague and commend him for his leadership on 
this issue, along with, of course, our distinguished majority leader so 
many others, including the wonderful staff we don't often mention--the 
remarkable work being done by the individual staff of Members and the 
committee staff of the Health, Education, Labor, and Pensions 
Committee. I see my good friend, Tom Harkin, who now chairs that 
committee, along with Max Baucus, and so many others of the leadership 
staff who have brought us to this moment.
  I rise to discuss the Health Care and Education Reconciliation Act. 
Although none of us are ignorant of the historic nature of the health 
care portion of our work this past week, I wish to take a few moments 
to talk about the significance of the education portion of the bill. I 
listened intently to my friend from Tennessee talk about this part of 
the bill as well. I have great admiration for him, having served as the 
Secretary of Education and as Governor of Tennessee. He has a wealth of 
knowledge on the subject matter. I commend him for it. However, we 
disagree with this particular portion.
  I rise to express a different point of view about why I believe what 
we have included in this bill has great value. Obviously, the major 
attention has been focused on the health aspects of what we are doing. 
That in itself is a major achievement. The reconciliation portion of 
this bill before us now strengthens a good bill and makes it even 
better.
  Last evening I discussed portions of the bill that I think add 
tremendous value to our efforts to provide health care once and for all 
for all Americans. But the education portion of this bill also has 
great significance.
  Since the Pell grant was established in the 1970s, as all of us know, 
it has made college a possibility for millions and millions of young 
Americans. I had the great pleasure of serving with Claiborne Pell as a 
Member of this body. He served in the 1960s up until only a few years 
ago. We lost him a number of months ago; he passed away. But it is 
incredible to think of what a difference that individual, that one 
Senator made in the lives of millions of our fellow citizens. In years 
to come, some may not know who Claiborne Pell was, but I would like the 
record to reflect he was a remarkable Senator. He authored legislation 
creating the Northeast Corridor, wrote the legislation that banned the 
testing of nuclear weapons on the ocean floor. He was the author, along 
with Jacob Javits, of the National Endowments for the Arts and 
Humanities, and he was the author of Pell grants. Unique and remarkable 
contributions, each and every one of them, but he should long be 
remembered for making education an opportunity that would not be denied 
because one lacked the resources to afford it.
  Those millions of young Americans are now leaders in our Nation. They 
are innovators, some of our most productive and successful citizens. 
This bill is not unlike the GI bill at the end of World War II, when we 
recall men who came back from the theaters of the Pacific and Europe 
who were able to receive an education under the GI bill, who would tell 
us what a remarkable investment it was.
  It has been repaid millions of times over by those who today make 
contributions to our country because they got an education because 
there was a creative Congress, because there was an administration that 
understood the value of an education in the midpart of the 20th 
century. Here we are now into the second decade of the 21st century 
facing a similar issue.
  There should be no doubt in anyone's mind about the value not only of 
making us a healthier country by the adoption of the health care 
provision of this bill, but a better educated country--

[[Page S1981]]

not only to advance our own needs--but to make sure individuals have 
the opportunity to maximize all of their potential. Today that wouldn't 
be the case without Pell grants. What they have done to and for our 
society has been remarkable. Countless individuals would not have had 
the opportunity to attend college without Pell grants.
  Since then the importance of a college education has only grown, not 
only for the individual students who want to achieve their full 
potential, but our Nation as well. America's ability to compete in the 
global economy depends on having a well-educated workforce in the 21st 
century. Today, that means a college-educated workforce. Unfortunately, 
while the urgency of opening the door to college has grown, the support 
provided to our most important college aid program has slipped. In 
fact, it has gone further--it has fallen off a cliff. In 1975, the 
maximum Pell grant covered 80 percent of the average student's tuition, 
fees, room and board at a 4-year public university. Today it covers 
less than one-third at a public university.
  Our failure to keep pace with the exploding cost of college threatens 
to slam the door on a generation of Americans, making college 
impossible for many and leaving those who do find a way to further 
their education with a debilitating burden of overwhelming debt.
  Make no mistake, allowing the Pell Grant Program to wither, as would 
be the case without the adoption of the language in this bill, isn't 
just a slap in the face to low and middle-income hardworking American 
families. It is a serious threat to America's competitiveness in the 
21st century. Fortunately, the legislation in front of us presents an 
opportunity to revitalize the Pell Grant Program and to unlock the 
opportunity of higher education for millions of Americans.
  The bill invests $13.5 billion to fill the shortfall in the Pell 
Grant Program and ensures that such a shortfall doesn't develop again, 
as the cost of college continues to increase in the years ahead. For 
instance, if we fail to act, the maximum Pell grant award could be a 
paltry $2,100 for the year 2010. Never before has the effectiveness of 
this program been at such risk. The legislation before us protects the 
maximum award at a level of $5,500 and increases to almost $6,000 by 
2017, 7 years from now.
  We all know that in 7 years the cost of education will have continued 
to skyrocket. I would be the first to admit that while we are putting 
tremendous resources into this program, we can imagine in 2017 what 
college education will be like, even at public universities. This Pell 
grant assistance, as important as it is, is not going to come close to 
meeting the needs of families, so we will continue to work to increase 
aid. But in this legislation, we also peg these increases to inflation 
in order to try to keep up with the cost of higher education.
  In my home State of Connecticut, this would enable more than 4,300 
additional students to go to college. In addition, this legislation 
makes important investments in Historically Black Colleges, community 
colleges, and the College Access Challenge Grant Program, which fosters 
partnerships between government and the nonprofit sector that helps 
low-income kids get a chance to go on to a higher education.
  It invests in programs that help students determine what college is 
best for them, as well as prepares them not only to get into those 
schools but to graduate from them. When those students do graduate, 
they will no longer be faced with that mountain of debt we have heard 
about over and over again that puts so many of their own careers and 
contributions to society on hold while they have to pay off these 
debts, seeking jobs and opportunities that may not be what they need 
for their future growth and potential.
  To help with this, our legislation caps repayment of Federal loans at 
10 percent of discretionary income and forgives payments after 20 
years. This represents an important investment not only in our 
children's future but in the future of our country. It will pay 
enormous dividends.
  This investment isn't just smart, it is fully paid for. In fact, the 
Congressional Budget Office estimates this legislation will reduce the 
national debt and deficit by $10 billion over the next 10 years. We 
accomplish that by eliminating what amounts to billions of dollars in 
wasteful spending within the Federal student loan program.

  Let me explain. Currently, some Federal student loans are made 
through the Direct Loan Program, while others are made through the 
Federal Family Education Loan Program, the so-called FFEL Program. This 
program overpays banks for servicing these Federal loans. The result is 
that money intended to help students go on to a higher education ends 
up instead helping to pad the profits of those lenders. That is a waste 
of money.
  What is more, banks in the FFEL Program get their loan guarantee and 
interest subsidy entitlements regardless of how they treat the student 
borrowers. While they bank the profits when the loans are repaid, 
taxpayers end up shouldering the risk of defaults. So our legislation 
converts all future Federal student loans to direct loans.
  This doesn't cut the private sector out of the student loan industry. 
What it does is as American as apple pie. It makes them compete. It 
ends these unnecessary payments and force banks to compete for the job 
of servicing student loans. When institutions have to compete, 
consumers benefit.
  For students and parents, it means better customer service and the 
same good rates that have always been the hallmark of Federal student 
loans.
  As for taxpayers, it means a savings of $61 billion over 10 years, 
money that now flows into the coffers of banks, but under this 
legislation will be used to help more kids go on to college and bring 
down our national deficit.
  In short, what we have here is a win-win, a fully paid for and much 
needed investment in equal opportunity and American competitiveness. I 
would be remiss if I did not note that we could and should be doing 
more. It comes as a serious disappointment to me and to education 
advocates across the country that funding for a new early childhood 
learning initiative was not included in this package. I desperately 
wanted it to be there, as did my friend Tom Harkin from Iowa who has 
worked with me, along with others, for years on early education. As 
important as it is to enable a high school student to graduate and 
attend college, it is just as critical that we prepare every child to 
be a viable candidate for their next step in the education process. The 
achievement gap that robs too many American children of their 
opportunity begins very early, before the age of 3, according to 
everything we know about child development. You know the statistics, as 
most of us do. Investments in early childhood education pay off tenfold 
when we consider the decreases in crime, the reduced need for special 
education and welfare services, and improved health of these children 
who have access to early education.
  Just as the increasingly competitive global economy calls us to 
unlock the door to higher education, we must also do everything we can 
to bring every American child to that threshold of maximizing his or 
her potential. That important work requires a serious commitment to 
early education. This legislation would have been a perfect opportunity 
to follow through on that commitment. So the fight will continue, 
unfortunately, without the strength this bill would have provided. But 
for now we have the chance to do some real good for young people and 
for our Nation.
  I urge my fellow Senators, both Democrats and Republicans, to support 
this commonsense measure, save the Pell Grant Program, and make a real 
difference in the lives of countless young Americans for years to come. 
I remind my colleagues this is just part of what is at stake in this 
debate. The amendments being offered, on too many occasions by our 
friends on the other side of the aisle, are doing nothing more than 
trying to stop this legislation from going forward. I hope that will 
stop. Let's pass this bill. We have a chance to not only change the 
quality of health in America but also to open the doors of opportunity 
for American students.
  For those reasons, I urge adoption of this package.
  I yield the floor.
  Mr. GREGG. I yield to Senator McCain such time as he may use.
  The PRESIDING OFFICER. The Senator from Arizona.
  Mr. McCAIN. Mr. President, I read a lot about what has been going on 
in the

[[Page S1982]]

health care debate, and all of us have. Americans are very aware of it. 
I keep hearing the word ``historic'' this, ``historic'' that, 
``historic.'' I agree. It is historic. This is a historic vote, and I 
think we are pretty aware of what the outcome will be sometime tonight, 
tomorrow, or the next day. It is the first time in history, the history 
of this country, that a major reform has been enacted on a purely 
partisan basis, the first time.
  Every major reform throughout history has had significant--you can go 
down the list--bipartisanship votes. In the 1970s--this one, purely 
partisan, rammed through from beginning to whatever this end is.

  It is historic, and it is the first time that a process called 
reconciliation has ever been used to affect one-sixth of the gross 
national product. I know the response will be: Well, Republicans did 
it--et cetera, et cetera. It will be the first time that 51 votes has 
been the measure of a decision on so-called reconciliation. Now, that 
is historic. That is historic because we have basically broken down the 
60-vote tradition of the Senate when we address it in this fashion--an 
issue of this magnitude.
  Let me tell you, when the President of the United States was still a 
Senator--another time we were doing reconciliation--what he said:

       You know, the Founders designed this system, as frustrating 
     [as] it is, to make sure that there's a broad consensus 
     before the country moves forward. . . . And what we have now 
     is a president----

  He was referring to former President Bush--

     who . . . [h]asn't gotten his way. And that is now prompting, 
     you know, a change in the Senate rules that really I think 
     would change the character of the Senate forever. . . . And 
     what I worry about would be you essentially have still two 
     chambers--the House and the Senate--but you have simply 
     majoritarian absolute power on either side, and that's just 
     not what the founders intended.

  That is what Barack Obama, the Senator from Illinois, said.
  So here we are. Yes, it is historic. It is historic. And it is 
historic what we have seen take place from the beginning. We have seen 
the special interests. We have seen the votes, the provisions in these 
bills that carve out special deals for special interests and special 
States, such as the ``Louisiana purchase,'' the $100 million inserted 
in this 2,733-page document that builds a hospital in Connecticut. Why 
Connecticut? Why $100 million? Why is it that there are these special 
provisions for certain locations in the country?
  It is historic in the special deals that have been cut--for PhRMA, 
for the American Medical Association, for the hospital association, for 
the unions in the taxation of Cadillac plans. Everybody has a deal but 
the American citizen--the average American.
  How many Americans, how many ordinary Americans who are, say, 
enrollees in Medicare Advantage in my State, who are going to see the 
Medicare Advantage program cut drastically--how many of them were 
allowed in the majority leader's office? How many of them were allowed 
in the Speaker's office? How many of them were allowed in the White 
House as the special interests' representatives went in and out?
  So there are winners and losers. That is what is being judged. The 
winners will be those who live in favored States who will have special 
deals. There will be those who are winners--PhRMA, the hospital 
association, the unions. Again, my congratulations to PhRMA. They are 
running $100 million-some worth of ads favoring this deal because they 
got a deal that is worth billions--worth billions.
  As I have quoted on the floor several times, their head lobbyists, or 
$2 million-a-year lobbyists, said: A deal is a deal. We expect the 
White House to keep it.
  So who are the losers? Who are the losers? Well, the first loser is 
the Senate because, as I said before, this reconciliation, requiring 
only 51 votes, is a radical departure from anything we have done in the 
past. I do not accept the statement that it has been done in the past--
not when it affects one-sixth of the gross national product, and as a 
direct result of the vote in the State of Massachusetts that gave this 
side 41 votes. If they still had 60 votes, we would not be doing this 
on reconciliation. We would be doing it in the regular way we address 
legislation--legislation through the House, legislation through the 
Senate, a conference committee, and then, obviously, a final vote. But 
they cannot afford a final vote because there are 41 votes now, not 60. 
So the Senate is a major casualty of this process.
  But the biggest losers probably are average citizens--average 
citizens who were told the Congressional Budget Office judged this to 
be deficit-neutral, and it would not cost the taxpayers additional 
money. I just had a conversation with the Senator from Montana who said 
clearly we are not going to cut physician payments by 21 percent; so, 
therefore, the assumption they gave the Congressional Budget Office is 
false--is false. So before we go any further, it is already a $150 
billion deficit because everybody knows we are not going to cut 
physicians' payments by 21 percent.
  So the American people are the ones who never had access to get a 
special deal. And 330,000 citizens of my State who have enjoyed and 
chosen the Medicare Advantage program are now going to see those 
benefits slashed. But the average citizen who thinks today there is a 
huge disconnect between their lives and that of the life that is led 
here and the way we do business here--last Saturday, I was in my own 
home State of Arizona. I did two townhall meetings, one in Prescott and 
one in East Valley Phoenix, and people are hurting. People are hurting, 
people are angry, they are frustrated, and they feel there is a huge 
disconnect between themselves and Washington. I come back the next day, 
and they are drinking champagne in celebration of a ``historic'' 
victory. Americans do not get it. Americans do not get it. They are 
angry. They are frustrated.
  I want to assure them--I want to assure them--this fight is not over. 
We will take it, as I mentioned before, to the towns and cities of 
America. We will have townhall meetings all over the country. We will 
register voters. We will urge them to turn out. We will urge them to 
take part in one of the most seismic elections in the history of this 
country.
  I know the liberal media is saying: The American people are going to 
move on. Well, they are not going to move on. They are not going to 
move on because they are sick and tired of the spending and the 
generational theft we have committed on future generations of 
Americans. This is only one part of their frustration. It is a big 
part, but it is only one part.
  So I know I speak for my colleagues when I say this fight is far from 
over. This struggle to regain control of this body and this institution 
in Washington, DC, and give it back to the people of this country will 
go on.
  I have great faith in this country and its future. That is why I am 
confident that over time, sooner or later, we will be back and we will 
repeal and we will replace--we will replace--this huge government 
takeover with medical malpractice reform, with going across State lines 
to get insurance of your choice, to reward wellness and fitness, to 
establish risk pools that insurance companies will bid on in order to 
treat people with preexisting conditions. We have a long list we will 
replace this mortgaging of America's future with that will be what all 
Americans want; that is, to maintain the quality of health care in 
America and, at the same time, bring costs under control.
  I thank the Senator from New Hampshire for his leadership. I thank 
the Senator from Montana for his courtesy during this debate over these 
days and weeks and even months, on days and nights and weekends. I want 
to assure my colleagues this debate is far from over.
  I yield the floor.
  Mr. GREGG. Mr. President, I just want to thank the Senator from 
Arizona for his excellent summation of where this issue lies and its 
impact on the American people. I hope that statement will be read 
across this country because it was a reflection of the concerns which 
are legitimate and which are being expressed by vast amounts of 
Americans. It is not unusual it should be expressed by the Senator from 
Arizona because he is so much a personality of this Nation and a force 
within our political process.
  I would reserve the remainder of my time.
  The PRESIDING OFFICER. The Senator from Montana.

[[Page S1983]]

  Mr. BAUCUS. Mr. President, I yield to the distinguished chairman of 
the HELP Committee, who has been so involved in health legislation, 
education legislation. Might I ask, how much time do we have left?
  The PRESIDING OFFICER. There remains 11 minutes 48 seconds.
  Mr. BAUCUS. Mr. President, I yield as much time to the Senator as he 
wishes to take, including 11 minutes 48 seconds.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. HARKIN. Mr. President, I thank my friend from Montana, the 
chairman of the Finance Committee. I thank him for all of his great 
leadership, and also Senator Dodd, who just spoke.
  If I might just add a little historical footnote. Senator Baucus, 
chairman of the Finance Committee; Senator Dodd, who led the effort 
through the HELP Committee; myself, as now chairman of the HELP 
Committee; Chairman Miller on the House side, chairman of the Education 
and Labor Committee; and Chairman Waxman, the chairman of the 
House Commerce Committee--all of whom had big parts of the whole health 
care bill to develop--a historical footnote: We were all sworn in on 
the same day in January of 1975. It was a great class, and our 
classmates, as history would have it, survived to be able to put 
together this great health care bill.

  I again want to thank my longtime friend and colleague from Montana, 
Senator Baucus, for his extreme patience and his endurance in getting 
us to this point.
  Mr. President, we are in the midst of a historic week in this 
Nation's Capital. Health care reform is no longer a bill; it is the law 
of the land. It has been signed.
  Just as the history books remember 1935 as the year FDR signed Social 
Security into law, and 1965 as the year when Lyndon Johnson signed 
Medicare into law, they will now remember the year 2010 as the year 
President Barack Obama signed comprehensive health reform into law.
  Each of these three bills marked a giant step forward for the 
American people. Each was stridently opposed by the special interests 
and defenders of the status quo. But in the end--in 1935, in 1965, and 
now in 2010--a critical mass of Senators and Representatives rose to 
the historic occasion. They voted their hopes, not their fears. They 
created a better, fairer, more compassionate America for all of our 
citizens.
  As a Nobel Prize-winning economist recently put it, the new health 
reform law is a ``victory for America's soul''--a ``victory for 
America's soul.'' At long last, we are realizing Senator Ted Kennedy's 
great dream of extending access to quality, affordable health insurance 
to every American. We are ending the last shameful bastion of legal 
discrimination and exclusion in our country.
  Think about it: Over the decades, we have outlawed discrimination 
based on race, color, and national origin. We have outlawed 
discrimination based on gender and religion. We have outlawed 
discrimination based on age and disability. But until now, it has been 
perfectly legal to discriminate against our fellow Americans because of 
illness--because of illness--and to exclude tens of millions of our 
citizens from decent health care simply because they could not afford 
insurance or afford health care--blatant discrimination.
  When President Obama signed health care reform into law on Tuesday, 
he set in motion a series of changes that will tear down these last 
barriers of discrimination and exclusion. That truly is a great moral 
victory. It is, indeed, a victory for America's soul.
  But our work is not done. The reconciliation bill now before us 
includes a number of modifications to strengthen the new health care 
reform law. It also includes reforms in the student lending program 
that in their own way are also profound and historic. I regret these 
landmark education reforms have not gotten the attention they deserve.
  Senator Dodd--I just listened to his speech--outlined in great detail 
what these reforms are and what they will mean for our families and for 
our students.
  This bill in front of us now eliminates $61 billion in wasteful 
subsidies to banks and redirects most of that money to low-income 
college students in the form of increased Pell grants. The status quo 
in student lending is a bizarre Rube Goldberg process that makes no 
sense. The Federal Government pays private banks to make entirely risk-
free loans. The banks then sell the loans back to the Federal 
Government and pocket hundreds of millions of dollars in fees. This is 
a brazen case of corporate welfare--a huge government giveaway to 
bankers. This bill at long last will put a stop to it.
  Mr. President, I want to state forthrightly I am not antibanker. I am 
not antibank. I have family members in the banking business and they do 
a great job. But who does not like free money? If you give the banks 
free money, they love it. But if we have money we want to give away, I 
say do not give it to the banks. Give it to low-income students so they 
can go to college. Banks have lots of ways in which they can make 
money. A low-income student has no other way to go to college but that 
we provide him and her access to meaningful Pell grants. I am 
disappointed our Republican colleagues are doing everything in their 
power to delay and obstruct and to kill this bill. Reportedly, they now 
plan to offer dozens and dozens of largely meaningless amendments to 
try to stretch the process out and delay a final vote. One might call 
this the Republican version of March madness. They know it is going to 
end; they just want to drag it out.

  Let's be clear what is at stake. A vote against this bill is a vote 
against eliminating the doughnut hole in the Medicare prescription drug 
plan for seniors. A vote against this bill is a vote against parents' 
rights to keep their kids on health insurance plans until age 26. A 
vote against this bill is a vote against a tough new crackdown on fraud 
and abuse in Medicare and Medicaid Programs. A vote against this bill 
is a vote against ending discrimination against rural areas in Medicare 
reimbursement rates. A vote against this bill is a vote against ending 
tens of billions of dollars in corporate welfare for banks, a vote 
against redirecting that money to more generous Pell grants for needy 
college students.
  I might add, a vote against this bill is a vote against a very 
important provision. I know an amendment has been offered to do away 
with what is called the CLASS Act. The CLASS Act is now the law of the 
land. Here is what it is. It is a voluntary program. No one has to join 
it. It is fiscally solvent for 75 years. All it says is that an 
individual during their working years can set aside some money. If 
they, God forbid, become disabled, they can have some income to be able 
to live in their own homes and not be put in a nursing home. That is 
the law of the land right now, and there is an amendment before us to 
do away with that. Over 275 groups representing people with 
disabilities and seniors support the CLASS Act, and we ought to keep it 
in the law and not repeal it with an amendment.
  In short, those who are determined to kill this reconciliation bill 
need to decide whose side they are on. Are they going to continue their 
die-hard defense of the health insurance companies and the banks or are 
they going to stand with ordinary Americans who want access to quality, 
affordable, reliable health coverage and with needy young people who 
need Pell grants in order to go to college? It is time to choose.
  We are going to have a whole series of amendments. Oh, some of them 
will sound nice. Some of them I would probably like to vote for myself 
if they weren't to this bill. But we can't be lured into this by the 
siren song of amendments that sound good but only have one purpose; 
that is, to kill this bill, to delay it, to kill it, to make sure it is 
not enacted into law. That is the only purpose of these amendments, 
make no mistake about it. So when an amendment comes up that I like and 
I might want to support, I will vote against it because it is that 
important to make sure this reconciliation bill gets passed and sent to 
the President for his signature.
  So I say to all of my friends on this side of the aisle: Don't be 
lured. Don't be lured by the siren song of amendments that may sound 
good. Don't be afraid that somehow they are going to use it against you 
in a campaign. Hey, they can use anything against you in a campaign. We 
all know that by now. Let's stand united. Let's stand strong. Let's say 
no to these amendments designed only to kill this bill.

[[Page S1984]]

  I urge my colleagues to support passage of the Health Care and 
Education Reconciliation Act of 2010, to defeat all of the amendments. 
Let's get this bill to the President, let's help our students get to 
college, and let's help the people of this country have better health 
care.
  Mr. President, one of the arguments raised by my Republican 
colleagues regarding the landmark new health reform law just signed 
into law by President Obama is that it is unconstitutional. Well, I 
strongly disagree. One example of the strong constitutional basis of 
the new law is outlined by the American Constitution Society in a paper 
released at the end of last year.
  I commend this paper to my colleagues and ask unanimous consent its 
conclusions be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

 [From the American Constitution Society for Law and Policy, Dec. 2009]

           Mandatory Health Insurance: Is It Constitutional?

