[Congressional Record (Bound Edition), Volume 155 (2009), Part 13]
[Senate]
[Pages 16988-16991]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              HEALTH CARE

  Mr. ALEXANDER. Mr. President, I heard the majority leader talk about 
denying care, and that is the issue before us--one of the major issues. 
The vision of the Republicans is that there will not be someone in 
between a patient and a doctor who would get in the way of a treatment 
you need or the care you need or have you stand in line or wait too 
long. Our great fear is the Democratic proposal so far, in which we 
have not had a chance to participate, would put the government between 
you and the doctor and the government doing the rationing.
  Republican proposals, such as those of Senator Gregg and Senator Burr 
and Senator Coburn and even the bipartisan proposal by Senator Wyden, a 
Democrat, and Senator Bennett, a Republican--of which I am a cosponsor 
of all--envision a system where those of us, the 250 million of us who 
already have health care insurance, would be permitted to keep it and 
that we would find a way to reform the Tax Code to give to individuals 
who do not have good health care the money they need to buy the health 
care and to choose it for themselves. Our concern is, the Government 
might become too much involved, and we might create a program that is 
filled with more debt, on top of the debt we already have, that our 
children and grandchildren simply couldn't afford it.
  Mr. McCain, the Senator from Arizona, has been, I guess, in more town 
meetings about health care than any other American, at least any other 
American who serves today in the Senate. He was in Texas last week and 
home last week in Phoenix, at some of our leading institutions, to hear 
what people had to say about it.
  I wonder if I could ask the Senator from Arizona if he heard concern 
from those in his home State of Arizona, or

[[Page 16989]]

those at M.D. Anderson in Texas, about the government getting in 
between the patient and the doctor.
  Mr. McCAIN. Mr. President, if I could say, first of all, I would like 
to thank the Senator from Tennessee for his leadership on this issue. 
It is a privilege to serve on the HELP Committee with him, and his 
continued involvement in the ongoing discussion and debate about one-
sixth of America's gross national product has been vital.
  I thank my friend from Tennessee. Could I also pick up on what the 
Senator was just saying, that the majority leader criticized the 
Republican leader in the House who said America has the best health 
care system in the world. What the Republican leader in the House was 
saying was the obvious: America has the highest quality health care in 
the world. And as the Senator from Tennessee just mentioned, I was in 
Houston at M.D. Anderson with Republican leaders, the Senator from 
Kentucky and Senator Cornyn from Texas. There were people there from 90 
countries around the world--90 countries, most of them wealthy people 
who could have gone anywhere in the world for health care.
  But they went to the best place in the world, M.D. Anderson--one of 
the best, I would argue. We have some facilities in Arizona and 
probably in Tennessee that are of equal quality.
  But is there any doubt, when people come from all over the world to 
the United States of America, that the highest quality health care is 
not in America? It is. The problem is, and I am afraid some of my 
colleagues do not get it, it is not the quality of health care, it is 
the affordability and the availability of health care.
  Our effort has been to try to make health care affordable and 
available. The latest proposal of the Democrats is that it only covers 
40 percent of the uninsured and costs trillions of dollars. So why not, 
I would ask my friend from Tennessee, why not let people go across 
State lines to get the insurance policy they want? Why could not a 
citizen of Arizona who does not like the insurance policies that are 
available there find one in Tennessee? Why not have meaningful 
malpractice reform? We all know where 10, 15, 20 percent, sometimes, of 
health care costs come from. They come from the practice of defensive 
medicine.
  Everybody knows it. It is one of the elephants in the room. So, 
therefore, we do not have--and consistently in the HELP Committee, 
amendments that have been proposed by the Senator from Tennessee and me 
and others to reform medical malpractice have been voted down.
  The State of California some years ago enacted meaningful and 
significant medical malpractice reform. Guess what. It has decreased 
health care costs. So we are not getting--and I say to my friend from 
Tennessee, I hope he agrees that we are going at the wrong problem. The 
problem is not the quality of health care. We want to keep the quality 
of health care. It is the cost and affordability of health care.
  We have not gotten affordable and available health care for all 
Americans.
  Mr. ALEXANDER. I agree with my friend from Arizona. I think of the 
pregnant women in rural counties in Tennessee who have to drive all the 
way to Memphis, or all the way to Nashville to get prenatal health care 
because there are no OB-GYN doctors after their medical malpractice 
cases have driven up their insurance. So there is no way for them to 
get health care.
  If I am not mistaken, I listened to the majority leader talking about 
the tragic case in Nevada of someone unable to get health care because 
of a preexisting condition. The Senator from Arizona knows all of the 
proposals. I believe all of the Republican proposals would say, 
everyone would be covered, that preexisting conditions would not 
disqualify you.
  The issue before us is whether we are going to address trillions to 
the debt or put the government in between the patient and the doctor.
  Mr. McCAIN. I totally agree. Could I mention, since the Senator from 
Tennessee and I are going up to another meeting in the HELP Committee, 
the Roll Call article this morning says:

       Senate Majority Leader Harry Reid on Tuesday strongly urged 
     Finance Chairman Max Baucus to drop a proposal to tax health 
     benefits and stop chasing Republican votes on a massive 
     health care reform bill. Reid, whose leadership is considered 
     crucial if President Barack Obama is to deliver on his 
     promise of enacting health care reform this year, offered the 
     directive to Baucus through an intermediary after consulting 
     with Senate Democratic leaders during Tuesday morning's 
     regularly scheduled leadership meeting.

  In other words, according to this article, any shred or semblance of 
bipartisanship is now out the window. So I think the Senator from 
Tennessee would agree with me. One of the very disappointing aspects of 
this whole debate is we have not changed the climate in Washington. Has 
there ever been, to the Senator's knowledge, a call to sit down at a 
table in a room with leading Republicans and Democrats and say: Hey, 
can't we work this out? What is your proposal? Here is ours. Can't we 
sit down and agree to save health care in America and preserve its 
quality and make it affordable and available? Way back in the 1980s 
when Ronald Reagan and Tip O'Neill sat down together, they saved Social 
Security.
  This is unfortunate that even the last shreds of attempts at 
bipartisanship are now gone. Now maybe it is because the 60th 
Democratic vote was sworn in yesterday. Maybe they figured they had the 
votes. Maybe they do. But anybody who alleges that this administration 
and the other side of the aisle are changing the climate in Washington, 
that is simply false.
  Mr. ALEXANDER. There is probably no one in the Senate who has been in 
the midst of bipartisan negotiations more times than the Senator from 
Arizona. This is not just for the purpose of feeling good, it is the 
way to actually get a broad base of support for an energy bill or an 
immigration bill or a Supreme Court nominee. Usually it involves, if I 
am not mistaken, sitting down with several members of each side and 
coming to a consensus, sharing insurance ideas, fighting off the left 
and right and producing 60 or 70 votes. If I am not mistaken, that is 
the way we do bipartisan bills around here.
  Mr. McCAIN. I say to my friend, indeed. One of the issues I think we 
ought to continue to understand is one of the key elements of this 
debate is whether we will have the so-called government option. I know 
the Senator from Tennessee is going to talk about that. I think it is 
important for us to look overseas at other countries that are highly 
industrialized, highly sophisticated, strong economies, countries that 
have government-run health care.
  To say the government option would be just another competitor clearly 
is not the case; otherwise, we would just have 1,501 new insurance 
companies in America. If you had the government option, it will lead to 
a government takeover of health care, and we ought to look at what 
other countries do.
  I am sure the Senator from Tennessee knows this, but it is health 
care rationing and a level of health care that will not be acceptable 
in the United States of America. I say that with great respect to our 
friends in Canada, the British, and other countries that have 
government-run health care systems. I think that is going to be one of 
the two major issues: the government-run health care and the employee 
mandate. Those are what this health care debate will come down to.
  It is of great concern, I know, to the Senator from Tennessee.
  Mr. ALEXANDER. I thank the Senator from Arizona. I know he is on his 
way to work on the health care bill, to take the leadership, to the 
extent we can, in making it a better bill. I thank him for coming to 
the floor to discuss that today, and to help us reemphasize that we do 
not have any disagreement with our friends on the other side about the 
need to reform health care. I do not think we have any disagreement. At 
least we want to make sure our principal goal is to make health care 
affordable for every American. We want your family and you to be able 
to buy health insurance at a price you can afford and to take care of 
tragic cases

