[Congressional Record (Bound Edition), Volume 155 (2009), Part 17]
[Senate]
[Pages 22574-22578]
[From the U.S. Government Publishing Office, www.gpo.gov]




                              HEALTH CARE

  Mr. ALEXANDER. Mr. President, I see the majority leader is still on 
the floor, and I wish to thank him and the Republican leader for 
organizing last night's reception honoring Henry Clay, a great Senator, 
whose portrait will be hanging in the stairway outside of here. There 
was a time in history when Henry Clay, Daniel Webster, and John Calhoun 
were better known than the Presidents of the United States. That was in 
the 1850s, before the Civil War. It was good to take a moment all 
together, Democrats and Republicans, and think about that history and 
to honor the man who was known as the great compromiser, who during a 
time when our Nation was completely split over the Civil War, on three 
different occasions, found a way to try to bring it together. Of 
course, he died before the great war.
  Mr. President, I ask unanimous consent that during the Republican 
morning business time I be permitted to enter into a colloquy with my 
colleagues Senator McCain, Senator Coburn, Senator Brownback, Senator 
Thune, and Senator Murkowski, who will be here shortly.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. ALEXANDER. Mr. President, health care reform is the agenda for 
the Nation and it ought to be. We, on the Republican side, want health 
care reform, but we want the right kind of health care reform. Our 
focus is on costs. Our focus is on the cost to each American as he or 
she buys their health care policy; our focus is on the cost of the 
Government of the United States, for which each American has a 
responsibility to pay. What we have to do is to reduce costs to make it 
easier for Americans to afford their health care and to afford their 
government.

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  Every single one of us knows that unless we reduce the increasing 
costs of health care we will not be able to pay our bills in 
Washington, DC. We are in the midst of appropriations bills, and there 
is well-meaning debate here about whether we should spend more money 
for national parks and for safe drinking water and other urgent needs 
we have. That is the bill we are talking about today--clean air. Well, 
we should spend money on those urgent needs. Americans want us to do 
that. But we can't have those dollars, as the Senator from Alabama 
pointed out yesterday, if we continue to increase the debt--trillions 
in debt--and run up the interest rate bill.
  We are headed toward a situation where, by the end of this decade, we 
will be spending $800 billion a year on debt--more than we spend on 
national defense, eight times as much as we spend from Washington on 
education this year. So those dollars could either be in the pockets of 
the American people for them to spend for themselves or we could be 
spending those dollars to clean the air, to relieve traffic congestion 
or to provide Pell grants and student loans so Americans can go back to 
school. Those are the things government ought to be spending money on, 
not on increasing debt.
  So health care reform is, first, about cost--the cost to Americans 
for their own health care policies and the cost of their debt. The 
President noted this the other night and said in his remarks to us and 
to the American people that the health care bill couldn't add one dime 
to the deficit. That is reassuring because the President's proposals 
are already adding $9 trillion to the deficit over the next 10 years. 
He is doubling or tripling the national debt, which means he is adding 
more to the debt by a factor of two and then three than all the other 
Presidents put together. So surely we don't want to add more to it with 
a health care reform bill.
  But when the President said that, he completely wiped out all the 
Democratic health care bills that have been proposed so far from the 
House and from the Senate. The Congressional Budget Office has said the 
Senate HELP Committee and the bills in the House all add to the debt in 
the first 10 years and in the years after that. So they should be off 
the table, according to the President's own standards.
  Now we are looking at the Finance Committee in the Senate to see what 
they can do. Mr. Baucus, the Senator from Montana, has worked very hard 
in a good-faith, bipartisan way to try to develop a bipartisan bill--a 
comprehensive bill. But as we read the bill, there are a great many 
things to be worried about. For example, if you don't buy a health care 
plan, the IRS will tax you.
  The President and George Stephanopoulos, on a Sunday show--and 
Senator Graham said the President seemed to be on every Sunday show 
except the Food Channel--were talking about the definition of tax. So 
that is the first thing. The second is the Medicare cuts.
  I see the Senator from Arizona has come, and I would say to the 
Senator, through the Chair, we have received permission from the Chair 
to engage in a colloquy between myself and other Republican Senators 
who might come. I have already pointed out that the President himself 
has disqualified all the plans our committee worked on, the HELP 
Committee and from the House, because they all add to the debt. Now we 
see the Baucus plan coming forward, and I wonder if the Senator from 
Arizona has had an opportunity to look at--of course, that is not a 
bill yet. We all understand that. It is just concepts, and we will want 
to make sure we have time to read the bill and to know what it costs. 