                           (By Simon Lazarus)


     VI. Conclusion: mandatory insurance is neither burdensome nor 
                             unprecedented.

       A major reason why all opponents' legal arguments fall 
     short is that they share a common factual foundation, which 
     itself is a fallacy. Their root assumption, or assertion, is 
     that requiring Americans to carry health insurance is both 
     extraordinarily novel--``unprecedented''--and extraordinarily 
     burdensome. But this endlessly repeated assertion is 
     specious, for several reasons:
       To begin with, experience demonstrates that mandatory 
     health insurance is neither unprecedented nor burdensome. 
     Hundreds of millions of millions of individuals live under a 
     variety of mandatory health insurance regimes, with very high 
     rates of compliance and no record of discontent with the 
     requirement, in other advanced economies and, indeed, as 
     noted above, in Massachusetts.
       As noted above, the overwhelming majority of Americans 
     already carry health insurance that satisfies the terms of 
     the mandate, so they will not be affected by the mandate at 
     all. Of the approximately 46 million Americans who currently 
     lack health insurance, the majority are in this state only 
     because it is unavailable or unaffordable, and they of 
     course, will welcome the opportunity presented by the 
     legislation to gain coverage.
       For those currently uninsured Americans who would prefer to 
     forego the cost of coverage, even with whatever level of 
     subsidy they will be in a position to claim, the mandate is 
     no more a burden than the requirement to pay Social Security 
     and Medicare taxes--indeed, it is less, since the coverage 
     they receive in return is available immediately, not when 
     they reach eligibility in their 60s.
       By conceding that social and health insurance taxes are 
     constitutionally valid restrictions on individual liberty, 
     while condemning functionally equivalent contributions to 
     private insurers, opponents effectively contend that a 
     single-payer, government-run program like Medicare is the 
     only type of universal health insurance system Congress may 
     establish. The Constitution surely does not impose such an 
     arbitrary strait jacket on Congress.
       The great majority of Americans live in jurisdictions that 
     require the purchase of automobile insurance. Health care 
     reform opponents claim that these state mandatory auto 
     insurance regimes are not ``precedents'' for federal 
     mandatory health insurance, for a variety of essentially 
     legalistic reasons. For example, they assert that auto 
     insurance is a voluntary payment in exchange for a 
     ``privilege,'' permission to drive on public roads. But for 
     most people, driving is an economic necessity. In terms of 
     its actual impact on people, mandatory auto insurance is a 
     common-sense indicator of whether the public would find novel 
     or inherently burdensome a mandate to purchase health 
     insurance from the private insurance industry.
       If, as opponents claim, the burden of mandatory health 
     contributions was--in principle--oppressive and unfair, 
     Medicare, and for that matter Social Security taxes would 
     raise constitutional questions no less than if these landmark 
     statutory programs were cast as regulations of interstate 
     commerce. In fact, of course, since 1937, such questions have 
     never been raised either in the courts or in Congress. The 
     reason is simple: most people regard these mandatory 
     contributions--in light of what they expect to receive in 
     exchange--as a bargain not a burden.

  Mr. HARKIN. Mr. President, this bill makes unprecedented investments 
to expand high-quality educational opportunities for all Americans. It 
invests in the Pell grant scholarship award, strengthens historically 
Black colleges and universities and other minority-serving 
institutions, and provides more resources to States for college access 
and other supports for students through the college access challenge 
grant program.
  Further, these investments are paid for without increasing our 
Nation's deficit, through key reforms in the Federal student loan 
programs designed to provide a stronger, more reliable, and more 
efficient student loan system. The legislation directs more than $10 
billion of the savings generated under this legislation to paying down 
the country's deficit.
  The education provisions of this legislation will convert all new 
Federal student loans to the Direct Loan Program starting in July 2010, 
saving $61 billion over the next 10 years. These changes will also 
upgrade the customer service borrowers receive when repaying their 
loans. The legislation will also maintain jobs by ensuring a robust 
role for the private sector, allowing lenders and not-for-profits to 
contract with the Department of Education to service Direct loans.
  The legislation significantly increases the Federal Pell grant award; 
the cornerstone of need-based Federal student assistance since its 
creation in 1972. Investments in this program are essential to ensuring 
access to higher education and making college more affordable for 
students and families. Both the House and Senate authorizing and 
appropriating committees have made significant investments in 
increasing the maximum Pell grant award in the past few years--32 
percent since 2006. This legislation includes $36 billion to help 
address the Pell grant shortfall in fiscal year 2011 and to increase 
the maximum Pell grant to $5,550 in 2010 and to $5,975 by 2017. 
Starting in 2013, the grant will be linked to match rising costs of 
living for 5 years by indexing it to the Consumer Price Index.
  The legislation includes $750 million to bolster college access and 
other supports for students. It will more than double funding for the 
college access challenge grant program to fund programs in every State 
that focus on informing students about college options and financing, 
increasing financial literacy and helping students persist from year to 
year and graduate.
  While this legislation seeks to ensure increased access and success 
for all students, we intend for the Secretary to work with States to 
address the unique access issues faced by underserved communities, 
including: low-income individuals, individuals with disabilities, 
homeless and foster care youth, disconnected youth, nontraditional 
students, members of groups that are traditionally underrepresented in 
higher education, individuals with limited English proficiency, 
veterans, including those just returning from active duty, and 
dislocated workers.
  The legislation also includes a continuation of funding for 
investments in historically Black colleges and universities, Hispanic-
serving institutions, tribal colleges and universities, institutions 
serving Alaska and Hawaiian Natives, predominantly Black institutions, 
institutions serving Asian American and Pacific Islanders, and 
institutions serving Native Americans, first made under the College 
Cost Reduction and Access Act of 2007, recognizing the critical role 
these institutions play in serving the Nation's minority populations. 
Minority serving institutions educate more than half 58 percent, of 
minority undergraduate students. While Hispanic serving-institutions 
(HSIs) comprise less than 8 percent of colleges and universities 
nationwide, they consistently graduate approximately one-third of all 
Hispanic students with degrees in science, technology, engineering and 
mathematics. Similarly, even though historically Black colleges and 
universities only make up 3 percent of all colleges and universities 
they graduate 40 percent of African Americans with degrees in science, 
technology, engineering and mathematics. These schools also produce 50 
percent of African-American teachers and 40 percent of African-American 
health professionals.
  Concerning the servicing contracts with eligible not-for-profit 
servicers, this legislation recognizes that not-for-profit servicers 
play a unique and valuable role in helping students in their States 
succeed in postsecondary education and that students should continue to 
benefit from the assistance provided by not-for-profit servicers.
  Including more high-quality servicers in the contracting process will 
increase competition amongst servicers and deliver better customer 
service for student borrowers. Under the bill, not-for-profit servicers 
will be allocated a minimum of 100,000 borrower loan accounts as a 
starting

[[Page S1985]]

point. The Secretary of Education has been given the authority to 
increase or decrease that volume based on factors that include capacity 
and customer service. With sufficient loan volume and competitive 
servicing rates, eligible not-for-profit servicers can individually or 
collectively generate sufficient revenue to continue the valuable 
services they provide to borrowers. Because of the significant increase 
in loan volume as all Federal loans are moved to the Direct Loan 
Program, additional servicing capacity will be needed and is provided 
for through the contracts provision. I encourage the Secretary to 
implement these provisions in a timely manner so that many local not-
for-profit servicers will continue to play a role in the student loan 
program.
  The Department of Education should use the not-for-profit servicers 
to increase competition and quality in the student loan programs. To 
ensure that occurs, the Department must hold not-for-profit lenders to 
the same high standards of quality, performance and integrity used for 
other Department of Education loan servicers. This bill would require 
that eligible not-for-profit servicers meet the same standards for 
servicing Federal assets as apply to all other servicing contracts 
under section 456. These standards relate to: information technology 
security; financial reporting; collection and payment processing by the 
Department of the Treasury; internal control management; and, Federal 
accounting practices and debt management. The standards are derived 
from a variety of statutory and other sources of guidance, including 
the Federal Information Security Management Act of 2002 (44 U.S.C. 3541 
et seq.); the Privacy Act (5 U.S.C. 552a); the Federal Financial 
Management Improvement Act of 1996 (P.L. 104-208); the Debt Collection 
Improvement Act of 1996 (P.L. 104-134);the Federal Managers Financial 
Integrity Act (31 U.S.C. 3512); the Chief Financial Officers Act of 
1990 (31 U.S.C. 901 et seq.); the ``Government Management Reform Act of 
1994'' (P.L. 103-356); OMB Circulars A-123 (Management's Responsibility 
for Internal Control), A-127 (Financial Management Systems), and A-129 
(Policies for Federal Credit Programs and Non-Tax Receivables); and the 
Treasury Financial Manual.
  Critical amendments will be made in America's community colleges 
through one additional important program that is funded in the Finance 
Committee's title of this bill. Community colleges serve an 
instrumental role in both our education and workforce systems. They 
provide needed postsecondary education and job training, particularly 
to individuals and families hardest hit by difficult economic times. 
This includes workers eligible for training under the Trade Adjustment 
Assistance for workers program, individuals who are, or may become 
eligible for unemployment compensation, and other individuals who have 
been impacted by the economic and employment crisis. To ensure that 
these institutions have access to the resources they need to develop 
and improve educational and career training programs designed to meet 
the needs of the workers in the affected communities, the legislation 
directs the Secretary of Labor to award community college career 
training grants especially to struggling 2-year public community 
colleges, (as defined in section 101 of the Higher Education Act of 
1965. As the legislation ensures that all States benefit from these 
resources with the inclusion of a State minimum, I also encourage that 
the Secretary strive to ensure a diverse geographical representation of 
community colleges in both urban and rural areas and to provide grants 
to both large and small community colleges. Finally, in order to ensure 
that these grants reach the institutions and students they are intended 
to serve, I encourage the Secretary of Labor to consult with the 
Secretary of Education in implementing grants provided under this 
program. I also remind the Secretary of Labor in implementing this 
program that community colleges are public 2-year degree-granting 
institutions of higher education that offer associate's degrees; or 
public 4-year institutions of higher education that offer associate's 
degrees, are not located reasonably close to a community college, and 
have an open enrollment policy for certificate or associate's degree 
programs; or tribal colleges or universities. This should be the 
universe of institutions awarded grants under the community college and 
career training grants program.
  Mr. President, I ask unanimous consent to have printed in the Record 
a document entitled ``Constitutional Findings regarding the Individual 
Responsibility Requirement.'' Furthermore, in support of this document, 
I commend to my colleagues a list of the following studies and papers:

       --http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-
KeyIssues.pdf
_http://content.healthaffairs.org/cgi/
     content/full/27/5/w399
       --http://www.familiesusa.org/assets/pdfs/hidden-health-
tax.pdf
_http://download.journals.elsevierhealth
     .com/pdfs/journals/00029343/PIIS0002934309004045.pdf
       --http://www.newamerica.net/files/
NAF_CostofDoingNothing.pdf
_http://www.urban.org/UploadedPDF/
411603_individual_mandates.pdf
_http://www.nber.org/papers/w13758.pdf
_http://content.healthaffairs.org/cgi/
     content/full/28/6/w1079
       --http://www.cbo.gov/ftpdocs/107xx/doc10781/11-30-
Premiums.pdf
_http://www.cms.hhs.gov/nationalhealthexpenddata/
downloads/proj2008.pdf
_http://www.cbo.gov/ftpdocs/108xx/doc10868/12-19-
Reid_Letter_Managers_Correction_
     Noted.pdf

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

    Constitutional Findings Regarding the Individual Responsibility 
                              Requirement

       The individual responsibility requirement provided for in 
     the Patient Protection and Affordable Care Act, and amended 
     by Section 1002 of the Health Care and Education 
     Reconciliation Act, is commercial and economic in nature, and 
     substantially affects interstate commerce in many ways, 
     including as a result of the following aggregate effects:
       (1) The requirement regulates activity that is commercial 
     and economic in nature, involving the distribution and 
     consumption of health care services throughout the national 
     economy, and in particular economic and financial decisions 
     about how and when health care is paid for and when health 
     insurance is purchased. Some individuals currently make an 
     economic and financial decision to forego health insurance 
     coverage and self-insure, paying for charges for services 
     directly to the provider and relying on uncompensated care. 
     The decision by individuals not to purchase health insurance 
     has many substantial effects on the national economy, the 
     national marketplace for health insurance, and interstate 
     commerce. Individuals who fail to purchase health insurance 
     have a diminished capacity to purchase health care services, 
     and increase overall health care costs. When such individuals 
     inevitably seek medical care, the costs of that caremust 
     often be paid for by providers, insured individuals and 
     businesses through higher premiums, or Federal, State, and 
     local governments. The requirement encourages prepayment for 
     services, and affects an individual's decision whether or not 
     to purchase health insurance by imposing penalties on 
     individuals who remain uninsured. Congressional Budget 
     Office, Key Issues in Analyzing Major Health Insurance 
     Proposals, December 2008.
       (2) The uninsured receive about $86,000,000,000 in health 
     care, of which about $56,000,000,000 is uncompensated. 
     Private spending on uncompensated care is $14,500,000,000, 
     and includes profits forgone by physicians and hospitals. 
     Government spending on uncompensated care is $42,900,000,000, 
     and is financed by taxpayers at both the State and Federal 
     levels. Jack Hadley et al., Covering the Uninsured in 2008: 
     Current Costs, Sources of Payment, and Incremental Costs, 
     Health Affairs, August 25, 2008.
       (3) Health care received by the uninsured is more costly. 
     The uninsured are more likely to be hospitalized for 
     preventable conditions. Jack Hadley, Economic Consequences of 
     Being Uninsured: Uncompensated Care, Inefficient Medical Care 
     Spending, and Foregone Earnings, Testimony before the Senate 
     Subcommittee on Labor, Health and Human Services, Education, 
     and Related Agencies, May 14, 2003. Hospitals provide 
     uncompensated care of $35,000,000,000, representing on 
     average 5 percent of hospital revenues. Health Affairs, 
     August 25, 2008.
       (4) Those who have private health insurance also pay for 
     uncompensated care. Medical providers try to recoup the cost 
     from private insurers, which increases family premiums by on 
     average over $1,000 a year. Families USA, Hidden Health Tax: 
     Americans Pay a Premium, May 2009.
       (5) The decision to self-insure increases financial risks 
     to households throughout the United States. 62 percent of all 
     personal bankruptcies are caused by illness or medical bills, 
     and a significant portion of medically bankrupted families 
     lacked health insurance or experienced a recent lapse in 
     coverage. David U. Himmelstein et al., American Journal of 
     Medicine, Medical Bankruptcy in the United States, 2007: 
     Results of a National Study, 2009.
       (6) The national economy loses up to $207,000,000,000 a 
     year because of the poorer health and shorter lifespan of the 
     uninsured. Elizabeth Carpenter and Sarah Axeen, The Cost of 
     Doing Nothing, New America Foundation, November 2008.

[[Page S1986]]

       (7) A large share of the uninsured are offered insurance at 
     low or zero premiums, but choose to forego coverage. New 
     America Foundation, December 6, 2007. According to one 
     estimate, the absence of a requirement from health reform 
     would leave 50 percent of the uninsured without coverage. 
     Linda J. Blumberg and John Holahan, Do Individual Mandates 
     Matter?, The Urban Institute, January 2008. While generous 
     subsidies alone would not achieve universal coverage, the 
     requirement further expands coverage. Congressional Budget 
     Office, December 2008. The requirement improves budgetary 
     efficiency by significantly lowering the federal cost per 
     newly insured. Jonathan Gruber, Covering the Uninsured in the 
     U.S., National Bureau of Economic Research, January 2008. In 
     Massachusetts, where a similar requirement has been in effect 
     since 2007, the share of uninsured declined to 2.7 percent in 
     2009. Massachusetts Division of Healthcare Finance and 
     Policy.
       (8) By regulating the decision to self-insure, and 
     expanding coverage, the requirement addresses the problem of 
     free riders who rely on more costly uncompensated care, 
     shifting costs to medical providers, taxpayers, and the 
     privately insured. It will also reduce the cost to the 
     national economy of the lower productivity of the uninsured.
       (9) The requirement is necessary to achieve near-universal 
     coverage while maintaining the current private-public system. 
     It builds upon and strengthens private employer-based health 
     insurance, which covers 176,000,000 Americans nationwide. In 
     Massachusetts, a similar requirement has strengthened 
     employer-based coverage: despite the economic downturn, the 
     number of workers offered employer-based coverage has 
     actually increased. Sharon K. Long and Karen Stockley, 
     Massachusetts Health Reform: Employer Coverage from 
     Employees' Perspective, Health Affairs, October 1, 2009.
       (10) Under the Patient Protection and Affordable Care Act, 
     if there were no requirement, many individuals would wait to 
     purchase health insurance until they needed care. Higher-risk 
     individuals would be more likely to enroll in coverage, 
     increasing premiums and costs to the government. The Urban 
     Institute, January 2008. The requirement will broaden the 
     private health insurance risk pool to include healthy 
     individuals, which will spread risk, stabilize the market, 
     and lower premiums. Congressional Budget Office, An Analysis 
     of Health Insurance Premiums Under the Patient Protection and 
     Affordable Care Act, November 30, 2009. It is necessary to 
     create effective private health insurance markets throughout 
     the country in which improved health insurance products that 
     are guaranteed issue and do not exclude coverage of pre-
     existing conditions can be sold.
       (11) Administrative costs for private health insurance, 
     which were $90,000,000,000 in 2006, are 26 to 30 percent of 
     premiums in the current individual and small group markets. 
     Congressional Budget Office, December 2008. The requirement 
     is necessary to create effective private health insurance 
     markets throughout the country that do not require 
     underwriting, eliminating its associated administrative 
     costs. By significantly increasing health insurance coverage 
     and the size of purchasing pools, which will increase 
     economies of scale, the requirement, together with the other 
     provisions of the Patient Protection and Affordable Care Act, 
     will significantly reduce administrative costs and lower 
     health insurance premiums.
       (12) Health insurance and health care services are a 
     substantial part of the national economy. National health 
     spending is projected to increase from $2,500,000,000,000, or 
     17.6 percent of the economy, in 2009 to $4,700,000,000,000 in 
     2019. Centers for Medicare & Medicaid Services, Office of the 
     Actuary, National Health Expenditure Projections, 2008-2018. 
     Private health insurance spending is projected to be 
     $854,000,000,000 in 2009, and pays for medical supplies, 
     drugs, and equipment that are shipped in interstate commerce. 
     Centers for Medicare & Medicaid Services, Office of the 
     Actuary. Since most health insurance is sold by national or 
     regional health insurance companies, health insurance is sold 
     in interstate commerce and claims payments flow through 
     interstate commerce.
       (13) The requirement, together with the other provisions of 
     the Patient Protection and Affordable Care Act, will add more 
     than 30,000,000 consumers to the health insurance market. 
     Congressional Budget Office, Patient Protection and 
     Affordable Care Act, Incorporating the Manager's Amendment, 
     December 19, 2009. In doing so, it will increase the demand 
     for, and the supply of, health care services. According to 
     one estimate, the use of health care by the currently 
     uninsured could increase by 25 to 60 percent. Congressional 
     Budget Office, December 2008.
       (14) Under the Employee Retirement Income Security Act of 
     1974, the Public Health Service Act, and the Patient 
     Protection and Affordable Care Act, the Federal Government 
     has a significant role in regulating health insurance. The 
     requirement is an essential part of this larger regulation of 
     economic activity, and the absence of the requirement would 
     undercut Federal regulation of the health insurance market.
       (15) Payments collected from individuals who fail to 
     maintain minimum essential coverage will contribute revenue 
     that will help the Federal government finance a reformed 
     health insurance system that ensures the availability of 
     health insurance to all Americans.
       The preceding 15 points cite numerous studies and papers 
     which illustrate the extensive evidence that the Patient 
     Protection and Affordable Care Act, as amended by Section 
     1002 of the Health Care and Education Reconciliation Act, 
     substantially affects interstate commerce. These citations 
     are included as hyperlinks or in their written entirety for 
     the record.

  Mrs. HAGAN. Mr. President, today I rise in support of a bill that 
builds upon the health care reform legislation that was signed into law 
yesterday.
  The new--and historic--law combined with the bill the Senate is now 
considering, will reform our health care system to reduce costs and 
improve patient care for North Carolina families and families across 
America.
  In 1996, the average family premium was $6,000. Today it is $12,000. 
Without health care reform, premiums would skyrocket to $24,000 by 
2016--or half of the average North Carolina family income.
  Without reform, health care costs were projected to reach 20 percent 
of GDP, or $4.3 trillion, by 2017. This trajectory was simply 
unsustainable.
  After decades of working to fix a broken health care system, 
President Obama yesterday signed into law a reform bill that controls 
exploding costs, increases access to health care and reduces our long-
term deficit by as much as $1.2 trillion within 20 years.
  By passing this bill, we will reduce the deficit, for a total savings 
of $143 billion by 2019.
  In addition to containing costs, health care reform will improve 
access and quality of health care for millions of Americans. 1.7 
million North Carolinians without insurance will now have access to a 
family doctor.
  It will provide immediate benefits to small businesses, middle class 
families, and seniors in North Carolina.
  While small businesses make up 98 percent of North Carolina's private 
sector employers, in 2008, only 38 percent offered health insurance.
  Small business owners I talk to want to provide coverage for their 
employees, but costs are prohibitive. This month, I received an e-mail 
from a small chiropractic practice in eastern North Carolina that had 
to drop its health insurance plan for employees because rates were 
doubled over 2 years. Most of the practice's employees are young women 
under 30.
  But starting today, 112,000 North Carolina small businesses will be 
eligible for tax credits to provide health care to employees.
  Within the next 6 months, hard-working, middle-class families will be 
able to add their children up to age 26 onto their health plans. This 
will benefit about 877,000 young adults in North Carolina.
  This year, insurance companies will no longer be able to deny 
coverage to a child for a preexisting condition, like asthma or 
diabetes.
  Health care reform means people can access preventive care without 
being saddled with copays or deductibles. This includes well-child 
visits and seasonal flu immunizations.
  I recently heard a story about a North Carolinian who, as a junior in 
college, had terrible stomachaches. But he could not afford a 
colonoscopy. He learned of his colon cancer too late for the doctors to 
save him. Health care reform means this young man would have had a 
chance.
  Health care reform means people with chronic illnesses will no longer 
have to fear losing their insurance because of an arbitrary, insurance 
company-set lifetime cap.
  And it means insurance companies will no longer be able to drop your 
coverage because you get sick or file too many claims.
  Seniors also will see immediate benefits. In North Carolina, 1.4 
million seniors will receive preventive services with no additional 
costs, and 247,000 seniors will have their drug costs in the ``donut 
hole'' immediately reduced and eventually eliminated.
  I am proud of these immediate benefits and our efforts to reform the 
health care system for the long term.
  This reform effort contains provisions that I have championed since 
coming to the Senate. In the United States, 23 million adults and 
children suffer from diabetes, and in North Carolina, diabetes costs 
our State $5.3 billion per year in medical interventions, lost 
productivity, and premature mortality.
  Given these dire numbers, I added to the health care reform bill the 
second