[[Page 16990]]

such as the one the majority leader talked about. I think there is a 
consensus on both sides of the aisle to make sure if you have a 
preexisting condition you can be insured, and it will not matter where 
you live.
  The Wyden-Bennett proposal, for example, and others, actually also 
say that you may carry your insurance from one job to the other, so 
that if you lose your job, or if you change your job, you still have 
your insurance because it is your insurance, and it does not just 
depend upon your employer.
  What we are concerned about is the fact that President Obama's 
administration has already proposed adding, over the next 10 years, 
more new debt, three times as much new debt actually as was spent in 
all of World War II in today's dollars. That is the first thing.
  The second thing is this idea of the so-called government option. 
Someone says: What is so bad about that? Think of it this way. Let's 
say you put some elephants and some mice in one room. You say: OK, 
fellows, compete. What do you think will happen? Pretty soon there are 
no mice left; they are all squished. You have a big elephant left. That 
is your only choice.
  We have an example of that in the current Medicaid Program, which is 
one of the worst government programs imaginable. There are 60 million 
Americans stuffed in it, primarily because they are low income or 
disabled. It is run jointly by the Federal Government and by the State 
government. Every Governor--and this has been true for 25 years, from 
the time I was Governor--has struggled with finding money to both fund 
the State's share of it and still have money for higher education and 
for other State needs.
  It is filled with waste. The Congressional Budget Office says 1 out 
of every 10 taxpayer dollars that are spent for Medicaid is fraud, 
waste, or abuse. That is $32 billion a year. That is $320 billion over 
10 years, enough to make a real dent in whatever we decide to do on 
health care.
  Yet the Democratic proposals that we are seeing involve putting more 
people into that government program. The problem for the taxpayer is 
how expensive that is. I have a letter from the Congressional Budget 
Office dated July 7 to Senator Gregg, the ranking member of the Budget 
Committee, which I ask unanimous consent to have printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                                    U.S. Congress,