But I wonder if the Senator from Arizona has had an opportunity yet to 
form an opinion about whether the Baucus bill does what we had hoped, 
which is reduce the cost to the American people of what their insurance 
costs and reduce the cost to the American people of their government in 
Washington.
  Mr. McCAIN. Well, I thank my colleague from Tennessee and the great 
work he has been doing. First of all, I would ask my friend if he has 
had the same experience I have had at townhall meetings and that is 
from one of the hand-done signs--not printed-out signs but one of the 
hand-done signs--which says: Have you read the bill? One of the first 
questions at the townhall meeting was: Have you read the bill? Of 
course, that is an impossibility for anyone to read the bill because 
there is no bill before the Finance Committee, it is my understanding. 
I understand it is about 200 pages of a ``framework.'' I think the 
Senator from Tennessee and I are keenly aware that many times there is 
a comma, a word inserted here, a word taken out there which changes the 
entire legislative impact.
  The American people are a lot smarter than we give them credit for. 
They know that in the middle of the night, many times legislation is 
written and turned into the kind of legislation that, frankly, unless 
you go through it page by page, word by word, you don't know the final 
impact. So what I, first, wish to say to my friend from Tennessee is 
that apparently the Finance Committee is working to turn out a 
legislative package that is not in legislative form, and I am curious 
how the Members would understand what is in it.
  I guess the second point is, there is still no serious consideration 
of a couple of the fundamentals--medical malpractice or medical 
liability reform or, obviously, the ability to go across State lines to 
purchase insurance and allowing small businesses to pool their assets 
so they can compete for health insurance policies that large 
corporations are able to.
  The other question I would ask, because I know my friend from 
Tennessee has had many roles in his long political life, has the 
Senator from Tennessee, as a former Governor, had any contact with the 
Governors and their organizations as to how much additional costs would 
be added to those States, which are already in dire shape--certainly 
mine is--in the form of additional Medicaid costs?
  I notice the majority leader at first complained about the bill and 
the cost it might accrue to his State of Nevada, but I guess that has 
been fixed to his satisfaction. But I don't think the other States--a 
State such as mine, which is still looking at over a $50 billion 
deficit--probably would be eager to absorb dramatically increased 
Medicaid costs. I wonder if my friend, a former Governor, former 
Cabinet member, former candidate for President, former dog catch--
excuse me, someone who has had many roles in American life, would 
respond to that.
  Mr. ALEXANDER. One of my friends said to me after I was Governor: 
Rooster today, feather duster tomorrow. And I am afraid I am in the 
feather duster category.
  The Senator has made a terrific point. I want to go to the Senator 
from Oklahoma, who has just arrived, to talk about this, one of the 
physicians in the Senate. But on the first point, we need to read the 
bill, and there is no bill. Yesterday, Republicans tried to get the 
Finance Committee to say once there is a bill that at least for 72 
hours it would be on the Internet. Then we need to know what it costs 
because even the President said----
  Mr. McCAIN. If I might interrupt, if it were on the Internet for 72 
hours, maybe as many Americans who wanted to would be able to read the 
bill themselves.
  Mr. ALEXANDER. They could let us know what they think of it, and then 
we need to know what it costs.
  As to Medicaid, every Governor in America is worried about this. The 
Democratic Governors and Republican Governors have said to us: If you 
want to expand the Medicaid Program, which the States pay 40 percent 
of, you pay for it because we can't raise State taxes or raise tuitions 
or cut the highway program to do that.
  The Senator from Oklahoma heard Senator McCain's question. The 
Senator from Oklahoma and Senator Barrasso the Senator from Oklahoma 
has delivered thousands of babies, and the Senator from Wyoming is an 
orthopedic surgeon. They have been touring the country, listening to a 
lot of doctors and physicians and medical personnel. I wonder if you 
have a reaction, Senator Coburn, to the questions of Senator McCain?
  Mr. COBURN. First of all, let me say my biggest concern for my 
patients in

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this whole debate is, will the American consumer still have the power 
and the ability to select who is going to give them this most personal 
of all care when this is over? The answer to that is ``no.'' It is not 
``no'' for everybody, but it is a ``no'' for half of the American 
public. That is what it means.