[[Page S1987]]

piece of legislation I introduced as a U.S. Senator--The Catalyst to 
Better Diabetes Care Act. The Senator from Texas, Mr. Cornyn, 
cosponsored the bill last July. It creates a national and State-by-
State level diabetes report card to track progress at beating the 
disease. It also requires the promotion of physician education on 
properly completing birth and death certificates, and requires that 
recommendations be made on appropriate levels of diabetes medical 
education that should be completed prior to medical licensing and board 
certification.
  I also worked with the Senior Senator from Colorado, Mr. Udall, to 
add a section to health care reform to improve access to health care in 
rural areas. The section we added will help medical schools establish 
programs designed to increase the number of graduates who practice in 
rural areas. It will give schools resources to recruit students from 
rural areas who have an interest in practicing medicine in their 
communities, and it provides for additional training in pediatrics, 
emergency medicine, obstetrics and behavioral health.
  I also want to take this opportunity to discuss how the bill the 
Senate is currently considering will help make college affordable for 
our families.
  One of the most significant provisions for our students in this 
legislation is the over $2.5 billion investment over the next 10 years 
in historically Black colleges and universities.
  There are 10 outstanding HBCUs in North Carolina. HBCUs graduate 40 
percent of African Americans with degrees in science, technology, 
engineering and mathematics; 50 percent of African-American teachers; 
and 40 percent of African-American health professionals.
  North Carolina A&T, an HBCU in my hometown of Greensboro, graduates 
more African Americans with PhDs in engineering than any other school 
in the country.
  This is a milestone week for the State of North Carolina. I am 
working with my colleagues to send this bill to the President's desk to 
further reduce costs for North Carolina's families and small 
businesses.
  This health care reform effort would not have been possible without 
the work of some tenacious Capitol Hill staff, and I want to personally 
thank my two incredible health care staffers, Michelle Adams and Tracy 
Zvenyach, who worked countless hours for reform in our country.
  Mr. CARDIN. Mr. President, I rise today in full support of the Health 
Care and Education Affordability Reconciliation Act of 2010. I assert 
that the investment we make in education with this bill is an 
investment in America's economic future.
  For too long, we have allowed America to lag behind other nations in 
education, specifically in the number of college graduates we produce. 
No more. Now is the time to train our workforce to compete in the 
global economy. Now is the time to provide affordable, accessible, 
quality educational opportunities so that America will shine as a 
beacon of ingenuity and prosperity once again. This bill answers the 
call by making college more affordable and accessible.
  Perhaps most significantly, the bill invests in and protects the Pell 
grant scholarship. It provides $36 billion over 10 years for this 
program which allows so many to attend college who would not otherwise 
have the opportunity. This includes funding to cover a shortfall due to 
demand. The failing economy has spurred a dramatic increase the number 
of those students who are eligible for Pell grants. In 2007, there were 
5 million Pell grant recipients. In 2009-2010, there were 8.3 million. 
The bill also provides an increase in the maximum annual award which 
will ultimately be indexed to the Consumer Price Index and thus linked 
to increases in the cost of living.
  In Maryland, over 85,000 students depend on Pell grants to help them 
attend college. With the additional funding, that number is expected to 
rise to 100,000. That is 15,000 additional students who have the 
opportunity to share in the American dream! Students like Morris 
Johnson from Baltimore. Morris is a double major in sociology and 
communications at Goucher College with a 3.5 grade point average. 
Morris credits those who believed in him and his academic promise for 
keeping his dream of attending college alive. But without financial 
aid, including a Pell grant, that dream would have been out of reach.
  For those who find it necessary to borrow to finance their education, 
the bill solidifies a mechanism for obtaining high-quality student 
loans. The direct loan program is a reliable lender and cost-effective 
mechanism for taxpayers. Beginning in July of this year, all new 
student loans will be originated through the direct loan program. This 
will bring an end to the costly federally-guaranteed student loan 
program that generated billions of dollars in subsidies for banks--at 
the expense of additional financial aid for more deserving students. 
Instead, direct loans will be serviced by contracted private lenders. 
Further, direct loans can only be serviced in the United States, 
thereby preserving American jobs.
  The bill also makes it easier for new borrowers after 2014 to repay 
Federal loans by lowering the existing cap on monthly Federal student 
loan payments from 15 percent to 10 percent of discretionary income. 
The legislation provides $1.5 billion for this income-based repayment 
program.
  Just paying for college, however, isn't enough. We need to make sure 
our students succeed in college and graduate. To that end, the bill 
supports additional key investments:
  The bill dramatically increases funding for the College Access 
Challenge Grant program. This program funds innovative financial 
literacy and retention projects. This will increase the number of low-
income students who are adequately prepared for the financial 
challenges of paying for college and related expenses.
  The bill underscores the role of minority-serving institutions in 
educating the Nation's low-income and minority students by providing 
$2.5 billion to support these institutions. This funding represents a 
significant investment in Maryland where we have four outstanding 
Historically Black Colleges and Universities. The bill also recognizes 
the role of community colleges and provides $2 billion for a 
competitive grant program to develop and improve career training 
programs.
  I said the time for making college more accessible and affordable has 
come and I believe that. But we also have to be fiscally responsible. 
This bill is both. It makes historic investments in Federal financial 
aid and yet comes at no cost to the taxpayers. This is possible by 
switching all Federal loans to the direct loan program. Doing so saves 
taxpayers a huge amount in subsidies that were going to the banks. 
According to the Congressional Budget Office, this savings will amount 
to $61 billion over 10 years. Even with the improvements, these 
education provisions in the legislation will reduce the deficit by $10 
billion over 10 years, at least.
  The education provisions in this legislation make college more 
affordable and accessible. It's necessary for America's students and 
for America's future.
  Ms. MIKULSKI. Mr. President, I am proud today to support the student 
loan reform provisions in the Health Care and Education Affordability 
Reconciliation Act of 2010. I've said this often, we in this country 
enjoy many freedoms: the freedom of speech, the freedom of the press, 
the freedom of religion. But there is an implicit freedom our 
Constitution doesn't lay out in writing, and its promise has excited 
the passions, hopes, and dreams of people in this country since its 
founding. The freedom to take whatever talents God has given you, to 
fulfill whatever passion is in your heart, to learn so you can earn and 
make a contribution--the freedom to achieve.
  When I was a young girl at a Catholic all-girls school, my mom and 
dad made it clear they wanted me to go to college. But, right around 
graduation, my family was going through a rough time because my dad's 
grocery store had suffered a terrible fire. I offered to put off 
college and work at the grocery store until the business got back on 
its feet. My dad said, ``Barb, you have to go. Your mother and I will 
find a way because no matter what happens to you, no one can ever take 
that degree away from you. The best way I can protect you is to make 
sure you can earn a living all of your life.'' My father gave me the 
freedom to achieve. And the provisions in this bill will give millions 
of

[[Page S1988]]

Americans that same freedom without adding a dime to the deficit.
  For too long, banks have gotten a free ride from the U.S. Department 
of Education by offering federally guaranteed student loans. The 
provisions in this bill will stop wasteful and unnecessary subsidies to 
lenders and put that money where it is needed most--in students' 
pockets. By reforming the Federal student loan program, we will save 
over $60 billion in the next 10 years. Many of those savings will go to 
increase the Pell grant, which has made college a reality for students 
of modest means for nearly half a century. But we also make critical 
investments in institutions that help our most underserved students: 
community colleges and Minority Serving Institutions, particularly 
Historically Black Colleges and Universities, HBCUs.
  I have fought alongside my colleagues for years to increase funding 
for these programs and there was a point where Democrats had to fight 
tooth-and-nail just to keep Pell funding from being cut. Now we are in 
a position where we can guarantee increases in the Pell grant, which 
helps more than 90,000 students in my home State of Maryland. My 
colleagues have spoken eloquently about the importance of the much-
needed investments in this bill, but I would like to take a moment to 
highlight the investments in HBCUs. I am the only senior Democrat on 
the HELP committee that has HBCUs in their State, and I have been a 
long-standing champion for these schools in both my work as an 
authorizer on the HELP committee and as an appropriator through my 
chairmanship of the Commerce, Justice, and Science Appropriations 
Subcommittee.
  I am proud that Maryland has four public HBCUs which provide an 
incredible benefit to African-American students and the communities 
they serve. Few people know, but HBCUs produce nearly a quarter of our 
Nation's African-American public school teachers. They also produce 
almost 40 percent of African-American graduates in physics, math, 
biology, and environmental sciences.
  Some of my colleagues might argue that HBCUs shouldn't be getting 
Federal funding based primarily on the racial makeup of their student 
bodies and, further, that there is no longer any place for these 
institutions in this day and age. What I would tell them is that 
Congress has been providing direct Federal support for HBCUs for more 
than 50 years mainly for two reasons. First, Congress recognizes the 
historical and cultural importance of HBCUs and their benefit to 
students who are often the first in their families to go to college. 
Second, the emergence of these institutions was a direct result of 
Federal action permitting the segregation of students in public 
education based on race.
  During those dark days, HBCUs were often the only pathways to college 
for African Americans; they were able to open the doors of opportunity 
that were so often shut. But these institutions are historically under-
resourced, and their students are by and large underserved. For that 
reason they have had to fight for representation, respect, and 
recognition since they were established. They've had to urge lawmakers 
to act ``now'' on behalf of their students when so many have told them 
to ``wait.'' So I am here to make sure that the more than 20,000 
students at Maryland's HBCUs get the resources they deserve by 
supporting the $850 million investment in HBCUs over 10 years enabled 
through this reconciliation bill. Maryland is slated to get $65 
million, and I am confident that the presidents of Morgan State 
University, Coppin State University, the University of Maryland Eastern 
Shore, and Bowie State University will be good stewards of this 
landmark Federal investment.
  Our work isn't done when it comes to equity in access for higher 
education, but this bill helps us get there.
  Mr. KAUFMAN. Mr. President, after decades of efforts and a year of 
extensive debate, Americans will finally have a health care system that 
controls costs, reduces the deficit, improves access, adds more 
protections for seniors and curbs insurance company abuses. The 
President has signed meaningful health care reform into law that will 
extend immediate benefits to millions of American families and small 
businesses.
  In implementing this comprehensive legislation, the Department of 
Health and Human Services will be called upon, as will other Federal 
agencies, and the States, to make assessments in a variety of contexts 
as to whether the marketplace is functioning properly, or whether 
abuses are occurring. In making these assessments, and in deciding on 
appropriate steps to address any abuses or dysfunction, the Federal 
agencies and the States can benefit greatly from competitive analysis 
provided by the Department of Justice's Antitrust Division and the 
Federal Trade Commission.
  One example where this advice would be particularly beneficial is in 
implementing the mandate to establish State and/or regional health 
exchanges. At present, many State health insurance markets are 
characterized by their extreme concentration. According to the American 
Medical Association, in 2007, at least one insurer had a combined HMO/
PPO market share of 50 percent or greater in 64 percent (200) of the 
local markets (or Metropolitan Statistical Areas) of the United States. 
And the two top insurers accounted for at least 60 percent of 
enrollment in almost 75 percent of these markets. High concentration 
and barriers to entry reduce price competition and customer choice.
  The law just passed contains an antitrust savings clause, which 
clarifies that Congress did not intend health care reform to erode the 
reach of the antitrust laws in any way. To restore true competition 
however, more than a savings clause is needed.
  I am pleased that the law vests in State exchange regulators the 
power to address competition failures in the market, including the root 
causes of industry concentration. This means curbing anticompetitive 
practices designed to keep prices high and choices low, and also 
encouraging new market participants by mitigating barriers to entry. 
Obvious market abuses, such as tying agreements, predatory practices 
and the like, must be stopped. But success also requires that the 
regulators get the more delicate issues right: does a preferred rate 
agreement constitute a de facto boycott? Will a regulation or exchange 
adversely impact the ability of a new participant to gain public trust? 
How does a proposed rule impact the ability of young insurance 
companies to develop a comprehensive network of health care providers?
  These are difficult questions and we should not expect State 
regulators to develop an expertise in them overnight. But our Federal 
antitrust agencies, have, through years of experience, developed just 
this expertise. I urge the exchange regulators, as well as the 
Department of Health and Human Services and other responsible agencies, 
to make full use of their assistance.
  Mr. NELSON of Florida. Mr. President, I rise today in support of two 
amendments, S.A. 3574 and S.A. 3575, offered by the junior senator from 
Florida. I am concerned the student loan reforms in the bill will lead 
to a substantial loss of jobs in my State. That is why I recently led a 
group of six Senators in asking Majority Leader Reid to consider 
alternative ways to reduce the cost of student loans. Unfortunately, 
that has not happened. The provisions in this bill could prove 
detrimental to thousands of employees who serve in the student loan 
industry throughout this country, about 700 who are located in Panama 
City, FL. Therefore, Mr. President, I urge the Senate to pass this 
amendment.
  Mrs. FEINSTEIN. Mr. President, I rise in support of the education 
provisions in the reconciliation legislation that reforms Federal 
student loan programs and will help our Nation's neediest students 
afford college by providing $35.5 billion for the critical Pell grant 
program.
  Nearly 700,000 students in California right now receive Pell grants 
of up to $5,550 out of over 8 million students nationwide. The majority 
of these students come from families where the average income is less 
than $40,000.
  The Pell grant funds in the bill will help prevent cuts to students' 
grants of up to 60 percent and prevent nearly 600,000 students from 
losing their grant entirely.
  It will also help 63,000 more students in California receive a Pell 
grant so they can afford to go to college during this tough economic 
time.
  Specifically, the legislation will allow the current Federal Direct 
Loan

[[Page S1989]]

Program, backed by the U.S. Treasury, to be the sole originator of all 
federal student loans; save $61 billion over 10 years by eliminating 
the Federal Family Education Loan Program, FFELP, which provides 
unnecessary subsidies to private lenders and banks for originating 
student loans.
  Of the $61 billion in savings, it directs $10 billion to help reduce 
the Federal deficit, and the remainder towards important education 
programs, such as $35.5 billion for Pell grants to help students afford 
college; direct $22.5 billion of the total $35.5 billion in new Pell 
Grant funds to increase the maximum award amount--from the current 
$5,550 to about $6,000 to help with rising college costs.
  The economic downturn has resulted in increased enrollment at 
colleges and universities, and increased eligibility in Federal student 
aid, with the number of Pell grant recipients increasing by 1 million 
students in the past two years alone.
  In my home state of California, these important provisions are 
supported by the University of California, UC, California State 
University, CSU, and California's public community college system--
which together serve approximately 500,000 Pell grant students.
  I urge my colleagues to support these provisions that are critically 
important to our Nation's students.


                              puerto rico

  Mr. MENENDEZ. Mr. President, I want to thank the chairman and his 
staff for taking the time and effort to ensure the 4 million residents 
in Puerto Rico are treated fairly in our health care system.
  Throughout my time in Congress, first in the House, and now here in 
the Senate, I have worked to see the people of Puerto Rico are not 
forgotten. The health care reform package we are debating today has 
several outstanding provisions for Puerto Rico. It is an example of the 
good we can do for its nearly 4 million U.S. citizens--who pay Social 
Security and Medicare taxes.
  But there is one issue I want to raise and that is the Medicare 
Advantage program on the island. Approximately 83 percent of the 
eligible Medicare beneficiaries in Puerto Rico participate in Medicare 
Advantage, compared to 25 percent in the States. This can be tracked to 
the fact that eligible seniors in Puerto Rico are not automatically 
enrolled in Medicare Part B when they turn 65. As a result, it is more 
beneficial for seniors in Puerto Rico to enroll in Medicare Advantage 
to receive all of their Medicare services.
  However, the fee-for-service, FFS, cost calculation for Puerto Rico 
is inaccurate and under counts expenditures per Medicare beneficiary. 
Last year the Medicare Payment Advisory Commission, MedPAC, alerted 
Congress to this and recommends that the Centers for Medicare & 
Medicaid Services, CMS, should expeditiously use its authority to 
employ an alternative calculation method . . .'.
  The fee-for-service cost calculation is important because it will 
soon be the basis for Medicare Advantage rates throughout the country 
and Puerto Rico. I strongly believe CMS should take a look at the under 
count. If there is validation that the FFS expenditures are too low, I 
believe the HHS Secretary and CMS should use current authority and 
adjust the calculations appropriately.
  I am asking HHS and CMS to look at the under count because there is a 
very real chance we could do harm to Medicare Advantage in Puerto Rico 
if we don't get the FFS costs accurate. I hope the chairman agrees with 
me.
  Mr. BAUCUS. I thank the Senator for bringing attention to this issue. 
He is a true champion for Puerto Rico and a constructive member of the 
Finance Committee.
  I share his concern about the possible under count of fee-for-service 
costs in areas like Puerto Rico. That is why we included a provision in 
the Medicare Improvements for Patients and Providers Act of 2008 to 
have MedPAC study the accuracy of the calculation and report to 
Congress. As he points out, MedPAC recommends that CMS alter the FFS 
cost calculation so that such under counts do not exist, particularly 
in areas like Puerto Rico where Medicare Advantage provides benefits to 
over 80 percent of its seniors.
  I strongly agree with him that CMS should promptly use its authority 
to correct any and all under counts that might exist in areas like 
Puerto Rico. The island has unique circumstances that could affect 
Medicare expenditures and spill over to Medicare Advantage. Moving 
forward I will continue to work with the Senator closely to monitor and 
correct this issue as expeditiously as possible.
  Mr. MENENDEZ. I thank the Chairman for his leadership and commitment 
on this issue.


                                  PEOs

  Mr. NELSON of Florida. Mr. President, I would like to ask the 
chairman of the Committee on Finance and its ranking member a question 
on the application of the legislation to Professional Employer 
Organizations or PEOs.
  As they know, there are millions of individuals throughout our 
country who are working for small businesses which are in PEO 
arrangements. The clear objective of this legislation is to create 
incentives for health care coverage and not to provide disincentives. I 
would like the chairman to clarify that, for purposes of the 
application of section 2716 of the Public Health Service Act 
(Prohibition on Discrimination in Favor of Highly Compensated 
Individuals) and for purposes of Internal Revenue Code sections 45R 
(Credit for Employee Health Insurance Expenses of Small Businesses) and 
4980H (Shared Responsibility for Employers), to any health plans 
sponsored by a Professional Employer Organization, PEO, or a PEO client 
organization, the rules would be applied to each client organization 
separately and eligibility for the small business tax credits and 
employer shared responsibilities would also apply to each client 
organization separately, and not at the PEO level.
  Mr. BAUCUS. If the individual providing services to the PEO client 
organization pursuant to the PEO arrangement continues to be an 
employee of the PEO client organization, the Senator from Florida is 
correct.
  Mr. GRASSLEY. I agree with the chairman.
  Mr. BAUCUS. Mr. President, I want to talk a moment about one of the 
only retroactive tax provisions in the Patient Protection and 
Affordable Care Act, Section 9016. This one deals with the special 
deductions given to the many nonprofit Blue Cross Blue Shield 
organizations which are no longer exempt from Federal income tax.
  Under section 833 of the Internal Revenue Code, these organizations 
receive a 25 percent deduction for claims and expenses and an exception 
from the--otherwise applicable--20 percent reduction in the deduction 
for unearned premium reserves. Effective January 1 of this year, these 
non-profit Blue Cross Blue Shield organizations must now meet a medical 
loss ratio of 85 percent or higher in order to take advantage of the 
tax benefits of section 833. This provision was included to ensure that 
recipients of this special deduction actually spend out most of their 
premium income on the people they insure and not on administrative fees 
or executive compensation.
  But I want to clarify two issues here. First, it was our intention 
that, in calculating the medical loss ratios, these entities could 
include both the cost of reimbursement for clinical services provided 
to the individuals they insure and the cost of activities that improve 
health care quality. Determining the medical loss ratio under this 
provision using those two types of costs is consistent with the 
calculation of medical loss ratios elsewhere in the legislation. This 
determination would be made on an annual basis and would only affect 
the application of the special deductions for that year.
  Second, it was our intention that the only consequence for not 
meeting the medical loss ratio threshold would be that the 25 percent 
deduction for claims and expenses and the exception from the 20 percent 
reduction in the deduction for unearned premium reserves would not be 
allowed. The entity would still be treated as a stock property and 
casualty insurance company.
  It is my understanding that the Joint Committee on Taxation scored 
this provision consistent with the policy I just outlined. We intend to 
clarify these two issues in a technical corrections bill as soon as 
possible.
  Mr. President, I want to speak concerning the accounting treatment of 
one of the tax provisions that passed in the Patient Protection and 
Affordable

[[Page S1990]]

Care Act, Section 9008, and that is proposed to be modified in the 
Health Care and Education Reconciliation Act. This deals with the 
annual fee on pharmaceutical manufacturers which, as passed, is to go 
into effect this year. It is our hope that Congress will delay the 
implementation of this fee by 1 year, to 2011, by passing the 
reconciliation bill which we are discussing today on the floor. This 
will give the government reporting agencies more time to establish 
systems to report the drug sales to the Secretary of the Treasury as 
required by health care reform.
  As a reminder of how the fee works: our legislation sets an 
aggregate, annual fee that is to be apportioned among the relevant 
companies based on their market share of branded U.S. prescription drug 
sales made to or funded by specified government programs. The U.S. 
Treasury will allocate this annual fee to each company based on its 
relative market share for the prior year.
  Now, we understand that there have been questions about the nature of 
this fee that are affecting how the fee should be treated for 
accounting purposes. It was our intent that the fee is assessed in the 
year that it is due. A fee is assessed on an entity in any given 
calendar year only if the entity is engaged in the business of 
manufacturing or importing branded prescription drugs and has sales to 
the specified government programs in that calendar year. The reference 
in the legislation to sales for the preceding calendar year is for the 
sole purpose of providing the method of calculating market share. It 
would be difficult to calculate market share and impose and collect the 
fee in the same year, so we decided to look back to a completed year as 
a proxy of market share. But it is not intended that a manufacturer or 
importer would be assessed an annual fee in a calendar year in which it 
had no branded prescription drug sales to the government programs. This 
is regardless of whether the manufacturer or importer had any relevant 
sales in the preceding year.
  As an example, suppose a pharmaceutical company made sales in 2011 
but in November 2011 shut down its U.S. operations and had no further 
sales to the specified government programs. In 2012, that 
pharmaceutical company would not be subject to the fee. Instead, the 
2012 aggregate fee would be allocated among those companies selling 
drugs in 2012 to the specified government programs.
  These same accounting questions may also be raised under the annual 
fee on health insurance providers--section 9010 of the Patient 
Protection and Affordable Care Act, as amended. On these issues, our 
intent as to the treatment of the fees is the same.
  We anticipate that the Secretary of the Treasury will provide 
guidance on how to determine the fees in situations involving mergers, 
acquisitions, business divisions, bankruptcy, or other situations where 
it may be difficult to account for sales taken into account in 
determining market share. We intend to work with the IRS and the 
affected groups to further clarify the law consistent with the policy I 
have just outlined.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, how much time is remaining on our side?
  The PRESIDING OFFICER. There is 1 minute 48 seconds remaining.
  Mr. BAUCUS. First, I thank all of my colleagues on both sides of the 
aisle. This has been a very civil discussion, very heartfelt feelings 
on both sides, and I appreciate that.
  Let me also say it is interesting that this is the first time in 
recent memory that a reconciliation bill has all amendments on one side 
only. These are clearly amendments designed to kill the reconciliation 
and therefore kill health care reform. So I very much hope that all of 
these amendments are defeated.
  I note there are 23 amendments pending. It is going to take 7 or 8 
hours, hopefully less. There will be many more amendments offered 
tonight. It is our expectation that we will continue voting on all 
amendments until we finally vote on all amendments and we can get 
reconciliation passed, and therefore all of the measures surrounding 
health care reform will be enacted and we can proceed.
  Mr. GRAHAM. Mr. President, I rise today with great disappointment in 
both the substance and process of this legislation.
  We should be working from a long held medical premise; first, do no 
harm. Instead, Americans know this government takeover of the health 
care system is bad and the tactics that have been used to do it are 
even worse. The policies contained in the recently passed health care 
bill combined with this reconciliation package will raise costs, lower 
the quality of care in our country, shift a new unfunded mandate onto 
the States, and will result in health care rationing.
  The reasons Democrats passed this bill on a party-line vote in the 
Senate on Christmas Eve and late this past Sunday night in the House 
are because of a slew of backroom deals and arm twisting to buy up last 
minute votes. Now we take up the reconciliation bill to remove some of 
these deals so the President can claim to have clean hands.
  There are many other reasons to oppose this bill, aside from the 
unsavory deals made to secure its passage. In both its scope and reach, 
the combination of health care legislation and reconciliation is 
unprecedented. It raises $644 billion in taxes and cuts $525 billion 
from Medicare. The Democrats' bill contains accounting gimmicks that 
would make Bernie Madoff proud.
  The Congressional Budget Office found that savings generated from 
Medicare will not be reinvested in the program, but rather will be used 
to pay for new programs, putting even more strain on the long-term 
viability of Medicare.
  There is no guarantee this plan lowers health care costs for 
consumers. What is sure is that 80 percent of Americans will find 
themselves in some form of government-run, government-controlled health 
care. The remaining 20 percent will soon be asked, if not required, to 
follow.
  Historically, large-scale social legislation has passed with great 
bipartisan support. Social Security legislation passed in 1935 with 77 
bipartisan votes. Medicare passed with 68 votes, and the Americans with 
Disabilities Act passed with 76 votes. Never before have we acted in a 
manner that would affect one-sixth of our economy on the whims of a 
single political party. The combination of tactics used to pass the 
health care bill and amend it through reconciliation moves us into 
uncharted territory.
  Even previous budget reconciliation measures cited by my colleagues 
on the other side have passed with large, bipartisan margins. The law 
that created the COBRA insurance program, often cited by my friends, 
achieved final passage in the Senate on a voice vote in 1985. In 
addition, welfare reform was supported by 78 Senators and SCHIP passed 
the Senate with a whopping 85 votes.
  While there are a number of things that Republicans and Democrats 
agree on when it comes to reforming the health care system, Democrats 
have chosen to pursue a winner take all strategy that leaves them in 
the position of having to clean up a messy bill through the process of 
reconciliation. They have adopted a hard-line ideological approach and 
continue to push a plan that will put us one giant step closer to the 
single-payer government run health care system they have long desired.
  Speaking of a federal takeover; if you want a federal takeover of the 
student loan industry, then your ship has come in. Every student in the 
country who needs to borrow money for college will now have to come to 
the Federal Government for a loan, which will make the United States 
Department of Education one of the Nation's largest banks. A portion of 
the proceeds from these loans, about $9 billion, will then be used to 
finance new health care spending instead of being put back into 
education programs. Students will be caught in the middle in terms of 
health care financing. Not only will their loan interest go to finance 
an unpopular health care proposal, but they will be paying higher taxes 
when they graduate and get a job.
  I am afraid that by dealing Republicans out of the game, Democrats 
have done great harm to comity in the Senate. I have never hesitated to 
work across the aisle on tough issues and try to reach consensus. After 
this maneuver, I fear that bipartisanship may be a