                                  Congressional Budget Office,

                                     Washington, DC, July 7, 2009.
     Hon. Judd Gregg,
     Ranking Member, Committee on the Budget,
     U.S. Senate, Washington, DC.
       Dear Senator: In response to your request, the 
     Congressional Budget Office (CBO) has considered the likely 
     effects on federal spending and health insurance coverage of 
     adding a substantial expansion of eligibility for Medicaid to 
     the Affordable Health Choices Act, a draft of which was 
     recently released by the Senate Committee on Health, 
     Education, Labor, and Pensions (HELP). CBO's preliminary 
     analysis of that draft legislation was provided to Senator 
     Edward M. Kennedy on July 2, 2009; that analysis is available 
     on CBO's web site, www.cbo.gov.
       The draft legislation would make a number of changes 
     regarding the financing and provision of health insurance, 
     including establishing insurance exchanges through which 
     coverage could be purchased and providing new federal 
     subsidies to help individuals and families with income 
     between 150 percent and 400 percent of the federal poverty 
     level (FPL) pay for that coverage. Although the draft 
     legislation envisions that Medicaid would be expanded to 
     cover individuals and families with income below 150 percent 
     of the FPL, it does not include provisions to accomplish that 
     goal, and our preliminary analysis (conducted jointly with 
     the staff of the Joint Committee on Taxation) did not reflect 
     such an expansion.
       The precise effects on federal costs and insurance coverage 
     of adding an expansion of eligibility for Medicaid up to 150 
     percent of the FPL would depend importantly on the specific 
     features of that expansion. For example, the effects would 
     depend on how eligibility for the program was determined and 
     on whether the expansion started immediately or only as the 
     proposed insurance exchanges went into operation. The effects 
     would also depend what share of the costs for newly eligible 
     people was borne by the federal government and what share was 
     borne by the states (which would be determined by the average 
     FMAP, or Federal Medical Assistance Percentage). In addition, 
     the effects would depend on whether states faced a 
     maintenance-of-effort requirement regarding their current 
     Medicaid programs.
       CBO has not yet had time to produce a full estimate of the 
     cost of incorporating any specific Medicaid expansion in the 
     HELP committee's legislation. However, our preliminary 
     analysis indicates that such an expansion could increase 
     federal spending for Medicaid by an amount that could vary in 
     a broad range around $500 billion over 10 years, Along with 
     that increase in federal spending would come a substantial 
     increase in Medicaid enrollment, amounting to perhaps 15 
     million to 20 million people. Such an expansion of Medicaid 
     would also have some impact on the number of people who 
     obtain coverage from other sources (including employers). All 
     told, the number of non-elderly people who would remain 
     uninsured would probably decline to somewhere between 15 
     million and 20 million. (For comparison, CBO's analysis of 
     the draft legislation that was released by the HELP committee 
     found that, absent any expansion of Medicaid or other change 
     in the legislation, about 33 million people would ultimately 
     remain uninsured if it were to be enacted.)
       Such an expansion of Medicaid would have some impact on 
     other aspects of the federal budget beyond Medicaid itself 
     (including tax revenues and the proposed payments to the 
     government by employers who do not offer coverage to their 
     workers, which the legislation labels ``equity 
     assessments''). Those additional effects might increase or 
     decrease the effect of the proposal on the federal deficit by 
     as much as $100 billion. It bears emphasizing that this 
     analysis is preliminary and the figures cited are approximate 
     because they do not reflect specific legislative language nor 
     do they incorporate, in detail, a variety of interactions and 
     other effects that changes in Medicaid would cause.
       I hope this information is helpful to you. If you have any 
     questions, please contact me or CBO's primary staff contacts 
     for this analysis, Philip Ellis and Holly Harvey.
           Yours truly,
                                             Douglas W. Elmendorf,
                                                         Director.

  Mr. ALEXANDER. That letter was from Douglas W. Elmendorf, the 
Director of the Congressional Budget Office, with whom I am about to 
meet, along with other members of the HELP Committee.
  It says: The proposal envisions that Medicaid--that is the Democratic 
proposal--would be expanded to cover individuals and families with an 
income below 150 percent of the Federal poverty level.
  That sounds good, but the draft legislation does not include 
provisions to accomplish the goal. About three-quarters of the people 
who would remain uninsured under this version of the legislation would 
have income--in other words, even though we are spending trillions more 
under this proposal, a lot of people are uninsured and three-quarters 
of them are going to be dumped into Medicaid. For the Federal 
Government, that is hundreds of billions of new dollars we would have 
to borrow, and the thought is over time it would be shifted to the 
States. In the State of Tennessee, based upon conversations we have had 
with the State Medicaid director, it might add an amount of money to 
the State's annual budget that would be equal to the amount that a new 
10-percent State income tax would take.
  That is not even the worst thing about it. The worst thing about it 
is what it would do to the low-income Americans who are stuffed into 
the proposal. Some 40 percent of doctors will not see Medicaid patients 
for all their services--40 percent of doctors. So we say: 
Congratulations, we are going to run up the Federal debt and add a big 
State tax, in order to stuff you into a proposal where 40 percent of 
the doctors today will not see you. It is like giving out a ticket to a 
bus system that does not have any buses.
  What is the alternative? The Republican proposals are completely 
different. They focus first on the 250 million of us who already have 
health insurance to try to make sure it is affordable to us, that we 
can afford it. Then we say let's take the money that is available and 
give it to the low-income Americans and let them buy, choose, a private 
health insurance policy more like the policies most of us have. We 
offer this instead of stuffing them into the Medicaid proposals which 
are filled with inefficiencies, cannot be managed, and which many 
doctors will not work with.
  That is a better course forward. But, unfortunately, our voices are 
not being