[[Page S1991]]

thing of the past for the foreseeable future. While there may have been 
the chance to work together on important topics, I believe Republicans 
must now pursue a strategy of repeal and replace. Repeal this damaging 
legislation and replace it with programs that promote fair tax 
treatment of health care, encourage innovation, reward wellness, and 
help those in need.
  I will be voting against this reconciliation bill because I believe 
that combined with the recently passed health care bill, it will do 
more harm than good for health care and higher education in America.
  The PRESIDING OFFICER. The Senator from New Hampshire.
  Mr. GREGG. How much time do we have on our side?
  The PRESIDING OFFICER. There is 4 minutes remaining.
  Mr. GREGG. Mr. President, a lot has been talked about here. A lot has 
been discussed. I don't want to get in an expansive discussion of the 
issue of the underlying bill. It has been fully aired. But this concept 
to vote down every amendment, that you have to do that in order to save 
this bill, seems to reject the concept of a constitutional process.
  Think about this for a moment. The whole series of amendments here 
are being offered to fulfill the statements made by the President of 
the United States. For example, Senator McCain has offered an amendment 
to take out the sweetheart deals. The President said the sweetheart 
deals would be taken out. Senator Barrasso has offered an amendment 
which says that if premiums go up, certain parts of this bill will not 
go into force. The President said premiums will not go up on working 
Americans. Senator Crapo has offered an amendment which says that if 
there are taxes on people earning less than $200,000, those taxes won't 
go into force. That is what the President promised. I have offered an 
amendment which says that if there are Medicare cuts in this bill, the 
cuts should go to Medicare and make Medicare more solvent--a promise 
also made from the other side of the aisle.
  All of these are amendments which are substantive and the purpose of 
which is to put forward the policies which the other side of the aisle 
represented they were going to have in their original bill. This is 
called the fix-it bill. Well, we are suggesting you fix it so it meets 
the conditions set out by the President and by the Democratic 
leadership. Yet now we hear that every amendment should be voted down. 
Why? Because the idea of sending the bill back to the House is anathema 
to the Democratic Party. Did I miss something? Isn't the House of 
Representatives controlled by the Democratic Party with a 
supermajority? You mean they couldn't survive the idea of knocking out 
the sweetheart deals, sending it back to the House, and coming back 
here? That is going to somehow fundamentally undermine this bill? That 
argument is absurd on its face. It is absurd on its face.
  I think the only answer is that the other side of the aisle has 
decided to proceed on this bill in a most arrogant process. From the 
beginning of the core of this bill being put together in a hidden room 
behind a hidden room behind a hidden door of the majority leader's 
office suite, brought to this floor on a Saturday afternoon, the tree 
was filled and we were told we had to vote on it on Christmas Eve. No 
amendments were allowed. Then it was taken over to the House, and the 
Speaker worked out the deals in the back rooms of her offices behind 
hidden doors without any public input, without C-SPAN there, as was 
represented it would be. And what happened? It passed the House without 
any amendments being allowed.
  Now, for the first time, we have a chance to offer amendments, and 
the position on the other side of the aisle is no amendments allowed 
even if they are good amendments.
  So, I guess, obviously, they consider their promises to be an 
inconvenience. Obviously, they presume the Republican Party is an 
inconvenience. The Democratic process is an inconvenience. It also 
appears, considering the opposition to this out in America, that the 
American people are an inconvenience and that amendments which make 
sense aren't going to be allowed to be passed because they don't want 
to send it back to the House of Representatives. It makes no sense to 
me, and I don't think it is going to make much sense to the American 
people.
  This bill is fundamentally flawed. It needs to be repealed and it 
needs to be replaced. We have suggested a whole series of amendments 
which will significantly improve this bill, and I hope some will be 
supported by the other side of the aisle since they are the policies of 
the other side of the aisle.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. BAUCUS. Mr. President, make no mistake----
  Mr. GREGG. Mr. President, point of order. Is there time remaining on 
the bill?
  The PRESIDING OFFICER. There is 53 seconds remaining for the 
majority.
  Mr. BAUCUS. Mr. President, make no mistake, the intent of every 
single one of the amendments offered on the other side of the aisle is 
to kill health care reform. That is the sole purpose of each of those 
amendments. That was the sole purpose of the amendments in the Finance 
Committee last year--to kill health care reform. It was the sole 
purpose in the HELP Committee, except for a few benign amendments--to 
kill health care reform. It was the sole purpose on the floor of the 
Senate when we took it up. Every amendment was to kill health care 
reform.
  A Senator on the other side of the aisle stood up and said that this 
is hopefully the President's Waterloo. They want to kill health care 
reform. It is clear they want to kill health care reform.
  The other side has said repeatedly in campaign statements in the 
other body that they want to repeal health care reform. They have 
orchestrated legislatures to repeal health care reform.
  Each amendment offered here is intended to kill health care reform, 
and that is why each amendment should fail.
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. REID. I note the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. REID. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. REID. Mr. President, I direct this comment through the Chair to 
my distinguished colleague, the Republican leader. All time has 
expired. Under the rules in the Senate, we start our vote-athon now, as 
the Republican leader knows. I would ask my friend, is it the desire of 
the minority that there be time before each amendment and a response to 
that?
  Mr. McCONNELL. Yes. I would say to my friend the majority leader, 
since the voting will all occur during the so-called vote-arama, if we 
could have a minute or so before each amendment simply to describe what 
it is, that would be helpful.
  Mr. REID. Mr. President, I say again through the Chair to my 
colleague and those Members of this body, we do not have to agree to 1 
minute, but we want everyone to understand we have tried to be as fair 
as we can through this whole process. There are some who said: Why 
should we waste--there would be 43 minutes or 46 minutes. I think there 
are 23 amendments pending, so that would be 46 minutes. But we want to 
be fair. In recent years, we have agreed by unanimous consent to have 1 
minute to explain the amendment and 1 minute to disagree with the 
amendment. I think that is the appropriate thing to do. We want to make 
sure everyone is treated fairly.
  But I alert everyone: The Chair is going to enforce--we are not 
waiting for the Parliamentarian--the Chair is going to enforce that to 
the letter of the law. Every time the Presiding Officer is here, there 
will be 1 minute--if this consent agreement is agreed to--there will be 
1 minute to explain the amendment and 1 minute to disagree with the 
amendment.
  Mr. McCONNELL. Would my friend yield for an observation?
  Mr. REID. Yes.
  Mr. McCONNELL. Even though allowing that, as the majority leader 
suggested, is certainly optional, it has been the custom of both sides, 
when we have been in these vote-arama situations in the past, to allow 
the time on

[[Page S1992]]

each side, and I appreciate the willingness of the majority leader to 
do that.
  Mr. REID. Mr. President, I ask unanimous consent, as I directed, or 
asked, that there be 1 minute to explain the amendment and 1 minute to 
disagree with the amendment.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. REID. Mr. President, I also ask unanimous consent that after the 
first amendment, on which we will do our normal 15 minutes with 5 
minutes of time after that, all votes thereafter be 10 minutes. I ask 
unanimous consent that prior to each vote there be 2 minutes of debate 
equally divided and controlled in the usual form; that upon use or 
yielding back of that time, the Senate proceed to vote in relation to 
the amendments and the motions in the order they have been offered--I 
think that is the fair way to go so we are not trying to catapult over 
other amendments people may have offered at an earlier time--with no 
intervening amendments or motions in order prior to a vote; further, 
that after the first vote in this sequence, the succeeding votes be 
limited to 10 minutes each.
  The reason I suggest 10 minutes is I have been told by Senator 
McConnell and others they want an opportunity to offer amendments, and 
this will maybe allow them to offer a few more.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. REID. Mr. President, I also note that with just the amendments 
that have been proposed, if we are fortunate, it will probably take 9 
hours or so, maybe more than that, to get rid of those. There will be 
continuous votes without any breaks. We are not going to have any 
breaks unless something untoward happens. Senators should be advised 
that they should remain close to the floor during this process. If 
people are not here at the end of the time, we are going to close it 
up. We need to move on. We have other things we have to do prior to the 
recess. I have to work with the Republican leader. It has taken an 
enormous amount of time to do this. Everybody stay here. It works a lot 
better if my colleagues stay close to their seats and, hopefully, we 
will have an orderly process as much as possible during the vote-arama.
  The PRESIDING OFFICER. The minority leader.
  Mr. McCONNELL. Mr. President, I am going to take a few minutes of my 
leader time before we begin the vote.
  The PRESIDING OFFICER. The leader has that right.
  Mr. McCONNELL. Mr. President, the administration and some in Congress 
wish this debate to be over. They want the American people to sit down 
and quiet down. That has been their approach to health care for an 
entire year.
  Well, Republicans think Congress serves the people, not the other way 
around.
  We have fought on behalf of the American people this week, and we 
will continue to fight until this bill is repealed and replaced with 
commonsense ideas that solve our problems without dismantling the 
health care system we have and without burying the American dream under 
a mountain of debt.
  That is what we have been doing all week in the Senate. While 
Democratic lawmakers and staffers threw a party for themselves at the 
White House yesterday, Republicans were here at the Capitol fighting a 
150-page postscript that Democrats added at the last minute to the 
health care bill. This add-on took a terrible health spending bill and 
made it even worse.
  If you thought the tax hikes in the original bill were bad, this bill 
raised them even higher. If you thought the Medicare cuts were bad, 
this bill made them even deeper. If you thought the first bill cost too 
much, this bill made it even more expensive. If you did not like the 
special deals in the first bill, they slipped more into this one. The 
whole thing was one last slap in the face of Americans across the 
country who have been howling at Democrats for the past year to stop 
this bill and to work instead across party lines on reforms that would 
actually drive costs down.
  Today Republicans will give Democrats one last chance to reject the 
horrible impact the underlying bill and this last-minute add-on will 
have on our country. Unfortunately, we already know that they plan to 
turn the other way.
  We will offer an amendment to direct the Medicare cuts in this bill 
back into Medicare, to preserve and strengthen it for future 
generations. They will reject it.
  We will offer an amendment to strike all the new sweetheart deals in 
this bill. They will reject it.
  We will offer an amendment that would have obliged the President to 
keep his pledge that families earning under $250,000 will not see any 
tax hikes as a result of this bill. They plan to reject it.
  We will offer an amendment requiring HHS to certify that this bill 
does not increase premiums. They will reject it.
  We will offer an amendment to strike a job-killing mandate on 
business. They will reject it.
  While the White House is trying to sell this health spending bill to 
a skeptical public, Senate Democrats today will speak loudly and they 
will speak clearly about the things in this bill the White House does 
not want people to know and vote to endorse them: massive cuts to 
Medicare for seniors; job-killing mandates and business tax hikes; 
higher insurance premiums; sweetheart deals; tax hikes on middle-class 
families. This is the real story of health care reform.
  Americans may not be hearing about it from the White House, but I 
assure you, they will be feeling the pain. Americans know this and they 
want to know that somebody is fighting for them in Washington to make 
their voices heard. That is what Republicans have been doing on this 
issue for the past year. That is what we have been doing this week. 
That is what we will be doing tonight. And that is what we will keep 
doing until those voices are heard. We are not giving up.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The majority leader.
  Mr. REID. Mr. President, USA Today-Gallup reported that the people of 
America, the citizens of America, favor what we did by a score of 49 to 
40. That is a pretty significant majority. People support this 
legislation. Why? Because they are tired of being treated by the 
insurance industry the way they have been treated.
  My friend talks about the mountain of debt of this bill. We have 
rules and guidelines in this body, in this Congress, and one of them is 
we have an independent body that has been set up, not by Republicans, 
not by Democrats, but by us. It is independent. It is not partisan. 
That agency, the Congressional Budget Office, determined this bill over 
the first 10 years will save about $140 billion; over the next 10 
years, $1.3 trillion. This is make-believe they talk about all these 
things that are going to cost so much--$1.3 trillion.
  I also have to comment on this. My friend, the Republican leader, 
talks about how hard they were working yesterday when we were at a 45-
minute meeting at the White House while the President made history 
signing for the first time in 100 years major health care reform in 
this country. They were working so hard here. They were working so hard 
today that they refused to let committees meet to hold sensitive, 
important hearings for our country.
  Carl Levin had to cancel a meeting because the Republicans refused to 
allow that meeting to go forward, dealing with the safety and security 
of this Nation. Claire McCaskill, with her subcommittee, had to cancel 
a hearing dealing with having police officers trained in Afghanistan. 
Canceled. Working hard, they are, to throw a monkey wrench in 
everything we are trying to do for the American people.

  To in any way denigrate, as has been done this afternoon, Chairman 
Max Baucus and Chairman Chris Dodd and the work done by the man 
replacing Ted Kennedy is an outrage. Max Baucus devoted his life to 
this legislation for the last 2 years: the number of roundtable 
discussions with Finance Committee members and invited guests, 3; the 
number of papers outlining health care reform, significant, important 
papers that were distributed to everybody around the country interested 
in health care, 4; the number of meetings of the Gang of 6--three 
Republicans and three Democrats--31 meetings; the number of member 
meetings on health care reform, 141.
  These are not back-room deals. This is how business is conducted in 
the Senate.

[[Page S1993]]

  The number of days in the Finance Committee the bill was available 
before the markup even took place, 6; the total number of amendments 
posted online before the markup, 564. They were public. Everyone in 
America could read them. The number of amendments considered during the 
markup, 135; the number of days the committee spent marking up the 
bill, 8; the number of days the final bill was available before the 
vote, 11.
  There is more, but you get the picture.
  Chairman Dodd conducted the longest markup in the history of the HELP 
Committee. On what subject? Health care. Public meetings, many of them 
on C-SPAN.
  There is no bill anymore. It was signed into law yesterday. The work 
that we did here on Christmas Eve, through the storms of 2010, is now 
the law of this country. We are going to start in just a few minutes 
making that law even better.
  In my State of Nevada, 600,000 people will be able to have insurance 
who have never had it before; 24,000 small businesses will be eligible 
for a subsidy for people they employ to have health insurance. They did 
not have health insurance because they were cheap or mean; they could 
not afford it. If they would get a palsy, they would cancel when 
somebody got sick or hurt.
  Now someone who is 26 years old can go to college or do whatever they 
want to do and not worry about losing their insurance until they 
establish themselves.
  This legislation extends Medicare for 9 years as a healthy entity. 
Medicare is not a perfect program, but it is a good program.
  My first elective job was a countywide job in Las Vegas, the 
metropolitan areas Clark County. When I went on that hospital board, 
the largest district in Nevada, 40 percent of seniors who came into 
that hospital had no health insurance. Their sons, their daughters, 
their mothers, their brothers, their cousins, their neighbors signed 
for them that they would be responsible for that bill. We had a large 
collection agency in that hospital. We went after those people.
  Not anymore. Now everybody who is a senior citizen who comes into 
that hospital is taken care of because of Medicare. We extend the life 
of that program for about 9 years.
  I had a letter written to me by a man from Nevada. He wrote to me and 
he said: Senator, I have a son who has diabetes, but it has become more 
complicated. Now he has Addison's disease. I lost my job. We have no 
health insurance. When I go to bed at night and say my prayers, I don't 
know whether to die or stay alive to help my son. That is how desperate 
he is.
  People such as this man from Nevada are no longer going to have to be 
desperate. No longer are we going to have 750,000 people file for 
bankruptcy, 70 percent of them because of health care costs and 80 
percent of the 70 percent have health insurance.
  The bill that is now the law of this country dealing with health care 
is a wonderful bill, and we are going to improve it tonight.


                    Amendment No. 3567, as Modified

  The PRESIDING OFFICER. There will be 2 minutes of debate equally 
divided prior to a vote on the Gregg amendment, as modified. Who yields 
time?
  Mr. GREGG. Mr. President, this amendment fulfills the obligation to 
our senior citizens. This bill reduces on its face $520 billion in 
Medicare by cutting Medicare beneficiaries through reducing providers 
and by eliminating or significantly reducing the Medicare Advantage 
Program. That number actually, when fully implemented, is $1 trillion 
over the first 10 years. That is $1 trillion of reductions in Medicare.
  That money is then taken and used to create new entitlements for 
people who are not seniors and who have, for the most part, not paid 
into the Medicare trust fund. That is wrong. Medicare is in serious 
trouble. We should use the Medicare savings in this bill for the 
purposes of making Medicare more solvent.
  That is exactly what this amendment does. It keeps Medicare savings 
in the Medicare trust fund and uses them to make Medicare more solvent.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, without being dramatic, this is a killer 
amendment, pure and simple. Why? Because it is basically designed to 
prevent spending. That means it will take away tax credits to middle 
Americans to help them buy insurance. This amendment would take it 
away. It would kill the assistance to seniors for prescription drugs. 
It would take that away. It would take away assistance to States. That 
is why it is a killer amendment.
  I proudly support this bill. Why? This bill reduces insurance costs 
for working-class and middle-class Americans, expands Medicare 
prescription drug coverage to more than 3 million seniors, provides 
immediate tax credits for nearly 4 million small businesses, stops $6 
billion in annual government subsidies for banks, and puts money into 
college grants for students and their families.
  In contrast, our friends on the other side do not want to do that. 
They want to kill this bill. I think that is patently against the 
wishes of the American people.
  Mr. President, I move to table the Gregg amendment, and I 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. The clerk will call the 
roll.
  The legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 56, nays 42, as follows:

                      [Rollcall Vote No. 64 Leg.]

                                YEAS--56

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

                                NAYS--42

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

                             NOT VOTING--2

     Byrd
     Isakson
       
  The motion was agreed to.
  The PRESIDING OFFICER. The majority leader.
  Mr. REID. Mr. President, we are going to cut the votes off after 10 
minutes. We are going to move these as quickly as we can. We want to 
get through this series of votes as rapidly as we can, and it is going 
to take hours to do that. People should stay close here. We are not 
going to take time for fun and games. We have to move through this 
process. It makes it so much easier if you are here to vote; otherwise, 
some people are going to miss the votes.


                           Amendment No. 3570

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate, equally divided, prior to a vote in relation to 
amendment No. 3570, offered by the Senator from Arizona, Mr. McCain.
  The Senator from Arizona.
  Mr. McCAIN. Mr. President, the amendment removes the following items 
from the legislation: additional Medicaid funding for Hawaii hospitals; 
additional Medicaid funding for Tennessee hospitals; provides special 
Medicaid funding for Louisiana; special Medicaid funding primarily for 
reclassified hospitals in Michigan and Connecticut; $100 million for a 
Connecticut hospital; frontier funding provision provided in new 
Medicare money for

[[Page S1994]]

Montana, South Dakota, North Dakota, and Wyoming; a provision allowing 
for certain residents in Libby, MT.
  I do not argue whether these are worthwhile or needed projects. I do 
argue the method in which they were inserted in this legislation--the 
one for Tennessee being as recently as yesterday or the day before--is 
the wrong process.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I think it is important to recognize this 
amendment for what it is. It is basically a political stunt at the 
expense of a lot of victimized people. One is victims of Hurricane 
Katrina, another is victims of asbestos in Libby, MT; it is at the 
expense of rural Americans; it is an attempt to derail the bill and 
force the House to have to vote again, therefore force, probably, the 
Senate to go through another vote-arama, go back and forth. It makes no 
sense whatsoever.
  Let's not forget the underlying legislation passed recently and 
signed by the President yesterday reduces insurance costs for working 
and middle-class Americans. This amendment would have the effect of 
taking that away if passed. If passed, it would take away Medicare 
prescription drug coverage for more than 3 million seniors. If passed, 
it would have the effect of taking away immediate tax credits for small 
businesses, and I could go on and on.
  I urge Members to support my motion to table. I ask for the yeas and 
nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be.
  The question is on agreeing to the motion to table.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from Alaska (Mr. Begich) and 
the Senator from West Virginia (Mr. Byrd) are necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 54, nays 43, as follows:

                      [Rollcall Vote No. 65 Leg.]

                                YEAS--54

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

                                NAYS--43

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

                             NOT VOTING--3

     Begich
     Byrd
     Isakson
  The motionm was agreed to.
  Mr. BAUCUS. Mr. President, I move to reconsider the vote.
  Mr. CARDIN. Mr. President, I move to lay that motion upon the table.
  The motion to lay upon the table was agreed to.


                         Crapo Motion to Commit

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate, equally divided, prior to a vote in relation to the 
motion to recommit offered by the Senator from Idaho, Mr. Crapo.
  Mr. CRAPO. Mr. President, the two health care bills, the one the 
President has already signed into law plus this one we are considering 
will spend another $2.6 trillion over the next 10 years.
  In order to pay for it, one of the things that these bills include is 
over $600 billion in new taxes. The President has pledged there would 
be no taxes on the middle class, and he defined that to be anybody who 
makes less than $200,000 as an individual or $250,000 as a couple or a 
family.
  All this motion to commit does is say: Let's take those taxes out of 
these bills. There are 73 million Americans who fall squarely in the 
middle class who make less than $200,000 a year as an individual or 
$250,000 as a couple who will pay the burden of these taxes if we do 
not make this change.
  It is time for this Congress----
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. CRAPO. To help the President keep his pledge.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I don't want to be dramatic about this, 
but it is a fact that this amendment is a killer amendment. That is why 
we cannot adopt it. I remind colleagues that the underlying bill the 
President signed yesterday is a very large tax cut. It has tax credits 
in the neighborhood of about $400-some billion. That is a big tax cut 
for Americans who today are having a hard time buying insurance, a tax 
credit that enables middle and lower income Americans to buy insurance. 
I think we should keep that in mind. A vote for this amendment would, 
in fact, prevent all the benefits this bill provides for forming a 
health insurance market, stopping preexisting conditions. It would 
prevent about $17 billion in tax credits that otherwise would go to 
small business.
  I strongly urge colleagues to support my motion to table this motion.
  I move to table the motion to commit and ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be.
  The question is agreeing to the motion to table the motion to commit.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 56, nays 43, as follows:

                      [Rollcall Vote No. 66 Leg.]

                                YEAS--56

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

                                NAYS--43

     Alexander
     Barrasso
     Bennett
     Bond
     Brown (MA)
     Brownback
     Bunning
     Burr
     Cantwell
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lincoln
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Wicker

                             NOT VOTING--1

       
     Isakson
       
  The motion was agreed to.
  Mr. BAUCUS. I move to reconsider the vote.
  Mr. LEVIN. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                         Enzi Motion To Commit

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate equally divided prior to a vote in relation to the 
motion to commit offered by the Senator from Wyoming, Mr. Enzi.
  The Senator from Wyoming.
  Mr. ENZI. Mr. President, this is not a killer amendment. This just 
kills a bad part of the bill.
  The reconciliation bill makes a bad employment situation even worse. 
It imposes $52 billion in new taxes on employers who cannot afford to 
provide health insurance to their workers. The

[[Page S1995]]

new employer tax will result in lower wages and lost jobs.
  According to CBO:

       Requiring employers to offer health insurance--or pay a fee 
     if they do not--is likely to reduce employment.

  Low-income workers are particularly hard hit by the employer mandate 
in the reconciliation bill. CBO says an employer mandate ``could reduce 
the hiring of low-wage workers'' and would ``increase incentives for 
firms to replace full-time workers with more part-time or temporary 
workers.''
  The Nation's unemployment rate is 9.7 percent, and in many States the 
unemployment rate is well into the teens. We should be doing everything 
possible to create new jobs, but the employer mandate in the 
reconciliation bill does the opposite.
  The job-killing taxes in the bill will slash wages and cut jobs.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. ENZI. I urge my colleagues to protect Americans' jobs by 
supporting my motion.
  The PRESIDING OFFICER (Mr. Begich). The Senator from Montana.
  Mr. BAUCUS. Mr. President, sending the bill to committee sounds like 
killing the bill to me. I have never heard of a motion to commit that 
is not, in effect, a motion to kill the bill.
  We are all in this together in America in enacting health care 
reform--all groups: business groups, consumers, labor, and so forth. We 
have consulted with business groups. They are an integral part of this. 
Business groups want to work with us and have worked with us to get 
health care reform passed.
  I might also remind my colleagues there are tax credits in here for 
small business to the tune of--I think it is $17 billion. Firms with 
fewer than 50 employees are totally exempt from any penalty.
  This clearly is a motion to kill the bill. Therefore, it would result 
in taking away all these provisions enacted.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. BAUCUS. Mr. President, I move to table the motion to commit 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 
commit.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 58, nays 41, as follows:

                      [Rollcall Vote No. 67 Leg.]

                                YEAS--58

     Akaka
     Baucus
     Bayh
     Begich
     Bennet
     Bingaman
     Boxer
     Brown (OH)
     Burris
     Byrd
     Cantwell
     Cardin
     Carper
     Casey
     Conrad
     Dodd
     Dorgan
     Durbin
     Feingold
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Inouye
     Johnson
     Kaufman
     Kerry
     Klobuchar
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     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--41

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

                             NOT VOTING--1

       
     Isakson
       
  The motion was agreed to.
  Mr. CARDIN. 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.


                           Amendment No. 3582

  The PRESIDING OFFICER. Under the previous order, there will be 2 
minutes of debate, equally divided, prior to a vote in relation to 
amendment No. 3582 offered by the Senator from Wyoming, Mr. Barrasso.
  The Senator from Wyoming.
  Mr. BARRASSO. Mr. President, my amendment protects families and 
protects small businesses from dramatic increases in insurance 
premiums. My amendment directs the Department of Health and Human 
Services to certify that insurance premiums will not rise faster under 
the new health care law than they would have if the law had not been 
passed. If they find that premiums are higher, then the new law would 
sunset.
  This month in Pennsylvania, the President said the Senate bill would 
reduce most people's premiums. I say to my friends on the other side of 
the aisle, if you believe the President and you believe that this bill 
lowers premiums, prove it. Vote for this amendment.
  This is a reasonable, straightforward amendment. It holds the 
President and it holds the Members of Congress accountable to the 
American people for promises made.
  Thank you, Mr. President.
  Mr. BAUCUS. Mr. President, all things being equal, I choose to 
believe the President. Second, I choose to believe the Congressional 
Budget Office. The Congressional Budget Office has concluded that 
premiums under this legislation will, all things equal, be reduced for 
big business as much as 3 percent. Small businesses will see a decrease 
of 11 percent if you factor in the small business tax credits for 
coverage. Individuals who receive tax credits in the exchange will find 
a 57-percent reduction in premiums; again, all things being equal.
  Will someone find an increase in premium? Somebody might buy a very 
expensive health insurance policy. Maybe that person's premiums might 
go up.
  Obviously, this is designed to kill the bill, and I strongly urge my 
colleagues not to support it. It prevents passage of the bill. It 
undermines the bill. It repeals the bill, in effect, that has already 
been signed by the President.
  So I move that this amendment be tabled, and I ask for the yeas and 
nays.
  The PRESIDING OFFICER. Is there a sufficient second? There is a 
sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from Delaware (Mr. Kaufman) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 57, nays 41, as follows:

                      [Rollcall Vote No. 68 Leg.]

                                YEAS--57

     Akaka
     Baucus
     Begich
     Bennet
     Bingaman
     Boxer
     Brown (OH)
     Burris
     Byrd
     Cantwell
     Cardin
     Carper
     Casey
     Conrad
     Dodd
     Dorgan
     Durbin
     Feingold
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Inouye
     Johnson
     Kerry
     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--41

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

                             NOT VOTING--2

     Isakson
     Kaufman
       
  The motion was agreed to.
  Mr. BAUCUS. I move to reconsider the vote.
  Mr. LEAHY. I move to lay that motion on the table.

[[Page S1996]]

  The motion to lay on the table was agreed to.


                           Amendment No. 3564

  The PRESIDING OFFICER. Under the previous order, there will be 2 
minutes of debate equally divided prior to a vote in relation to 
amendment No. 3564, offered by the Senator from Iowa, Mr. Grassley.
  The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, my amendment would require the 
President, the Vice President, Cabinet members, and White House staff 
to use exchanges created in this bill. It would also fix a loophole so 
that the committee and leadership staff are also required to obtain 
coverage in these exchanges.
  Today, after seeing my amendment, the White House announced that 
President Obama will voluntarily participate in the health insurance 
exchange that starts in 2014.
  This is a little presumptuous since he has another election before 
2014, but it is still effectively an endorsement of my amendment to 
make sure that political leaders live under the laws they pass for 
everyone else. But the principle should not be voluntary for political 
leaders. Congress and President Clinton confirmed that in 1995 by 
enacting the Congressional Accountability Act that Senator Lieberman 
and I sponsored. It is a matter of not having a double standard.
  I urge my colleagues to support my amendment and make sure we are 
living under the same laws.
  The PRESIDING OFFICER. The time of the Senator has expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, I could be mistaken, but it is my 
understanding that the underlying amendment, which also includes 
Members of Congress in the exchange, is language that was drafted on a 
bipartisan basis in the HELP Committee. I don't see Senator Dodd here. 
It is an amendment Senator Coburn worked on and was agreed to in the 
HELP Committee. It covered Members of Congress and who all should be 
included.
  Frankly, I don't think it is wise at this point to try to negotiate 
who should additionally be covered in the exchanges and who should not. 
It was agreed to before. I say to my good friend from Iowa--he has been 
my very good friend--I don't think it is intended to embarrass the 
President and the executive branch people, but I think it is 
inappropriate.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. BAUCUS. I say to my friend, he can be happy when Northern Iowa 
beats Michigan State this Friday. It will make him happy.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. BAUCUS. I make a point of order that the pending amendment 
violates section 313(b)(1)(C) of the Congressional Budget Act of 1974.
  Mr. GRASSLEY. Mr. President, pursuant to section 904(c) of the 
Congressional Budget Act of 1974, I move to waive section 313 of the 
Budget Act for the consideration of the pending amendment.
  Mr. BAUCUS. I 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.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 43, nays 56, as follows:

                      [Rollcall Vote No. 69 Leg.]

                                YEAS--43

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

                                NAYS--56

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

                             NOT VOTING--1

       
     Isakson
       
  The PRESIDING OFFICER. On this vote, the yeas are 43, the nays are 
56. Three-fifths of the Senators duly chosen and sworn not having voted 
in the affirmative, the motion is rejected.
  The point of order is sustained, and the amendment falls.


                       Alexander Motion to Commit

  The PRESIDING OFFICER. Under the previous order, we will have 2 
minutes of debate equally divided prior to a vote on the motion to 
commit offered by the Senator from Tennessee, Mr. Alexander.
  The Senator from Tennessee.
  Mr. ALEXANDER. Mr. President, this is an effort to stop the Federal 
Government from overcharging 19 million college students to help pay 
for the health care bill. It would reduce from 6.8 percent to 5.3 
percent the interest on their loans. It would save $1,700 to $1,800 on 
the average of a $25,000 loan over 10 years.
  Why are we talking student loans during a health care bill? Because 
we can't trust the other side with the Yellow Pages. If they find it in 
there, they think the government ought to be doing it. They have taken 
over the Federal student loan program, and they are running up the debt 
$\1/2\ trillion to do it. They are firing 31,000 people by July 1. They 
are going to borrow money at 2.8 percent and loan it to students at 6.8 
percent and use the rest to help pay for health care and for the 
government. CBO has said this is $8.7 billion of overcharging students 
to pay for health care. So a ``yes'' means don't overcharge.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. ALEXANDER. A ``no'' means savings to students.
  Mr. HARKIN. The last time we took up higher education, in 2007, we 
lowered interest rates on student loans and crafted the interest-based 
repayment program. In this bill, we lower that down even more--from 15 
percent to 10 percent--and we make a historic investment in Pell 
grants.
  I would agree, I am all for lowering interest rates. I would just 
note that my friend from Tennessee didn't take to the floor to complain 
when Sallie Mae was charging over 20 percent interest on its loans to 
students. I didn't see that.
  This amendment is not about lowering interest rates. What it is about 
is continuing a $61 billion subsidy to the big banks in this country. 
We take that money and give it to students in Pell grants.
  Mr. President, I move to table the motion to commit, and I ask for 
the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second? There is a 
sufficient second.
  The question is on the motion.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 58, nays 41, as follows:

                      [Rollcall Vote No. 70 Leg.]

                                YEAS--58

     Akaka
     Baucus
     Bayh
     Begich
     Bennet
     Bingaman
     Boxer
     Brown (OH)
     Burris
     Byrd
     Cantwell
     Cardin
     Carper
     Casey
     Conrad
     Dodd
     Dorgan
     Durbin
     Feingold
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Inouye
     Johnson
     Kaufman
     Kerry
     Klobuchar
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     McCaskill
     Menendez
     Merkley
     Mikulski
     Murray
     Nelson (FL)
     Pryor
     Reed
     Reid
     Rockefeller
     Sanders
     Schumer

[[Page S1997]]


     Shaheen
     Specter
     Stabenow
     Tester
     Udall (CO)
     Udall (NM)
     Warner
     Webb
     Whitehouse
     Wyden

                                NAYS--41

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

                             NOT VOTING--1

       
     Isakson
       
  The motion was agreed to.


                           Amendment No. 3586

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes equally divided prior to a vote in relation to amendment No. 
3586 offered by the Senator from Florida, Mr. LeMieux.
  The Senator from Florida is recognized.
  Mr. LeMIEUX. Mr. President, I have heard my friends on the other side 
of the aisle talk about 30 million new people in America having health 
care. What they are not talking about is 16 million of those folks are 
going into Medicaid. Medicaid is a program that doesn't work. Forty 
percent of physicians according to MedPac no longer will see Medicaid 
patients. Pharmacies will not fill prescriptions. You cannot find a 
specialist.
  I have also heard our friends on the other side of the aisle come to 
the Senate floor and say the people of America should have the same 
great health care that we have in this body. The corollary should be 
true as well. We should have the same health care that we are willing 
to put 16 million new Americans in and 50 million Americans in total. 
We should all be on Medicaid.
  My amendment says 535 Members of Congress, as well as the Vice 
President of the United States, will go into Medicaid. If it is good 
enough for them, it should be good enough for us. We talk the talk 
around here a lot, now let's see if we will walk the walk.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I don't think this is really a serious 
amendment that requires all Members of Congress to withdraw from their 
Federal health insurance plan, and it requires all Members of Congress 
to be in Medicaid. Medicaid is a safety net for vulnerable Americans. 
It should not be the subject for political gamesmanship like this 
amendment. It is a slap in the face of vulnerable, poor Americans.
  Ironically, this killer amendment will have the effect of reducing 
payments to States which are in the underlying bill. It would take that 
away. I don't think that is the intent of the author of the amendment.
  Mr. President, I make a point of order the pending amendment violates 
section 313(b)(1)(C) of the Congressional Budget Act of 1974.
  The PRESIDING OFFICER. The Senator from Florida.
  Mr. LeMIEUX. Pursuant to section 904 of the Congressional Budget Act 
of 1974 and section 4(G)(3) of the statutory pay-as-you-go act of 2010, 
I move to waive all applicable sections of those acts for purposes of 
my amendment, and I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second? There is a 
sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 40, nays 59, as follows:

                      [Rollcall Vote No. 71 Leg.]

                                YEAS--40

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

                                NAYS--59

     Akaka
     Baucus
     Bayh
     Begich
     Bennet
     Bingaman
     Boxer
     Brown (OH)
     Burris
     Byrd
     Cantwell
     Cardin
     Carper
     Casey
     Conrad
     Dodd
     Dorgan
     Durbin
     Feingold
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Inouye
     Johnson
     Kaufman
     Kerry
     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

       
     Isakson
       
  The PRESIDING OFFICER. On this vote, the yeas are 40, the nays are 
59. Three-fifths of the Senators duly chosen and sworn not having voted 
in the affirmative, the motion is not agreed to.
  The point of order is sustained, and the amendment falls.


                         Hatch Motion To Commit

  Under the previous order, there will now be 2 minutes of debate 
equally divided prior to a vote in relation to the motion to commit 
offered by the Senator from Utah, Mr. Hatch.
  Mr. HATCH. Mr. President, I urge my colleagues to support my motion 
to commit.
  Simply put, this motion protects the 11 million Medicare 
beneficiaries, both seniors and the disabled, currently participating 
in the Medicare Advantage program.
  If the HHS actuary certifies that the Medicare Advantage cuts 
included in the health reform law would result in 1 million Medicare 
Advantage beneficiaries losing current health benefits, those Medicare 
Advantage cuts would not go into effect.
  Medicare Advantage makes a tremendous difference in the lives of 
beneficiaries. They have told me over and over again how important it 
is for them to have lower deductibles, premiums, and copayments.
  And what a difference it makes to have dental and vision benefits.
  The Medicare Advantage cuts in the health reform law would take away 
those benefits. For that reason, I strongly oppose these cuts and urge 
my colleagues to support my motion to commit and do the right thing for 
Medicare beneficiaries, seniors and disabled individuals, across 
America.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, as a motion to commit, this clearly is 
designed to kill the bill. All motions to commit have that intent and 
effect. Let's remind ourselves, the underlying bill protects all 
Medicare beneficiaries. All statutory benefits are guaranteed in the 
underlying legislation. Second, the underlying bill reforms Medicare 
Advantage which rewards high performance Medicare Advantage programs, 
those providing value, whereas under current law that is not the case. 
In addition, if this amendment passes, fee-for-service Medicare 
beneficiaries would have to pay a $90-a-year penalty to pay for the 
excess subsidy of Medicare Advantage plans. For lots of reasons, this 
motion should not prevail.
  I move to table the motion to commit 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 
commit.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 56, nays 42, as follows:

                      [Rollcall Vote No. 72 Leg.]

                                YEAS--56

     Akaka
     Baucus
     Bayh
     Begich
     Bennet
     Bingaman
     Boxer
     Brown (OH)
     Burris
     Cantwell
     Cardin
     Carper
     Casey
     Conrad
     Dodd
     Dorgan
     Durbin
     Feingold
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Inouye
     Johnson
     Kaufman
     Kerry

[[Page S1998]]


     Klobuchar
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     McCaskill
     Menendez
     Merkley
     Mikulski
     Murray
     Nelson (FL)
     Pryor
     Reed
     Reid
     Rockefeller
     Sanders
     Schumer
     Shaheen
     Specter
     Stabenow
     Tester
     Udall (CO)
     Udall (NM)
     Warner
     Whitehouse
     Wyden

                                NAYS--42

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

                             NOT VOTING--2

     Byrd
     Isakson
       
  The motion was agreed to.


                           Amendment No. 3556

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate equally divided prior to a vote in relation to 
amendment No. 3556, offered by the Senator from Oklahoma, Mr. Coburn.
  The Senator from Oklahoma.
  Mr. COBURN. Mr. President, this amendment saves $6.5 billion over the 
next 10 years for what it does on fraudulent Medicaid prescriptions--
$6.5 billion--$650 million a year on fraudulent prescriptions. It also 
creates a prohibition so that erectile dysfunction drugs are not paid 
for by the American taxpayers to convicted rapists, those convicted of 
sexual assault, and pedophiles in this country.
  You can say a lot of things about a lot of amendments. This is not a 
game amendment; it actually saves money. All the States are struggling 
with Medicaid. This is a way to spread $650 million a year to the 
States.
  I reserve the remainder of my time.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, this legislation is about filling the 
doughnut hole for seniors. It is about providing health care for 
working families, for children. It is about reducing our national debt. 
It is a serious bill. It deserves serious debate.
  The amendment offered by the Senator from Oklahoma makes a mockery of 
this Senate, the debate, and the American people. It is not a serious 
amendment. It is a crass political stunt aimed at making 30-second 
commercials, not public policy.
  I urge my colleagues to oppose the amendment.
  I move to table the amendment, and ask for the yeas and nays.
  Mr. COBURN. Mr. President, do I have time remaining?
  The PRESIDING OFFICER. The Senator from Oklahoma still has time.
  The Senator from Oklahoma.
  Mr. COBURN. I would make the following point: The vast majority of 
Americans do not want their taxpayer dollars paying for this kind of 
drug for those kind of people.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I move to table the amendment, and ask for 
the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 57, nays 42, as follows:

                      [Rollcall Vote No. 73 Leg.]

                                YEAS--57

     Akaka
     Baucus
     Begich
     Bennet
     Bingaman
     Boxer
     Brown (OH)
     Burris
     Byrd
     Cantwell
     Cardin
     Carper
     Casey
     Conrad
     Dodd
     Dorgan
     Durbin
     Feingold
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Inouye
     Johnson
     Kaufman
     Kerry
     Klobuchar
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     McCaskill
     Menendez
     Merkley
     Mikulski
     Murray
     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
     Bennett
     Bond
     Brown (MA)
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Wicker

                             NOT VOTING--1

       
     Isakson
       
  The motion was agreed to.
  Mr. CARDIN. 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.


                           Amendment No. 3608

  The PRESIDING OFFICER. Under the previous order, there will be 2 
minutes of debate, equally divided, prior to a vote in relation to 
amendment No. 3608 offered by the Senator from Texas, Mrs. Hutchison.
  Mrs. HUTCHISON. Mr. President, we are hearing from State leaders all 
over our country begging Congress to abandon this bill that is an 
unconstitutional preemption of States rights, State innovation, and 
State prerogatives. Thirteen States have already filed suit against 
this bill.
  My amendment would restore the 10th amendment rights reserved to the 
States by allowing State legislatures to pass legislation to allow them 
to opt out of this bill, opt out of the job-killing taxes, opt out of 
the cuts to Medicare, opt out of the unfunded Medicaid mandates, when 
our States are hurting already. They are not balancing their budgets 
right now. This is going to make it worse.
  This is an easy ``yes'' vote, and I hope our colleagues will help our 
States to opt out of this bill if they choose.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, this is another in a long series of killer 
amendments. Clearly, allowing States to opt out of any or all 
provisions of the underlying health care reform bill would have that 
result. States could decide not to abide by health care market reforms, 
preexisting conditions, provisions against rescissions, et cetera. 
States could decide not to provide health care coverage to their 
citizens. One State versus the national program. States could decide 
they are not going to pay the fees, enact the fees that are required on 
State pharmaceuticals or insurance industries. States could make all 
kinds of decisions which basically would have the effect of killing 
this bill.
  So I urge my colleagues to not support the amendment of the Senator 
from Texas.
  I move to table the amendment, and I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second? There is a 
sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 58, nays 41, as follows:

                      [Rollcall Vote No. 74 Leg.]

                                YEAS--58

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

                                NAYS--41

     Alexander
     Barrasso
     Bennett
     Bond
     Brown (MA)
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi

[[Page S1999]]


     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Wicker

                             NOT VOTING--1

       
     Isakson
       
  The motion was agreed to.
  Mr. INOUYE. I move to reconsider the vote.
  Mrs. MURRAY. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                           Amendment No. 3638

  The PRESIDING OFFICER. There will now be 2 minutes of debate prior to 
a vote in relation to amendment No. 3638, offered by the Senator from 
Maine, Ms. Collins.
  The Senator from Maine.
  Ms. COLLINS. Mr. President, just last week we passed the HIRE Act, 
which included a tax credit offered by Senator Schumer and Senator 
Hatch to encourage companies to hire unemployed workers. It makes no 
sense for any of us to have voted for that bill and then not to support 
the amendment that I have offered.
  The amendment I am offering would waive the onerous fines that are in 
this bill for small businesses that hire unemployed workers. If you 
voted for the HIRE Act giving a tax credit, why in the world would you 
support a policy of imposing penalties on businesses that hire 
unemployed workers?
  Mr. President, I urge support of the amendment.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, this amendment basically has the intent of 
creating a group of second-class employees. It is very similar to the 
issue of subminimum wage. It makes all the sense in the world to 
distinguish the two, between the HIRE Act and this amendment.
  The HIRE Act gave incentives for firms to hire new employees. This 
amendment creates a group of second-class employees. It says you can 
hire employees so long as they do not have health insurance. I think 
that is wrong. I do not think we should have a second class of 
employees, which is the effect of the amendment. I urge it be defeated.
  I move to table the amendment, and I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER (Mr. Casey). Are there any other Senators in 
the Chamber desiring to vote?
  The result was announced--yeas 58, nays 41, as follows:

                      [Rollcall Vote No. 75 Leg.]