[[Page 16991]]

heard on that subject. But we are going to continue to make our case. 
We have the Burr proposal, the Gregg proposal, the Coburn proposal, the 
Wyden-Bennett proposal. All are different from the government option, 
and all do not run up the debt.
  In fact, the Wyden-Bennett proposal, which is the only bipartisan 
proposal before this body today, with several Republican Senators and 
several Democratic Senators, adds zero to the debt according to the 
Congressional Budget Office.
  Maybe as we go through, if we were seriously considering it, we would 
find a need to add some costs. But at least we start with the idea that 
instead of adding $1, $2, or $3 trillion over the next 10 years to the 
Federal deficit and dumping a new program onto the States after a few 
years, which the States in their bankrupt condition, in some cases, 
cannot afford, at least we would start out with an increased deficit of 
zero.
  We are almost working at the wrong end. Our biggest problem facing 
the country is the cost of health insurance to every American, not just 
the uninsured Americans but the 250 million who already have insurance. 
The other big issue is the cost of government, caused by rising health 
care costs, and we have gotten away from thinking of ways to bring that 
under control. There are even proposals floating around to take 
savings, to cut Medicare and Medicaid and use those dollars to help pay 
for the Democratic plan.
  If we reduce the growth of spending in Medicaid, we should spend it 
on Medicare, which is increasing at a rate that is going to cause our 
children and grandchildren never to be able to pay off the national 
debt.
  Republicans stand ready to work with Democrats to produce health care 
reform this year, despite the majority leader's statement that it is 
time for Senator Baucus to stop chasing Republican votes. We are glad 
he is chasing Republican votes, and we hope he gets some. But the way 
we do things around here usually is a group of 15 or 20 Senators, such 
as Senator McCain and others, sit around and say: OK, let's put our 
ideas together and come up with a consensus bill, not to operate from a 
procedure that we won the election, we have 60 votes, and we will write 
the bill. It is more complicated than that. It needs a broad base of 
support in the Senate to have a broad base of support in the country. 
Without that base of support, it will not be successful.
  We have made our proposals--the Burr proposal, the Gregg proposal, 
the Coburn proposal, the Wyden-Bennett proposal. Senator Hatch and 
Senator Cornyn have a slightly different idea that would give the money 
to the Governors and let them find a way to cover low-income 
individuals. As a former Governor, I like that idea. We have an 
imaginative Democratic Governor in Tennessee who has brought the 
Medicaid Program there under some control and has come up with several 
innovative ideas. The difficulty he and other Governors have is that it 
takes them a year to get permission from Washington to try their 
innovative ideas to offer the kind of health care to low-income 
individuals they might need which could be different in Tennessee and 
different in California.
  This is the biggest issue before our country today. It is certainly 
the biggest issue before Congress. Republicans have our proposals on 
the table. We are ready to go to work. We want to make sure there are 
no preexisting conditions left out that disqualify people. We want to 
make sure that everyone is covered and that we have access to health 
care at a cost the family budget can afford. We are resolute in our 
determination not to add trillions more to the national debt and not to 
dump new debt on the States. We are resolute in our determination not 
to dump low-income people into a failing government program called 
Medicaid when a much better alternative is to give them the credits and 
the vouchers and the cash so they can purchase private health insurance 
and have coverage more like the rest of Americans have.
  I yield the floor and suggest the absence of a quorum.
  The ACTING PRESIDENT pro tempore. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. VITTER. I ask unanimous consent that the order for the quorum 
call be rescinded.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. VITTER. I ask unanimous consent to speak in morning business for 
up to 15 minutes.
  The ACTING PRESIDENT pro tempore. In my capacity as a Senator from 
New Mexico, I object.
  The Senator from Illinois.

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