                                YEAS--58

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

                                NAYS--41

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

                             NOT VOTING--1

       
     Isakson
       
  The motion was agreed to.
  Mrs. MURRAY. I move to reconsider the vote.
  Mr. LEVIN. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                           Amendment No. 3639

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate equally divided prior to a vote in relation to 
amendment No. 3639, offered by the Senator from South Dakota, Mr. 
Thune.
  Mr. THUNE. Mr. President, this amendment gets at the issue of the 
student loan program and what this bill would propose to do to that 
program.
  Under this bill, students in this country would have one option to 
get a student loan--the Federal Government. Today, there are 2,000 
lenders across this country that make student loans. A recent article 
in the Wall Street Journal pointed out that the shift to government 
lending would mean lending would now be operated by the Department of 
Education, which is ``distinguished in its Soviet-style customer 
service.''
  There are 30,000 to 35,000 jobs in this country that are associated 
with the student loan program. At a time of record-high unemployment 
levels, we need to ensure that moving student lending to the Department 
of Education does not place more Americans on unemployment. As our 
economy recovers, we should be focused on ways to increase jobs in the 
private sector, not ending those positions in favor of adding more 
government bureaucrats in Washington.
  This amendment would require the Secretary of Education to certify 
that no State would experience a net job loss as a result of the 
Federal Family Education Student Loan Program being terminated.
  I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  Mrs. MURRAY. I move to table.
  The PRESIDING OFFICER. A motion to table is not in order.
  There is not a sufficient second at this time.
  The Senator from Iowa.
  Mr. HARKIN. Mr. President, this amendment is not about protecting 
jobs, because the bill already does that. We carve out a role for 
nonprofit lenders to service loans. We provided $50 million in this 
bill to incentivize companies--private companies, too--to keep jobs in 
the same towns and cities where they are now. Private lenders will 
continue to service the $450 billion in outstanding private loan 
volume.
  Let me say this also about Sallie Mae. They took a couple thousand 
jobs out of this country. Guess what. They are bringing them back 
because they get to service the loans. Under Treasury rules, in order 
for them to service the loans, it has to be done in this country. So 
Sallie Mae is bringing jobs back to America.
  This amendment is not about protecting jobs. It is about killing the 
bill and leaving the subsidies to the big banks, where they are today.
  I move to table the amendment, and I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 55, nays 43, as follows:

                      [Rollcall Vote No. 76 Leg.]

                                YEAS--55

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

[[Page S2000]]



                                NAYS--43

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

                             NOT VOTING--2

     Byrd
     Isakson
       
  The motion was agreed to.


                           Amendment No. 3640

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate, equally divided, prior to a vote in relation to 
amendment No. 3640, offered by the Senator from South Dakota, Mr. 
Thune.
  Mr. THUNE. Mr. President, this amendment would strike the CLASS Act 
from the bill. The CLASS Act, as we all know, is a new entitlement 
program. We have two entitlement programs that are already destined to 
be bankrupt that have unfunded liabilities in the neighborhood of $60 
trillion. It does not make a lot of sense to add a third one.
  Here is what everybody said about this. One of our Democratic 
colleagues has called the CLASS Act ``a Ponzi scheme of the first 
order, the kind of thing that Bernie Madoff would be proud of.''
  Even the Washington Post described it as a ``gimmick . . . designed 
to pretend that health care is fully paid for.''
  The administration's Chief Actuary said ``there is a significant risk 
of failure, there is a significant risk that the problem of adverse 
selection would make the CLASS program unsustainable,'' and the CBO 
said the additional deficit increases would amount to ``the order of 
tens of billions of dollars for each 10-year period'' after 2029.
  We know what this is. This is a gimmick. It is a budgetary gimmick 
used to make this bill look like it is paid for when it is not. We 
ought to strike it from the bill, and I hope my colleagues will support 
this amendment.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. HARKIN. Mr. President, the CLASS Act is a voluntary, self-funded 
insurance program, with enrollment for people who are presently 
employed. There are no taxpayer dollars involved whatsoever.
  The statement that the Senator referred to was made before we made 
sure it was paid for. It is all paid for. In fact, the Senator from New 
Hampshire in our committee offered an amendment that made sure it was 
fully funded for 75 years. The Congressional Budget Office has 
certified this will be solvent for 75 years. Plus, it will save 
taxpayers money.
  By letting people put some money aside, so if they become disabled 
they can stay at home rather than going to a nursing home, we save 
Medicaid dollars. This saves taxpayer dollars from paying more into 
Medicaid in the future.
  Mr. President, I raise a point of order that the Thune amendment 
violates section 310(D)(2) of the Congressional Budget Act.
  The PRESIDING OFFICER. The Senator from South Dakota.
  Mr. THUNE. Mr. President, pursuant to section 904 of the 
Congressional Budget Act of 1974 and section 4(G)(3) of the statutory 
Pay-As-You-Go Act of 2010, I move to waive all applicable sections of 
those acts and applicable budget resolutions for purposes of my 
amendment and ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second? There is a 
sufficient second.
  The question is on agreeing to the motion. The clerk will call the 
roll.
  The assistant legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 43, nays 55, as follows:

                      [Rollcall Vote No. 77 Leg.]

                                YEAS--43

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

                                NAYS--55

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

                             NOT VOTING--2

     Byrd
     Isakson
  The PRESIDING OFFICER. On this vote, the yeas are 43, the nays are 
55. Three-fifths of the Senators duly chosen and sworn not having voted 
in the affirmative, the motion is not agreed to. The point of order is 
sustained, and the amendment falls.


                        Cornyn Motion To Commit

  Under the previous order, there will now be 2 minutes of debate 
equally divided prior to a vote in relation to the motion to commit 
offered by the Senator from Texas, Mr. Cornyn.
  The Senator from Texas.
  Mr. CORNYN. Mr. President, mine is a motion to commit the 
reconciliation bill back to the Finance Committee to report the bill 
back without the brandnew, whopping 3.8 percent tax on investment and 
savings. This is a $123 billion mistake. It will discourage savings and 
investment and decrease the standard of living for millions of 
Americans. Simply put, increasing taxes on investment income and 
savings income is a job killer. It is just one of many job-killing 
provisions of this bill, $100 billion of new taxes and fees on health 
care consumers, an employer mandate that will kill jobs.
  My motion will also make sure the bill does not break another one of 
the President's promises when he pledged that everyone in America will 
pay lower taxes than they would under the rates Bill Clinton had in the 
1990s.
  I ask my colleagues for their support.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, this is an honest, straightforward 
amendment which is concerned about people making more than $200,000. 
The effect of some amendments prior to this moment have been trying to 
protect people making less than $200,000. This amendment is the exact 
opposite; it is only concerned about people making more than $200,000 
in income.
  The bill itself also provides that people whose investment income is 
above $200,000 should contribute to the Medicare trust fund. Currently, 
they do not. Only taxes on wages contribute to the Medicare trust fund. 
The thought is that people with unearned income should also contribute. 
This tax only applies to those who make above $200,000. There is a 
passthrough exemption, subchapter S. Other passthroughs are exempted. 
Retirement income is exempted. It doesn't make sense that people making 
over $200,000 should be exempt.
  I move to table the motion to commit 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 
commit.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 52, nays 46, as follows:

[[Page S2001]]

                      [Rollcall Vote No. 78 Leg.]

                                YEAS--52

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

                                NAYS--46

     Alexander
     Barrasso
     Bayh
     Bennett
     Bond
     Brown (MA)
     Brownback
     Bunning
     Burr
     Cantwell
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lincoln
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Nelson (FL)
     Pryor
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Wicker

                             NOT VOTING--2

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


                           Amendment No. 3579

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate, equally divided, prior to a vote in relation to 
amendment No. 3579, offered by the Senator from Kansas, Mr. Roberts.
  The Senator from Kansas.
  Mr. ROBERTS. Mr. President, included in the new taxes in this health 
reform is a tax hike of $20 billion on medical devices. The nonpartisan 
Congressional Budget Office and Joint Committee on Taxation both 
confirmed these excise taxes will not--will not--be borne by the 
medical device industry but, instead, are passed on to patients in the 
form of higher prices and higher insurance premiums.
  Who are these folks who will bear the burden of this new tax? People 
with disabilities, diabetics, amputees, people with cancer, just to 
name some of the people--and more--who will see their costs go up 
because of this tax. We do not want to do this. Why should we want to 
do this on those who are most vulnerable?
  This amendment would prevent this new tax from raising the already 
high costs for this group and a tax that will stifle the Medicaid 
device technology and innovation of this country.
  I urge my colleagues to support this amendment. It is offset by an 
amendment similar to that offered by Senator Schumer in the Finance 
Committee so it must be bipartisan.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, how have Kansas and Kansas State done 
lately?
  This is a very simple amendment. This health care bill is premised on 
the assumption that all groups should participate in finding the 
correct health care solution for our health care system. That includes 
hospitals, pharmaceuticals, and it also includes device manufacturers. 
This amendment would exclude one section: device manufacturers.
  How is it paid for? It is paid for by reducing the number of people 
who would otherwise get tax credits to help pay for their health 
insurance. I do not think that is what we want to do. We do not want to 
reduce the number of people who have health insurance. This amendment 
would reduce coverage for people who need help buying insurance.
  So I move to table this amendment, and I 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.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 56, nays 42, as follows:

                      [Rollcall Vote No. 79 Leg.]

                                YEAS--56

     Akaka
     Baucus
     Begich
     Bennet
     Bingaman
     Boxer
     Brown (OH)
     Burris
     Cantwell
     Cardin
     Carper
     Casey
     Conrad
     Dodd
     Dorgan
     Durbin
     Feingold
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Inouye
     Johnson
     Kaufman
     Kerry
     Klobuchar
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     McCaskill
     Menendez
     Merkley
     Mikulski
     Murray
     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
     Bennett
     Bond
     Brown (MA)
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Wicker

                             NOT VOTING--2

     Byrd
     Isakson
       
  The motion was agreed to.
  Mr. NELSON of Nebraska. 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.


                           Amendment No. 3588

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate equally divided prior to a vote in relation to 
amendment No. 3588 offered by the Senator from Oklahoma, Mr. Inhofe.
  The Senator from Oklahoma.
  Mr. INHOFE. Mr. President, we just heard from Senator Roberts about 
the medical devices. I think he pointed out very clearly that there is 
kind of another hidden tax in this legislation of some $20 billion on 
medical devices. I think it is important to listen to what Senator 
Roberts said, that it was not--it is not the device companies that will 
be paying this; it will be the individuals who would be paying it.
  Now, the difference between my amendment and Senator Roberts' 
amendment is that mine excludes those devices for children and those 
with disabilities. For example, some of our troops coming home have 
lost limbs, and they have prosthetic devices. This is for them. This is 
for the 8-year-old whose heart quit beating in the middle of the night 
and they put a pacemaker in and it saved his life. It is for incubators 
and this type of thing. It is the same thing. It is the same offset as 
Senator Roberts and Senator Schumer had, and I would ask that you 
seriously consider this amendment. This is for the children and those 
with disabilities.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, two subjects. First, I wish to correct the 
record. I mistakenly stated that the Kansas Wildcats were not in the 
Sweet 16. That was an error. The Kansas State Wildcats are very much in 
the Sweet 16, and my apologies to coach Frank Martin of the Wildcats. I 
wish them very well in the tournament.
  Mr. ROBERTS. Will the chairman yield?
  Mr. BAUCUS. Well, I don't have much time, but I will do my very best.
  Mr. ROBERTS. I am just so sorry that Montana lost in the first round.
  Mr. BAUCUS. I would say to my good friend, he isn't nearly as sorry 
as I am.
  Basically, this is like the last amendment--two flaws. It exempts a 
certain group from the shared responsibility in helping to finance 
health care reform. The second flaw is that it reduces coverage by 
changing the income threshold. This is not a way to do business.
  I move to table the amendment and ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second? There appears to 
be a sufficient second.

[[Page S2002]]

  The question is on agreeing to the motion.
  The clerk will call the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 57, nays 41, as follows:

                      [Rollcall Vote No. 80 Leg.]

                                YEAS--57

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

                                NAYS--41

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

                             NOT VOTING--2

     Byrd
     Isakson
       
  The motion was agreed to.


                           Amendment No. 3644

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate equally divided prior to a vote in relation to 
amendment No. 3644, offered by the Senator from Utah, Mr. Hatch.
  The Senator from Utah.
  Mr. HATCH. Mr. President, there is a tax hike of $20 billion on 
medical devices in this bill. These taxes are passed on to patients in 
the form of higher prices and higher insurance premiums.
  My amendment would prevent this new tax from raising costs or hurting 
access for American soldiers and veterans by exempting medical devices 
used by the TRICARE Program and the Veterans Health Program.
  We need to protect our wounded warriors who rely on these medical 
devices for recovery and to live a normal life.
  I reserve the remainder of my time.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, this amendment is very similar to the past 
two amendments we voted on. It seeks to exempt a sympathetic group of 
individuals from the excise tax on medical device manufacturers. The 
amendment is misplaced. We already exempt retail purchases of medical 
devices, such as Band-Aids, glasses--all those kinds of items. The tax 
only applies to large manufacturers. The government negotiates with the 
large manufacturers. The government is large enough to exact a better 
price. It does not pass that on to individuals, not on our military, 
not on our vets who already receive prescribed health care coverage.
  Second, this amendment is paid for by increasing the number of 
uninsured. I do not think we want to increase the number of uninsured. 
We want to decrease the number of uninsured.
  I reserve the remainder of my 15 seconds so the Senator from Utah can 
finish.
  The PRESIDING OFFICER. The Senator from Utah.
  Mr. HATCH. Mr. President, I feel deeply about this. I do not think we 
should leave these wounded warriors without access to the best medical 
devices, and I do not think we should be assessing them extra costs. 
This is a simple amendment. This is one we all ought to vote for.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, very simply, this will not be passed on. 
The government is a large payer. They will be able to negotiate for 
better prices.
  I move to table the amendment 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.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 54, nays 44, as follows:

                      [Rollcall Vote No. 81 Leg.]

                                YEAS--54

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

                                NAYS--44

     Alexander
     Barrasso
     Bennett
     Bond
     Brown (MA)
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hagan
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Tester
     Thune
     Vitter
     Voinovich
     Webb
     Wicker

                             NOT VOTING--2

     Byrd
     Isakson
       
  The motion was agreed to.
  Mr. DURBIN. Mr. President, I move to reconsider the vote.
  Mrs. MURRAY. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                           Amendment No. 3651

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate equally divided prior to a vote in relation to 
amendment No. 3651, offered by the Senator from New Hampshire, Mr. 
Gregg.
  The Senator from New Hampshire.
  Mr. GREGG. Mr. President, this amendment addresses what is a core 
problem we have with our health care system, which is the fact that 
every year we cut our doctors' pay--those doctors who deliver Medicare 
services. This year, it will be cut 21 percent. This amendment restores 
that pay so that those cuts don't occur for a period of 3 years. This 
is known as the doctors fix.
  It should have been in the bill to begin with. The reason it wasn't 
in the bill was because the other side wanted to not put it in the bill 
because of its cost, because it scores at $280 billion over 10 years. 
The other side didn't want to absorb that score because it would have 
thrown the entire bill out of whack relative to the budget.
  We have come up with a way to address this doctor problem that pays 
for it for 3 years. Let's do it. Let's take care of these doctors who 
are delivering these services so they can continue to deliver services 
to Medicare recipients.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, the Senator from New Hampshire and I kid 
each other about this. The fact is, this is another killer amendment, 
and it is apparent it is designed to kill this bill. Why do I say that? 
Because on October 21 of last year, the sponsor of this amendment, and 
every other Senator on the other side of the aisle, voted against 
invoking cloture on a bill to accomplish the very same thing they 
profess to desire at this point.
  Also, we have been advised by the Congressional Budget Office that it 
is not paid for. According to CBO--they recently sent us a note--the 
Gregg amendment would increase the deficit by $65 billion over the next 
5 years.

[[Page S2003]]

  We will solve the SGR problem at the appropriate time. This body will 
then decide at that time the degree to which we want to pay for the 
SGR. This is not the time or the place. This is a killer amendment.
  According to CBO, it increases the deficit by $65 billion over the 
next 5 years; therefore, I raise a point of order that the Gregg 
amendment violates section 310(d)(2) of the Congressional Budget Act.
  The PRESIDING OFFICER. The Senator from New Hampshire.
  Mr. GREGG. Mr. President, parliamentary inquiry: This amendment pays 
for the doctors fix for 3 years, does it not?
  The PRESIDING OFFICER. The Chair is unaware.
  Mr. GREGG. I withdraw the inquiry.
  Pursuant to section 904 of the Congressional Budget Act of 1974 and 
section 4(G)(3) of the Statutory Pay-As-You-Go Act of 2010, I move to 
waive all applicable sections of those acts and applicable budget 
resolutions for purposes of my amendment, and I ask for the yeas and 
nays.
  The PRESIDING OFFICER. Is there a sufficient second? There is a 
sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 42, nays 56, as follows:

                      [Rollcall Vote No. 82 Leg.]

                                YEAS--42

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

                                NAYS--56

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

                             NOT VOTING--2

     Byrd
     Isakson
       
  The PRESIDING OFFICER. On this vote, the yeas are 42; the nays are 
56. Three-fifths of the Senators duly chosen and sworn not having voted 
in the affirmative, the motion is rejected.
  The point of order is sustained, and the amendment falls.
  Mr. LEVIN. 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.


                           Amendment No. 3652

  The PRESIDING OFFICER. There will now be 2 minutes, equally divided, 
prior to a vote in relation to the amendment No. 3652, offered by the 
Senator from North Carolina, Mr. Burr.
  Who yields time?
  Mr. BURR. Mr. President, my amendment is quite simple. In the rush to 
finish this bill, there were some errors. One of the errors was 
clarifying the status of some veterans programs, specifically the 
TRICARE program, the VA spina bifida program--that is the children of 
Agent Orange exposure from Vietnam--and the last one is the CHAMPVA 
program.
  What this amendment simply does is set the minimum essential coverage 
as met on these programs, so the veterans' families, the children of 
veterans, are not at risk of determining that their insurance does not 
meet the minimum essential coverage, therefore, exposing them to fines.
  Some might suggest it does not need to be fixed. The House went back 
very quickly and fixed TRICARE but not CHAMPVA or spina bifida. It is 
my belief we should act on that on the appropriate mechanism, which is 
this fix-it bill.
  The PRESIDING OFFICER. The Senator from Virginia.
  Mr. WEBB. Mr. President, I would suggest to my colleague from North 
Carolina and my colleagues on the other side of the aisle that if we 
want to fix this problem, we can fix it right now and we should fix it 
right now.
  We should not allow things to be tied up in the separate melodrama of 
the moment. I introduced a bill on Monday which passed the House 
unanimously on Saturday to fix the TRICARE part of this. The chairman 
of the Veterans' Committee introduced a bill today to fix the spina 
bifida problem.
  I ask unanimous consent that the Finance Committee be discharged from 
further consideration of S. 3148, a bill to amend the Internal Revenue 
Code to provide for the treatment of Department of Defense health 
coverage as minimal essential coverage, sponsored by myself; further, 
that the Senate proceed to its immediate consideration en bloc, along 
with the bill introduced earlier today by Senator Akaka, S. 3162, a 
bill to clarify the health care provided by the Secretary of Veterans 
Affairs that constitutes minimum essential coverage; that all 
Democratic Senators be added as cosponsors to this measure; that the 
bills be read a third time and passed en bloc, and the motions to 
reconsider be laid upon the table en bloc, with no intervening action 
or debate.
  The PRESIDING OFFICER. Is there objection? The Senator from Oklahoma.
  Mr. COBURN. Reserving the right to object.
  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. COBURN. We got this 1\1/2\ minutes ago to see the language. You 
have an amendment on the floor that actually accomplishes everything 
you want to do. Why are we doing this? Because you do not want to mess 
up a package that is clean. It has every application, the Burr 
amendment, to this.
  With that, and the fact that this is exactly the kind of shenanigans 
the American people do not want, I object.
  Mr. WEBB. Let the American people understand, the Republicans 
objected to a matter that could have been fixed by law tomorrow.
  The PRESIDING OFFICER. Objection is heard.
  The Senator from Hawaii.
  Mr. AKAKA. Mr. President, I move that we table the Burr amendment, 
and I 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.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 54, nays 44, as follows:

                      [Rollcall Vote No. 83 Leg.]

                                YEAS--54

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

                                NAYS--44

     Alexander
     Barrasso
     Bennett
     Bond
     Brown (MA)
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hagan
     Hatch
     Hutchison

[[Page S2004]]


     Inhofe
     Johanns
     Kyl
     LeMieux
     Lincoln
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Pryor
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Wicker

                             NOT VOTING--2

     Byrd
     Isakson
       
  The motion was agreed to.
  Mr. DURBIN. I move to reconsider the vote.
  Mrs. MURRAY. I move to reconsider and to lay that motion on the 
table.
  The motion to lay on the table was agreed to.


                           Amendment No. 3553

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate equally divided prior to a vote in relation to 
amendment No. 3553 offered by the Senator from Louisiana, Mr. Vitter.
  The Senator from Louisiana.
  Mr. VITTER. Mr. President, this amendment is very straightforward. It 
would repeal the ObamaCare bill. That bill is fatally flawed in terms 
of its core, and we do need to repeal and replace it with a very 
different, more targeted, focused, step-by-step approach. What is that 
core? It is more than $\1/2\ trillion in Medicare cuts on our seniors, 
which is wrong; over $\1/2\ trillion of tax increases, including on 
middle-class families, which is wrong; increasing health care costs 
rather than doing the opposite, decreasing them. That is what the CBO 
says, nonpartisan. That will result in increased individual health care 
premiums, 10 to 13 percent, and government getting even more involved 
in our lives, including over 16,000 new IRS agents.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I give a prize to the Senator from 
Louisiana. This is very transparent. It is very straightforward. It is 
totally honest. It is not dressed up. It is not camouflaged. It is 
straight repeal of health care reform.
  Therefore, I move to table the amendment 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.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Georgia (Mr. Isakson) and the Senator from Missouri (Mr. Bond).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 58, nays 39, as follows:

                      [Rollcall Vote No. 84 Leg.]

                                YEAS--58

     Akaka
     Baucus
     Bayh
     Begich
     Bennet
     Bingaman
     Boxer
     Brown (OH)
     Burris
     Cantwell
     Cardin
     Carper
     Casey
     Conrad
     Dodd
     Dorgan
     Durbin
     Feingold
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Inouye
     Johnson
     Kaufman
     Kerry
     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
     Brown (MA)
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lugar
     McCain
     McConnell
     Murkowski
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Wicker

                             NOT VOTING--3

     Bond
     Byrd
     Isakson
  The motion was agreed to.
  Mrs. MURRAY. 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.


                           Amendment No. 3577

  The PRESIDING OFFICER. There are 2 minutes now evenly divided before 
a vote with respect to the Roberts amendment.
  The Senator from Kansas.
  Mr. ROBERTS. Mr. President, this amendment protects the rural health 
care delivery system by exempting critical access hospitals from 
dangerous payment cuts by the Independent Payment Advisory Board. This 
board is an unelected and unaccountable body, nefarious to be sure, 
with unprecedented power to set payment rates and make other Medicare 
policy changes.
  While most hospitals are exempt from the board's cuts by virtue of 
the special deals they cut with the administration--for shame--critical 
access hospitals, which are among the most vulnerable in the country, 
are not exempt.
  I do not know why critical access hospitals were let out of this 
exemption--perhaps a drafting error; I do not know--but I can think of 
no other more deserving providers than critical access hospitals 
throughout our rural areas--in Montana and in Kansas--to be spared from 
the Independent Payment Advisory Board's cuts. Save the rural health 
care delivery system.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, I agree--Kansas, Montana, anywhere--
critical access hospitals should be treated the same way as other 
hospitals. And when we get to that point, I say to my good friend from 
Kansas, I will work with him, and I know he will with me, so we can 
exempt critical access hospitals from this commission.
  However, the Parliamentarian tells us it is not permissible to amend 
programs subject to fast-track rules such as this commission in a 
reconciliation bill. Critical access hospitals are not in. It is a 
technical error, oversight--there are all kinds of reasons why it 
should be in, but they are not, and I cannot, at this point, agree with 
my friend to take them out now. I will at a later date, but we cannot 
now.
  Mr. ROBERTS. Surely, you are not going to raise a point of order?
  Mr. BAUCUS. Mr. President, surely I have to do the right thing. The 
right thing is to raise a point of order. I raise a point of order that 
the Roberts amendment violates section 313(b)(1)(D) of the 
Congressional Budget Act.
  Mr. ROBERTS. Mr. President, I take it the chairman has raised the 
point of order, so we are at regular order.
  Mr. BAUCUS. We are, and the Senator can make his motion.
  Mr. ROBERTS. I thank the Senator. Mr. President, pursuant to section 
904 of the Congressional Budget Act of 1974 and section 4(g)(3) of the 
statutory Pay-As-You-Go-Act of 2010, I move to waive all applicable 
sections of those acts and applicable budget resolutions for purposes 
of my amendment in saving rural hospitals, and I 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.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
and the Senator from Maryland (Ms. Mikulski) are necessarily absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Missouri ( Mr. Bond) and the Senator from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 42, nays 54, as follows:

                      [Rollcall Vote No. 85 Leg.]

                                YEAS--42

     Alexander
     Barrasso
     Bennett
     Brown (MA)
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lincoln
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Webb
     Wicker

[[Page S2005]]



                                NAYS--54

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

                             NOT VOTING--4

     Bond
     Byrd
     Isakson
     Mikulski
  The PRESIDING OFFICER (Mr. Brown of Ohio). On this vote, the yeas are 
42, the nays are 54. Three-fifths of the Senators being duly chosen and 
sworn not having voted in the affirmative, the motion is not agreed to. 
The point of order is sustained, and the amendment falls.
  Mr. REID. Mr. President, I move to reconsider the vote.
  Mr. PRYOR. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                        Roberts Motion to Commit

  The PRESIDING OFFICER. There is now 2 minutes equally divided before 
the vote with respect to the Roberts motion to commit.
  The junior Senator from Kansas.
  Mr. ROBERTS. Thank you, Mr. President.
  This motion commits the bill back to the Finance Committee with 
instructions to repeal ``the four rationers'' of health care reform. 
These four horsemen of the rationing apocalypse are the Patient Center 
Outcomes Research Institute, already conducting research that will be 
used to deny coverage and ration care; the CMS Innovation Center, which 
will grant new powers to CMS--that should be a pleasant thought by any 
beleaguered hospital administrator--the U.S. Preventive Services Task 
Force, which is given new powers--that is the outfit that said women 
should not have mammograms until age 50--wonderful--and the Independent 
Payment Advisory Board, vested with extraordinary power to set Medicare 
payment rates and make policy decisions.
  These rationers comprise the infrastructure for the ``Brave New 
World'' of big government intrusion into health care decisions of all 
Americans, and they must be repealed.
  Start over. Put patient care first. Get them back in the corral. 
Support the amendment.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, saying it doesn't make it so. It is not at 
all as it has been described.
  We very much in this country have to work to control health care 
costs. Doctors and hospitals--especially doctors--want to practice 
evidence-based medicine, even more than they do now. They want the 
evidence. They want the information. They want to know which procedures 
and medicine, et cetera, work better than others. These commissions 
will help them get that information. Then, they make the decisions 
alone, independently, with their patients as to what to do. But they 
want more evidence so they can make more evidence-based decisions.
  Second, I am not going to sugarcoat it. This independent advisory 
board is very important to help improve quality of care and to control 
costs. It does have some teeth in it. But I say to my colleagues, if we 
really want to do something about health care costs in this country, 
this is a start. CBO says this does score positively. I, therefore, 
move to table the motion, and I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second? There appears to 
be.
  The question is on agreeing to the motion to table the motion to 
commit.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
and the Senator from Maryland (Ms. Mikulski) are necessarily absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Missouri (Mr. Bond) and the Senator from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 59, nays 37, as follows:

                      [Rollcall Vote No. 86 Leg.]

                                YEAS--59

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

                                NAYS--37

     Alexander
     Barrasso
     Bennett
     Brown (MA)
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lugar
     McCain
     McConnell
     Murkowski
     Risch
     Roberts
     Sessions
     Shelby
     Thune
     Vitter
     Voinovich
     Wicker

                             NOT VOTING--4

     Bond
     Byrd
     Isakson
     Mikulski
  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 lay on the table was agreed to.
  The PRESIDING OFFICER. The majority leader is recognized.
  Mr. REID. Mr. President, we have finished the first tranche of 
amendments and motions, some 23 in number, all of which were amendments 
pending at the end of the 20 hours. I think it is time we pause for a 
minute and find out where we are and where we need to go.
  First of all, I congratulate the entire Senate. I think the decorum 
of the Senate has been maintained in the highest standards. The debate 
has been good. I especially appreciate the work of the staff, the 
professionals they always are.
  We have handled, as I indicated, 23 amendments and motions. Not a 
single one has been adopted. All of the amendments and motions have 
been offered by the minority, which is their right. The average, 
according to CRS, number of amendments offered during this same type of 
proceeding is 21. We are two over that now.
  I want, of course, to congratulate my friend, Senator Gregg, who has 
managed these budget-type proceedings on many occasions and is always a 
gentleman, easy to work with. There could have been a lot of 
controversy. There has been none. There has been no reading of 
amendments. There has been agreement that time would be allowed to 
speak on behalf of amendments.
  I think, though--I am speaking to my chairs: Harkin, Baucus, Dodd, 
Conrad--they agree unanimously we need to just continue. The House of 
Representatives worked all weekend moving this issue along, and I think 
we need to move this along and find out if they have to take any action 
on this tomorrow, which is today.
  I say to my colleague, my counterpart, the Republican leader, through 
the Chair that I think we would like to know what the plans are. We are 
not going to offer any amendments. We would like to know if there is 
some indication from the Republican side as to how many more amendments 
we are going to deal with this morning.
  The PRESIDING OFFICER. The Republican leader is recognized.
  Mr. McCONNELL. Mr. President, I say to my friend the majority leader, 
I agree, I think the process has been well handled today. The top 
number of amendments that have been offered on past reconciliation 
bills is 53. We have offered 23.
  We have had a number of discussions off the floor, I say for the 
benefit of everyone in the Chamber, about some process to complete this 
bill and to complete the next bill that will be brought up by the 
majority after we finish this bill. I think there is a chance we might 
be able to reach some agreement on the disposition of this bill and 
that bill. I think we should

[[Page S2006]]

continue to discuss it. I will be happy to continue those discussions 
with the majority leader. In the meantime, it strikes me we can either 
continue voting tonight or we could set a reasonable time in the 
morning after everybody has had a chance to get some sleep, continue 
voting and discussing and see if we can't wrap up both this measure and 
the next one in the not too distant future.
  The PRESIDING OFFICER. The majority leader is recognized.
  Mr. REID. Mr. President, my focus is on this legislation, and I know 
there are other things we have to deal with before we leave, but I am 
not concerned about those at this stage. I want to finish this 
legislation, and I want to do that as quickly as we can.
  So I would ask that we just proceed. I hope there aren't that many 
more amendments, but we are here for the duration.
  I would note--and I am certainly in no way trying to denigrate those 
amendments that have been offered, but we have to understand that not a 
single one has been adopted. I don't know what we are trying to 
accomplish. We have listened intently. Most of the comments from our 
side have been from the chairman of the Finance Committee because most 
of these issues deal with the jurisdiction he has. But it is very clear 
there is no attempt to improve the bill. There is an attempt to destroy 
this bill.
  We already have a law in place. It is the bill that we passed on 
Christmas Eve 2009. That is the law of this land. This is a matter to 
improve that, and I have to suggest that we are going to continue down 
this road. I am not sure it is a good picture for the American people, 
to have all these amendments and not a single one of them having enough 
votes to pass, but that judgment is not mine. We are here to try to 
move this along.
  The House of Representatives is waiting for us to act, as we speak. I 
think they have proven they are willing to work hard, as indicated this 
past weekend and over the last several weeks. So let's continue forward 
in the same spirit we have gotten this far. But I would hope that my 
friends understand I think it would be to the benefit of most everyone 
if we could get out of here at a decent hour today. If it is not, if we 
are going to keep going, that is the way it is. I am an old marathoner, 
and getting older every day.
  The PRESIDING OFFICER. The Republican leader is recognized.
  Mr. McCONNELL. I would just add that there are some obvious 
disadvantages to the minority to be in a reconciliation contest, but 
one of the advantages is that we have had more amendment votes today 
than we had in the entire month of December on the previous health care 
bill. So the majority leader may not think we are serious about 
changing the bill, but we would like to change the bill. And with a 
little help from our friends on the other side, we could improve this 
bill significantly.
  But rather than subject all of our Members to listening to the 
majority leader and myself go back and forth, I would simply suggest it 
might be a better use of his and my time for us to continue the 
discussions we have been having off the floor, continue to offer the 
amendments, and see if we can reach an accommodation that satisfies 
both sides. Maybe the best way to do that would be for Senator Reid and 
myself to continue our discussions while we will keep voting, if that 
is what the majority would like.
  The PRESIDING OFFICER. The junior Senator from Kentucky is 
recognized.


                           Amendment No. 3681

  Mr. BUNNING. Mr. President, I would like to call up Bunning amendment 
No. 3681.
  The PRESIDING OFFICER. The clerk will report the amendment.
  The bill clerk read as follows:

       The Senator from Kentucky [Mr. Bunning] proposes an 
     amendment numbered 3681.

  Mr. BUNNING. Mr. President, I ask unanimous consent to dispense with 
the reading of the amendment.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To allow individuals to elect to opt out of the Medicare part 
                              A benefits)

       At the end of subtitle B of title I, add the following:

     SEC. __. ALLOWING INDIVIDUALS TO ELECT TO OPT OUT OF THE 
                   MEDICARE PART A BENEFIT.

       Notwithstanding any other provision of law, in the case of 
     an individual who elects to opt out of benefits under part A 
     of title XVIII of the Social Security Act, such individual 
     shall not be required to--
       (1) opt out of benefits under title II of such Act as a 
     condition for making such election; and
       (2) repay any amount paid under such part A for items and 
     services furnished prior to making such election.

  The PRESIDING OFFICER. The Senator has 1 minute.
  Mr. BUNNING. Mr. President, I rise to offer a very important 
amendment to many of our seniors. My amendment would allow individuals 
to voluntarily opt out of Medicare Part A benefits. Right now, if you 
don't want to have Medicare Part A, you have to forego Social Security 
checks and you also have to repay any Medicare benefits that have been 
paid on your behalf. I don't think that is fair.
  If a senior doesn't want Part A, they shouldn't be forced to take it. 
My amendment says that anyone who opts out of Part A will not have to 
give up their Social Security benefits and would not have to repay 
Medicare payments that have already been made on their behalf. This 
amendment does not allow anyone to opt out of paying their Medicare 
taxes. Instead, it just allows them to not take Medicare benefits 
without being penalized.
  I think this is a fairness issue, and I hope Members can support it.
  The PRESIDING OFFICER. The time has expired.
  The senior Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, since 1965, Medicare has provided security 
and health to millions of seniors. Along with Social Security, it is 
one of the two most successful and best social programs this country 
has adopted. Now, after 45 years of success, what does this amendment 
seek to do? It seeks to undermine the foundation of our social 
insurance program.
  It is a two-tiered system. The wealthy can take care of themselves. 
Then, when they leave Medicare, it leaves a second-class seniors health 
care system remaining in Medicare. It is unthinkable, frankly, that we 
would have a two-tiered system for our seniors under Medicare. I 
therefore move to table the Bunning amendment, and I ask for the yeas 
and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Missouri (Mr. Bond) and the Senator from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 61, nays 36, as follows:

                      [Rollcall Vote No. 87 Leg.]

                                YEAS--61

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

                                NAYS--36

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

                             NOT VOTING--3

     Bond
     Byrd
     Isakson
  The motion was agreed to.

[[Page S2007]]

  Mr. CONRAD. Mr. President, I move to reconsider the vote, and I move 
to lay that motion on the table.


                           Amendment No. 3699

  Mr. GRASSLEY. I send an amendment to the desk and ask for its 
consideration.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Iowa [Mr. Grassley], proposes an amendment 
     numbered 3699.

  Mr. GRASSLEY. I ask unanimous consent that reading of the amendment 
be dispensed with.
  Mr. BAUCUS. Mr. President, I object. I object.
  The PRESIDING OFFICER. The Senator from Montana objects.
  The assistant legislative clerk continued with the reading of the 
amendment.
  Mr. BAUCUS. Mr. President, I ask unanimous consent that further 
reading of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

    (Purpose: To provide a temporary extension of certain programs)

       At the end of the bill, insert:

           TITLE III--TEMPORARY EXTENSION OF CERTAIN PROGRAMS

     SEC. 300. SHORT TITLE.

       This title may be cited as the ``Continuing Extension Act 
     of 2010''.

     SEC. 301. EXTENSION OF UNEMPLOYMENT INSURANCE PROVISIONS.

       (a) In General.--(1) Section 4007 of the Supplemental 
     Appropriations Act, 2008 (Public Law 110-252; 26 U.S.C. 3304 
     note) is amended--
       (A) by striking ``April 5, 2010'' each place it appears and 
     inserting ``May 5, 2010'';
       (B) in the heading for subsection (b)(2), by striking 
     ``april 5, 2010'' and inserting ``may 5, 2010''; and
       (C) in subsection (b)(3), by striking ``September 4, 2010'' 
     and inserting ``October 2, 2010''.
       (2) Section 2002(e) of the Assistance for Unemployed 
     Workers and Struggling Families Act, as contained in Public 
     Law 111-5 (26 U.S.C. 3304 note; 123 Stat. 438), is amended--
       (A) in paragraph (1)(B), by striking ``April 5, 2010'' and 
     inserting ``May 5, 2010'';
       (B) in the heading for paragraph (2), by striking ``april 
     5, 2010'' and inserting ``may 5, 2010''; and
       (C) in paragraph (3), by striking ``October 5, 2010'' and 
     inserting ``November 5, 2010''.
       (3) Section 2005 of the Assistance for Unemployed Workers 
     and Struggling Families Act, as contained in Public Law 111-5 
     (26 U.S.C. 3304 note; 123 Stat. 444), is amended--
       (A) by striking ``April 5, 2010'' each place it appears and 
     inserting ``May 5, 2010''; and
       (B) in subsection (c), by striking ``September 4, 2010'' 
     and inserting ``October 2, 2010''.
       (4) Section 5 of the Unemployment Compensation Extension 
     Act of 2008 (Public Law 110-449; 26 U.S.C. 3304 note) is 
     amended by striking ``September 4, 2010'' and inserting 
     ``October 2, 2010''.
       (b) Funding.--Section 4004(e)(1) of the Supplemental 
     Appropriations Act, 2008 (Public Law 110-252; 26 U.S.C. 3304 
     note) is amended--
       (1) in subparagraph (C), by striking ``and'' at the end;
       (2) by inserting after subparagraph (D) the following new 
     subparagraph:
       ``(E) the amendments made by section 2(a)(1) of the 
     Continuing Extension Act of 2010; and''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect as if included in the amendments made by 
     section 2 of the Temporary Extension Act of 2010 (Public Law 
     111-144).

     SEC. 302. EXTENSION AND IMPROVEMENT OF PREMIUM ASSISTANCE FOR 
                   COBRA BENEFITS.

       Subsection (a)(3)(A) of section 3001 of division B of the 
     American Recovery and Reinvestment Act of 2009 (Public Law 
     111-5), as amended by section 3(a) of the Temporary Extension 
     Act of 2010 (Public Law 111-144), is amended by striking 
     ``March 31, 2010'' and inserting ``April 30, 2010''.

     SEC. 303. INCREASE IN THE MEDICARE PHYSICIAN PAYMENT UPDATE.

       Paragraph (10) of section 1848(d) of the Social Security 
     Act, as added by section 1011(a) of the Department of Defense 
     Appropriations Act, 2010 (Public Law 111-118) and as amended 
     by section 5 of the Temporary Extension Act of 2010 (Public 
     Law 111-144), is amended--
       (1) in subparagraph (A), by striking ``March 31, 2010'' and 
     inserting ``April 30, 2010''; and
       (2) in subparagraph (B), by striking ``April 1, 2010'' and 
     inserting ``May 1, 2010''.

     SEC. 304. EHR CLARIFICATION.

       (a) Qualification for Clinic-Based Physicians.--
       (1) Medicare.--Section 1848(o)(1)(C)(ii) of the Social 
     Security Act (42 U.S.C. 1395w-4(o)(1)(C)(ii)) is amended by 
     striking ``setting (whether inpatient or outpatient)'' and 
     inserting ``inpatient or emergency room setting''.
       (2) Medicaid.--Section 1903(t)(3)(D) of the Social Security 
     Act (42 U.S.C. 1396b(t)(3)(D)) is amended by striking 
     ``setting (whether inpatient or outpatient)'' and inserting 
     ``inpatient or emergency room setting''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall be effective as if included in the enactment of the 
     HITECH Act (included in the American Recovery and 
     Reinvestment Act of 2009 (Public Law 111-5)).
       (c) Implementation.--Notwithstanding any other provision of 
     law, the Secretary of Health and Human Services may implement 
     the amendments made by this section by program instruction or 
     otherwise.

     SEC. 305. ELIMINATION OF A SWEETHEART DEAL THAT INCREASES 
                   MEDICARE REIMBURSEMENT JUST FOR FRONTIER 
                   STATES.

       Effective as if included in the enactment of the Patient 
     Protection and Affordable Care Act, section 10324 of such Act 
     (and the amendments made by such section) is repealed.

     SEC. 306. EXTENSION OF USE OF 2009 POVERTY GUIDELINES.

       Section 1012 of the Department of Defense Appropriations 
     Act, 2010 (Public Law 111-118), as amended by section 7 of 
     the Temporary Extension Act of 2010 (Public Law 111-144), is 
     amended by striking ``March 31, 2010'' and inserting ``April 
     30, 2010''.

     SEC. 307. EXTENSION OF NATIONAL FLOOD INSURANCE PROGRAM.

       (a) Extension.--Section 129 of the Continuing 
     Appropriations Resolution, 2010 (Public Law 111-68), as 
     amended by section 8 of Public Law 111-144, is amended by 
     striking ``by substituting'' and all that follows through the 
     period at the end and inserting ``by substituting April 30, 
     2010, for the date specified in each such section.''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall be considered to have taken effect on February 28, 
     2010.

     SEC. 308. SATELLITE TELEVISION EXTENSION.

       (a) Amendments to Section 119 of Title 17, United States 
     Code.--
       (1) In general.--Section 119 of title 17, United States 
     Code, is amended--
       (A) in subsection (c)(1)(E), by striking ``March 28, 2010'' 
     and inserting ``April 30, 2010''; and
       (B) in subsection (e), by striking ``March 28, 2010'' and 
     inserting ``April 30, 2010''.
       (2) Termination of license.--Section 1003(a)(2)(A) of 
     Public Law 111-118 is amended by striking ``March 28, 2010'', 
     and inserting ``April 30, 2010''.
       (b) Amendments to Communications Act of 1934.--Section 
     325(b) of the Communications Act of 1934 (47 U.S.C. 325(b)) 
     is amended--
       (1) in paragraph (2)(C), by striking ``March 28, 2010'' and 
     inserting ``April 30, 2010''; and
       (2) in paragraph (3)(C), by striking ``March 29, 2010'' 
     each place it appears in clauses (ii) and (iii) and inserting 
     ``May 1, 2010''.

     SEC. 309. COMPENSATION AND RATIFICATION OF AUTHORITY RELATED 
                   TO LAPSE IN HIGHWAY PROGRAMS.

       (a) Compensation for Federal Employees.--Any Federal 
     employees furloughed as a result of the lapse in expenditure 
     authority from the Highway Trust Fund after 11:59 p.m. on 
     February 28, 2010, through March 2, 2010, shall be 
     compensated for the period of that lapse at their standard 
     rates of compensation, as determined under policies 
     established by the Secretary of Transportation.
       (b) Ratification of Essential Actions.--All actions taken 
     by Federal employees, contractors, and grantees for the 
     purposes of maintaining the essential level of Government 
     operations, services, and activities to protect life and 
     property and to bring about orderly termination of Government 
     functions during the lapse in expenditure authority from the 
     Highway Trust Fund after 11:59 p.m. on February 28, 2010, 
     through March 2, 2010, are hereby ratified and approved if 
     otherwise in accord with the provisions of the Continuing 
     Appropriations Resolution, 2010 (division B of Public Law 
     111-68).
       (c) Funding.--Funds used by the Secretary to compensate 
     employees described in subsection (a) shall be derived from 
     funds previously authorized out of the Highway Trust Fund and 
     made available or limited to the Department of Transportation 
     by the Consolidated Appropriations Act, 2010 (Public Law 111-
     117) and shall be subject to the obligation limitations 
     established in such Act.
       (d) Expenditures From Highway Trust Fund.--To permit 
     expenditures from the Highway Trust Fund to effectuate the 
     purposes of this section, this section shall be deemed to be 
     a section of the Continuing Appropriations Resolution, 2010 
     (division B of Public Law 111-68), as in effect on the date 
     of the enactment of the last amendment to such Resolution.

     SEC. 310. USE OF STIMULUS FUNDS TO OFFSET SPENDING.

       The unobligated balance of each amount appropriated or made 
     available under the American Recovery and Reinvestment Act of 
     2009 (Public Law 111-5) (other than under title X of division 
     A of such Act) is rescinded pro rata such that the aggregate 
     amount of such rescissions equals $9,200,000,000 in order to 
     offset the net increase in spending resulting from the 
     provisions of, and amendments made by, sections 2 through 10. 
     The Director of the Office of Management and Budget shall 
     report to each congressional committee the amounts so 
     rescinded within the jurisdiction of such committee.

     SEC. 311. ELIMINATION OF ADVANCE REFUNDA-BILITY OF EARNED 
                   INCOME CREDIT.

       (a) In General.--Section 3507, subsection (g) of section 
     32, and paragraph (7) of section 6051(a) are repealed.

[[Page S2008]]

       (b) Conforming Amendments.--
       (1) Section 6012(a) is amended by striking paragraph (8) 
     and by redesignating paragraph (9) as paragraph (8).
       (2) Section 6302 is amended by striking subsection (i).
       (c) Effective Date.--The repeals and amendments made by 
     this section shall apply to taxable years beginning after 
     December 31, 2010.

  The PRESIDING OFFICER. The Senator from Iowa is recognized for 1 
minute.
  Mr. GRASSLEY. This amendment is based largely on the extenders 
package that passed the House last week. It includes a 30-day extension 
for unemployment insurance, COBRA coverage, and the SGR Medicare 
physicians payment fix. It includes provisions on Federal poverty 
guidelines, national flood insurance, satellite television and 
compensation for highway programs.
  There is one very important difference between my amendment and the 
House bill. My amendment is fully offset. We can do this without adding 
to the deficit. I urge its passage and reserve the remainder of my 
time.
  The PRESIDING OFFICER. The senior Senator from Montana is recognized.
  Mr. BAUCUS. Mr. President, there is discussion in progress on how to 
deal with extenders that is ongoing with the majority leader and 
minority leader. In fact, the minority leader referred to it when he 
spoke just about a half hour ago. I think it is best to continue that 
process. More important, I think, this amendment is a killer amendment 
designed to send the reconciliation bill back to the House and let it 
go all over again. It is paid for by repealing some stimulus dollars. 
It is paid for by cutting back on the fundability of the EITC--clearly 
nonstarters. I might say, too, there are other pay-fors in here that 
are not going to fly, frankly.
  I raise a point of order the Grassley amendment violates section 
313(b)(1)(C) of the Congressional Budget Act.
  Mr. GRASSLEY. Do I have time left?
  The PRESIDING OFFICER. The Senator from Iowa has 20 seconds.
  Mr. GRASSLEY. Yes? Mr. President, let's wake up. This has to be 
passed. It has to be passed before the end. One of the problems we 
always have is that it is not offset. It was included in the Baucus-
Grassley bill way back in February. The leader had the chutzpah to dump 
his own chairman aside and go ahead with a partisan bill. Then the 
other side complained about the Bunning filibuster, and we have an 
opportunity now to avoid all that. We ought to avoid it and move on.
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. BAUCUS. I raise the point of order that the Grassley amendment 
violates section 313(b)(1)(C) of the Congressional Budget Act.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, pursuant to section 904 of the 
Congressional Budget Act of 1974 and section 4(G)(3) of the statutory 
pay-as-you-go act of 2010, I move to waive all applicable provisions of 
those acts and applicable budget resolutions for purposes of my 
amendment and ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second. The question is on agreeing to the 
motion. The clerk will call the roll.
  The bill clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
and the Senator from New Jersey (Mr. Lautenberg) are necessarily 
absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Missouri (Mr. Bond) and the Senator from Georgia (Mr. Isakson).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 40, nays 56, as follows:

                      [Rollcall Vote No. 88 Leg.]

                                YEAS--40

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

                                NAYS--56

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

                             NOT VOTING--4

     Bond
     Byrd
     Isakson
     Lautenberg
  The PRESIDING OFFICER. On this vote, the yeas are 40, the nays are 
56. Three-fifths of the Senators duly chosen and sworn having not voted 
in the affirmative, the motion is not agreed to, the point of order is 
sustained, and the amendment falls.
  Mr. REID. Mr. President, I move to reconsider the vote and lay that 
motion upon the table.
  The motion to lay upon the table was agreed to.
  The PRESIDING OFFICER. The junior Senator from Utah is recognized.


                           Amendment No. 3568

  Mr. BENNETT. I call up my amendment No. 3568.
  The PRESIDING OFFICER. The clerk will report.
  The bill clerk read as follows:

       The Senator from Utah [Mr. Bennett], for himself, Mr. 
     Wicker, Mr. Brownback, Mr. Hatch, Mr. Roberts, Mr. Inhofe, 
     and Mr. Cornyn, proposes an amendment numbered 3568.

  Mr. BENNETT. I ask unanimous consent that the reading of the 
amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To protect the democratic process and the right of the people 
            of the District of Columbia to define marriage)

       At the end of subtitle B of title I, add the following:

     SEC. ___. RIGHT OF THE PEOPLE OF THE DISTRICT OF COLUMBIA TO 
                   DEFINE MARRIAGE.

       (a) Findings.--Congress finds that--
       (1) a broad coalition of residents of the District of 
     Columbia petitioned for an initiative in accordance with the 
     District of Columbia Home Rule Act to establish that ``only 
     marriage between a man and a woman is valid or recognized in 
     the District of Columbia'';
       (2) this petition anticipated the Council of the District 
     of Columbia's passage of an Act legalizing same-sex marriage;
       (3) the unelected District of Columbia Board of Elections 
     and Ethics and the unelected District of Columbia Superior 
     Court thwarted the residents' initiative effort to define 
     marriage democratically, holding that the initiative amounted 
     to discrimination prohibited by the District of Columbia 
     Human Rights Act; and
       (4) the definition of marriage affects every person and 
     should be debated openly and democratically.
       (b) Referendum or Initiative Requirement.--Notwithstanding 
     any other provision of law, including the District of 
     Columbia Human Rights Act, the government of the District of 
     Columbia shall immediately suspend the issuance of marriage 
     licenses to any couple of the same sex until the people of 
     the District of Columbia have the opportunity to hold a 
     referendum or initiative on the question of whether the 
     District of Columbia should issue same-sex marriage licenses.

  Mr. BENNETT. Mr. President, with eight other cosponsors, we have 
offered a bill that would allow the people of the District of Columbia 
to exercise the same right that has been exercised by 31 States with 
respect to the issue of whether there would be gay marriage in their 
jurisdiction.
  This bill does not take any position with respect to gay marriage, 
simply allows the District to hold a referendum. The Home Rule Charter, 
which is a constitution for the District, guarantees the people the 
right to challenge acts passed by the District Council by referendum, 
and the District Council has repeatedly ignored that right. It is in an 
effort to restore that that we offer this amendment.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, no matter where you are on the issue of 
marriage, no matter where you are on the issue of DC home rule, we 
ought to be able to agree that neither issue has anything to do with 
this bill, neither one. Therefore, I raise a point of order that the 
amendment is not germane and thus violates section 305(b)(2) of the 
Congressional Budget Act.

[[Page S2009]]

  Mr. BENNETT. Pursuant to section 904 of the Congressional Budget Act 
of 1974 and section 4(g)(3) of the statutory Pay-as-you-go Act of 2010, 
I move to waive all applicable sections of those acts and applicable 
budget resolutions for purposes of my amendment and ask for the yeas 
and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be.
  The question is on agreeing to the motion.
  The yeas and nays have been ordered.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
and the Senator from New Jersey (Mr. Lautenberg) are necessarily 
absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Missouri (Mr. Bond), the Senator from Georgia (Mr. Isakson), and 
the Senator from Ohio (Mr. Voinovich).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 36, nays 59, as follows:

                      [Rollcall Vote No. 89 Leg.]

                                YEAS--36

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

                                NAYS--59

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

                             NOT VOTING--5

     Bond
     Byrd
     Isakson
     Lautenberg
     Voinovich
  The PRESIDING OFFICER. On this vote, the yeas 36, the nays are 59. 
Three-fifths of the Senators duly chosen and sworn not having voted in 
the affirmative, the motion is rejected. The point of order is 
sustained, and the amendment falls.
  The senior Senator from New Hampshire is recognized.
  Mr. GREGG. Mr. President, just so people know, on our side the order 
we are going to proceed on is that the next amendment will be by the 
Senator from Idaho, followed by the Senator from Texas, followed by the 
Senator from Louisiana, then the Senator from South Carolina, and then 
the Senator from Oklahoma. That is the next group of five amendments.
  The PRESIDING OFFICER. The junior Senator from Idaho is recognized.
  Mr. RISCH. Oh, thank you so much, Mr. President.


                           Amendment No. 3645

  I call up amendment No. 3645 and ask for its immediate consideration.
  The PRESIDING OFFICER. The clerk will report the amendment.
  The legislative clerk read as follows:

       The Senator from Idaho [Mr. Risch], for himself, and Mr. 
     Crapo, proposes an amendment numbered 3645.

  Mr. RISCH. Mr. President, I ask unanimous consent that reading of the 
amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

    (Purpose: To repeal the limitation on itemized medical expense 
                              deductions)

       At the end of subtitle E of title I, insert the following:

     SECTION __. REPEAL OF LIMITATION ON ITEMIZED DEDUCTIONS FOR 
                   MEDICAL EXPENSES.

       (a) In General.--Section 9013 of the Patient Protection and 
     Affordable Care Act is hereby repealed effective as of the 
     date of the enactment of such Act and any provisions of law 
     amended by such section are amended to read as such 
     provisions would read if such section had never been enacted.
       (b) Expansion of Affordability Exception to Individual 
     Mandate.--Section 5000A(e)(1)(A) of the Internal Revenue Code 
     of 1986, as added by section 1501(b) of the Patient 
     Protection and Affordable Care Act and amended by section 
     10106 of such Act, is amended by striking ``8 percent'' and 
     inserting ``5 percent''.
       (c) Application of Provision.--The amendment made by 
     subsection (b) shall apply as if included in the Patient 
     Protection and Affordable Care Act.

  The PRESIDING OFFICER. The Senator from Idaho is recognized for 1 
minute.
  Mr. RISCH. Thank you, Mr. President.
  Fellow Senators, I cannot imagine anyone wanting to vote against this 
amendment. Let me tell you what we have here. It is very simple. 
Apparently, you made an error when you drafted the original bill 
because what you did was you levied a tax on people who make less than 
$200,000 a year. Very simply, what this amendment does is it corrects 
that.
  Right now, under the bill the President signed on Monday, it raised 
the threshold to 10 percent from 7.5 percent at which you can deduct 
medical expenses. That tax falls on the most vulnerable people in 
America--mostly the elderly, mostly very low income. And it raises 
taxes on 14.7 million people who make less than $200,000 a year. The 
President of the United States said--he told us, he committed--he would 
not raise taxes on people who make less than $200,000 a year. I am sure 
he was just confused when he signed the bill on Monday.
  Let's adopt this amendment and get the bill corrected.
  Thank you, Mr. President. I reserve the remainder of my time.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, the goal of health care reform is to 
increase coverage so more people have health insurance. That is the 
goal of health care reform. What does this amendment do? It goes in the 
opposite direction. Compared with the bill that was just signed by the 
President, this amendment will cause many more people to lose health 
insurance. Why? Because it lowers the income threshold from 8 percent 
down to 5 percent. That is going to mean fewer Americans get tax 
credits to pay for health insurance. That means fewer Americans are 
going to have health insurance compared with current law. That is the 
main reason we should vote against this amendment, because it expands 
the number of people who are uninsured rather than expand the number of 
people who would be insured.
  The provision the Senator talks about, frankly, was changed under 
current law because with health insurance people have less need for 
that deduction and less need for catastrophic coverage because health 
insurance will not pay for it.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. BAUCUS. Mr. President, I move to table the Risch amendment, and I 
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.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
and the Senator from New Jersey (Mr. Lautenberg) are necessarily 
absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Missouri (Mr. Bond), the Senator from Georgia (Mr. Isakson), and 
the Senator from Ohio (Mr. Voinovich).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 55, nays 40, as follows:

                      [Rollcall Vote No. 90 Leg.]

                                YEAS--55

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

[[Page S2010]]


     Udall (CO)
     Udall (NM)
     Warner
     Webb
     Whitehouse
     Wyden

                                NAYS--40

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

                             NOT VOTING--5

     Bond
     Byrd
     Isakson
     Lautenberg
     Voinovich
  The motion was agreed to.
  The PRESIDING OFFICER. The senior Senator from Texas.


                           Amendment No. 3635

  Mrs. HUTCHISON. Mr. President, I call up amendment No. 3635 and ask 
for its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Texas [Mrs. Hutchison] proposes an 
     amendment numbered 3635.

  Mrs. HUTCHISON. Mr. President, I ask unanimous consent that the 
reading of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

 (Purpose: To repeal the sunset on marriage penalty relief and to make 
     the election to deduct State and local sales taxes permanent)

       At the end of subtitle F of title I, add the following:

     SEC. 15__. PERMANENT TAX RELIEF PROVISIONS.

       (a) Repeal of Sunset on Marriage Penalty Relief.--Title IX 
     of the Economic Growth and Tax Relief Reconciliation Act of 
     2001 (relating to sunset of provisions of such Act) shall not 
     apply to sections 301, 302, and 303(a) of such Act (relating 
     to marriage penalty relief).
       (b) Permanent Extension of Election to Deduct State and 
     Local Sales Taxes.--Subparagraph (I) of section 164(b)(5) of 
     the Internal Revenue Code of 1986 is amended by striking ``, 
     and before January 1, 2010''.
       (c) Rescission of Stimulus Funds.--Any amounts appropriated 
     or made available and remaining unobligated under division A 
     of the American Recovery and Reinvestment Act of 2009 (Public 
     Law 111-5; 123 Stat. 115) (other than under title X of such 
     division A), are hereby rescinded.

  The PRESIDING OFFICER. The Senator from Texas is recognized for 1 
minute.
  Mrs. HUTCHISON. Mr. President, this is a very simple amendment. It 
would just make relief from the marriage penalty and the sales tax 
deduction permanent. If we don't act, people across our country are 
going to start getting the marriage penalty tax once again. This was 
corrected under previous tax law, but that is going out of existence at 
the end of this year. Sales tax deduction is something that affects 
eight States that do not have a State income tax. It just gives people 
everywhere in America, if they have either an income tax or a sales 
tax, the ability to choose what they deduct from their Federal income 
taxes.
  We need to make this law permanent, and I hope everyone will support 
this amendment.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, I would remind my colleagues that the 
Hutchison amendment uses as its offset rolling back the Recovery Act; 
that is, rolling back stimulus funds. That is taking stimulus funds to 
permanently pay for the marriage penalty relief as well as sales tax 
relief.
  With unemployment as high as it is, hovering around 10 percent, it 
makes no sense to cut back stimulus dollars. Stimulus dollars are a 
proven job creator. All mainstream economists and the CBO tell us that.
  I think we should continue to create jobs by using the stimulus 
dollars. I, therefore, urge my colleagues to not support the Hutchison 
amendment.
  In addition to that, there are funds not within the jurisdiction of 
reconciled committees. For that reason, I raise a point of order that 
the Hutchison amendment violates section 313(B)1(C) of the 
Congressional Budget Act.
  The PRESIDING OFFICER. The Senator from Texas.
  Mrs. HUTCHISON. Pursuant to section 904 of the Congressional Budget 
Act of 1974 and section 4(G)(3) of the Statutory Pay-As-You-Go Act of 
2010, I move to waive all applicable sections of those acts and 
applicable budget resolutions for purposes of my amendment, and I 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.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
and the Senator from New Jersey (Mr. Lautenberg) are necessarily 
absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Missouri (Mr. Bond), the Senator from Georgia (Mr. Isakson), and 
the Senator from Ohio (Mr. Voinovich).
  The PRESIDING OFFICER (Mr. Franken). Are there any other Senators in 
the Chamber desiring to vote?
  The yeas and nays resulted--yeas 40, nays 55, as follows:

                      [Rollcall Vote No. 91 Leg.]

                                YEAS--40

     Alexander
     Barrasso
     Bayh
     Bennett
     Brown (MA)
     Brownback
     Bunning
     Burr
     Cantwell
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Graham
     Grassley
     Hatch
     Hutchison
     Inhofe
     Johanns
     Kyl
     LeMieux
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Wicker

                                NAYS--55

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

                             NOT VOTING--5

     Bond
     Byrd
     Isakson
     Lautenberg
     Voinovich
  The PRESIDING OFFICER. On this vote, the yeas are 40 and the nays are 
55. Three-fifths of the Senators duly chosen and sworn not having voted 
in the affirmative, the motion is rejected. The point of order is 
sustained, and the amendment falls.
  The Senator from Louisiana.


                           Amendment No. 3668

  Mr. VITTER. Mr. President, I call up amendment No. 3668 and ask for 
its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Louisiana [Mr. Vitter] proposes an 
     amendment numbered 3668.

  Mr. VITTER. Mr. President, I ask unanimous consent that the reading 
of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

   (Purpose: To increase women's access to breast cancer screenings)

       At the end of subtitle F of title I, add the following:

     SEC. 15__. REFUNDS OF FEDERAL MOTOR FUEL EXCISE TAXES FOR 
                   FUEL USED IN MOBILE MAMMOGRAPHY VEHICLES.

       (a) Refunds.--Section 6427 of the Internal Revenue Code of 
     1986 (relating to fuels not used for taxable purposes) is 
     amended by inserting after subsection (f) the following new 
     subsection:
       ``(g) Fuels Used in Mobile Mammography Vehicles.--Except as 
     provided in subsection (k), if any fuel on which tax was 
     imposed by section 4041 or 4081 is used in any highway 
     vehicle designed exclusively to provide mobile mammography 
     services to patients within such vehicle, the Secretary shall 
     pay (without interest) to the ultimate purchaser of such fuel 
     an amount equal to the aggregate amount of the tax imposed on 
     such fuel.''.
       (b) Exemption From Retail Tax.--Section 4041 of such Code 
     is amended by adding at the end the following new subsection:
       ``(n) Fuels Used in Mobile Mammography Vehicles.--No tax 
     shall be imposed under this section on any liquid sold for 
     use in, or used in, any highway vehicle designed exclusively 
     to provide mobile mammography services to patients within 
     such vehicle.''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect on the date of the enactment of this Act.


[[Page S2011]]


  Mr. VITTER. Mr. President, a short time ago the distinguished 
majority leader urged there to be amendments to improve the bill, not 
to do any harm to the broader ObamaCare bill. This is exactly such an 
amendment.
  This amendment would pass my Mobile Mammography Act, S. 2051. This 
amendment would allow mobile mammography units to purchase fuel without 
the Federal excise tax. This is exactly similar to an existing 
exemption for blood centers. These units are very important to give 
access to women for breast cancer screening. And this only scores $1 
million, so there is no significant budget impact. This does improve 
the bill. This does nothing to the underlying ObamaCare bill.

  This reconciliation bill is already going back to the House, so I 
urge a bipartisan vote in support of this good idea.
  I reserve the remainder of my time.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. VITTER. Mr. President, I ask unanimous consent to have printed in 
the Record two letters relating to my amendment.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                   LSU Health Sciences Center,

                                                 October 23, 2009.
     Re Mobile Mammography Promotion Act

       Hon. David Vitter: I am writing in support of the Mobile 
     Mammography Act which will eliminate the Federal Excise tax 
     on fuel for mobile mammography vehicles. At the LSU Health 
     Sciences Center in Shreveport, Feist-Weiller Cancer Center, 
     this year we have put our mobile mammography vehicle into 
     service. We perform free mammograms for the uninsured and 
     underinsured in North Louisiana. As you know this is an 
     expensive operation and fuel costs can be significant. Any 
     savings in fuel cost will allow us to reach more patients in 
     our service area.
       Mobile Mammography is especially important in Louisiana, 
     which according to 2005 SEER statistics has the highest 
     breast cancer mortality of all the states. The rural areas in 
     Louisiana are particularly underserved as 40% of the parishes 
     in North Louisiana have no mammography facilities; and those 
     parishes with mammography are often unaffordable to our lower 
     income patients.
       On behalf of the women in Louisiana. I applaud your efforts 
     and support for a vital resource--mobile mammography.
           Sincerely,
                                          Jerry W. McLarty, Ph.D.,
                                  Professor of Medicine, Director,
     Cancer Prevention & Control.
                                  ____



                                Mobile Health Clinics Network,

                                                 October 29, 2009.
     Hon. David Vitter,
     U.S. Senate, Hart Senate Office Building,
     Washington, DC.
       Dear Senator Vitter: We are writing to support for your 
     proposed amendment to the IRS Code of 1986 to allow refunds 
     of Federal motor fuel excise taxes on fuels used in Mobile 
     Mammography vehicles.
       Most of the nearly 200 Mobile Mammography programs 
     throughout the U.S. are non-profits organizations; many 
     provide screenings for medically underserved women. In the 
     past year, non-profits have been struggling due to the 
     economic downturn, resulting in a decrease in donor dollars. 
     Because of the downturn, there are also more and more 
     Americans that need to access the services we provide, and it 
     is very difficult to predict when the benevolence of 
     Americans who can give will be restored to previous levels. 
     Thus, every cost savings that we can realize makes a 
     difference in our ability to continue the vital health 
     services that we offer. The change that you propose to the 
     tax code may be the difference between continued operations 
     and closing services for some programs, and with Mobile 
     Healthcare, our continuation gives us the opportunity to 
     further impact lives, and in some cases, saving lives of 
     Americans across the nation. We encourage the passage of this 
     important amendment, cited as the ``Mobile Mammography 
     Promotion Act of 2009''.
       It is our sincere hope that the impact from this change 
     will be great enough to encourage you and your colleagues in 
     the Senate and the House to consider expanding the 
     application of the amendment to include all Mobile Healthcare 
     programs. There are approximately 2,000 Mobile Health 
     programs operating in the U.S., serving millions of women, 
     men, and children--many of whom have no other access to 
     affordable preventive and primary care, mammography 
     screenings, and oral healthcare. It is widely recognized that 
     Mobile Healthcare programs yield improved health outcomes for 
     the underserved and save the healthcare system billions of 
     dollars.
       Mobile Health Clinics Network (MHCN) is a nationwide, 
     membership-based association of Mobile Health programs 
     primarily operated by non-profit entities such as community 
     health clinics, hospitals, and university schools of 
     medicine, nursing and dentistry. MHCN completed its Fifth 
     Annual Mobile Health Clinics Forum this past April, and we 
     are pleased to send you (under separate mail) a copy of the 
     official Program Binder. It will certainly offer you a view 
     toward the breadth and scope of Mobile Healthcare programs 
     that now operate in the U.S. and internationally.
       On behalf of Mobile Mammography and Mobile Health clinics 
     across the nation, we thank you for your efforts toward 
     introducing the IRS amendment and for your continued 
     attention to making positive impacts that will support 
     continued operation of these unique healthcare delivery 
     systems. Early detection is the most effective method to 
     preventing and treating disease, and for Americans who rely 
     on Mobile Health services for these critical interventions, 
     this tax change could ensure many more years of access to a 
     healthcare system that provides potentially life-saving 
     services.
     Sincerely,
                                              Anthony Vavasis, MD,
       Advisory Board Chair, Mobile Health Clinics Network, 
     Clinical Director, Health Outreach to Teens Program, New 
     York, NY.
     Darien DeLorenzo,
       CEO & Executive Director, Mobile Health Clinics Network.


                      MHCN Advisory Board Members

       Melissa Lofton, Administrative Manager, Mobile Mammograph, 
     Breast Diagnostic Clinic, M.D. Anderson Cancer Center, 
     Houston, TX, Mammography Co-Chair, 2010 MHCN Annual Forum.
       Candy Simbalenko, RN, BS, Manager, Breast Health Programs, 
     St. Joseph's Medical Center, Stockton, CA.
       James Comeaux, LCSW, Chief Operating Officer, St. Charles 
     Community Health Center, Luling, LA.
       Jennifer Bennet, Executive Director, The Family Van, 
     Harvard Medical School, Boston, MA.
       Tina Hembree, MPH, Program Manager, Cancer Detection & 
     Early Prevention, Norton Healthcare, Cancer Institute, 
     Louisville, KY, Chair, MHCN Mammography SIG.
       Shirley Hampton, RN, Development Director, Nevada Health 
     Centers, Inc., Carson City, NV.
       Karen McInerney, RTRM, Director, Breast Imaging Services, 
     Swedish Medical Center, Seattle, WA.
       Leah Berger, MPH, Director, Community Health Programs, 
     Planning & Development, Office of Community Affairs & Health 
     Policy, Tulane University School of Medicine, New Orleans, 
     LA.

  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I strongly support--I think every Member 
in this Chamber does--prevention and treatment of breast cancer and 
women's health generally. And the bill the President signed Tuesday 
makes great strides to that end. For example, it prohibits gender 
rating and eliminates the ability of insurers to limit coverage based 
on preexisting conditions. In addition to the preventive services 
available to everyone in the exchange, the health reform bill ensures 
that women have access to the unique preventive services they need, 
such as wellness exams.
  I might also add that the amendment further drains dollars from the 
highway trust fund. We don't want to go in that direction. Therefore, 
Mr. President, I move to table the amendment, and I 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 the motion.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
and the Senator from New Jersey (Mr. Lautenberg) are necessarily 
absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Missouri (Mr. Bond), the Senator from Georgia (Mr. Isakson), and 
the Senator from Ohio (Mr. Voinovich).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 56, nays 39, as follows:

                      [Rollcall Vote No. 92 Leg.]

                                YEAS--56

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

[[Page S2012]]



                                NAYS--39

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

                             NOT VOTING--5

     Bond
     Byrd
     Isakson
     Lautenberg
     Voinovich
  The motion was agreed to.
  Mr. DURBIN. 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.
  The PRESIDING OFFICER. The majority leader.
  Mr. REID. Mr. President, it goes without saying we all appreciate 
everyone's cooperation, having the Senate work so well, yesterday and 
today. Therefore, after having had long discussions with my friend, the 
distinguished Senator from Kentucky, I ask unanimous consent that we 
are going to adjourn in a few minutes; that we will convene at 9:45 
a.m. this morning, resume the bill, consider amendments up to 2 p.m., 
we will dispose of points of order that have been determined--and one 
is still under review--by 2 p.m. There will be no further amendments 
after 2 p.m., and the third reading will occur after points of order 
are disposed of after 2 p.m.
  I ask that in the form of a unanimous consent agreement.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. WHITEHOUSE. Mr. President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. WHITEHOUSE. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.

                          ____________________