  Mr. McCAIN. Would it be ``no'' for the individual who has employer-
based health care and that employer then opts for the so-called public 
option, which would be a government-run health program? Could that 
employee see the same doctor?
  Mr. COBURN. We don't know, but most likely half of them will not. The 
whole debate ought to be how do we get more value out of the health 
care system we have today rather than how do we add more money to the 
cost of health care to cover more people.
  The reason my patients have trouble getting care is cost. Right now, 
they have choice, except if they are in Medicaid, and they have some 
choice if they are in Medicare because we are seeing a larger and 
larger percentage of doctors who cannot afford to take the Medicare 
reimbursements. But can they afford the care? This bill does nothing to 
lower health care costs. It does nothing to lower health care costs.
  Mr. McCAIN. Isn't it true, in fact, that the Congressional Budget 
Office has said that these increased costs, at least half of them, will 
be passed on to the individual?
  Mr. ALEXANDER. I would say to the Senator from Arizona, that is 
exactly right. The Congressional Budget Office did an analysis of the 
impact of Senator Baucus's plan on insurance premiums. It showed the 
premiums for those in the individual market would go up. So, to the 
point of the Senator from Oklahoma, one of the effects of the one 
remaining bill that is being considered here, at a time when we are 
trying to reduce the cost to Americans of their policies and their 
government, is that premiums would go up.
  Mr. COBURN. Premiums will.
  Mr. McCAIN. I have one very important question. There is no one who 
has led the fight against waste, fraud, and abuse more than Dr. 
Coburn!.
  Dr. Coburn, the President keeps saying we will eliminate all this 
fraud and abuse and waste. If we can, why don't we start tomorrow?
  Mr. COBURN. I agree. We have offered for years a couple of ways to do 
this. I think it is important for the American people to know how much 
there is. The Department of Health and Human Services estimated in 
2007--that is the last year for which they have numbers--that $62 
billion was improperly paid out of Medicare. The GAO, when they looked 
at that report, said: No, you are way off. It is at least $85 billion, 
and we think it is higher.
  If you look at that, that is almost 20 percent--20 cents out of every 
dollar--Medicaid pays out is lost to fraud. Why wouldn't we fix that 
first rather than say that if we fix it, we are going to take it from 
Medicare and put it somewhere else, when the trust fund, the HI trust 
fund, the hospital insurance fund, is going to be belly-up in 2017?
  Mr. ALEXANDER. Mr. President, I ask Senator Coburn, isn't it true 
that, under the Baucus plan, about half of it would be paid for by 
Medicare cuts, which would then be spent on a new program?
  Mr. COBURN. That is right. And Medicare is already unsustainable. So 
what is going to happen? There is another factor, which is we have it 
fixed that, with this bill, there will not be a big cut to the payments 
to doctors under Medicare. But in the years that follow that, there 
will be a 25-percent cut. If access is a problem for Medicare patients 
today, it is going to get worse. It is part of the lack of truth in 
this bill that they do not address what we have set in motion to take 
dollars away from the health care industry.
  Mr. McCAIN. May I ask Dr. Coburn again, if we start tomorrow, what 
can we do?
  Mr. COBURN. The first thing is you put uncovered patients in the 
Medicare system and you put people in jail who are defrauding Medicare. 
If 30 or 40 doctors went to jail in the next 6 months in this country, 
you would lower Medicare costs by 10 percent because all of a sudden 
they would start thinking about: I can't skirt this. I can't play this 
game. I can't do it. The risk is too high.
  As a matter of fact, here is one of the things we know. In Florida, 
the drug dealers have switched from being drug dealers to Medicare 
suppliers because they can make more money defrauding the Federal 
Government. It is harder to get caught and the penalties, when you are 
caught, are less than when you are dealing drugs. Consequently, we have 
all these people in the business of defrauding Medicare, and there has 
not been a plan that has been effective in cutting Medicare fraud 
because nobody knows--and the government is all about Medicare. So it, 
by its very design, is designed to be defrauded. We should make 
structural changes so it is not and with that get better care and lower 
cost care, like paying for outcomes rather than paying the American 
Medical Association to use their CPT code.
  Mr. ALEXANDER. The Senators from South Dakota and Kansas have joined 
us.
  Senator McCain is leading a colloquy on the Baucus bill and health 
care.
  I wonder, I ask Senator Thune, if you see the Baucus bill as a bill--
it is not a bill yet--that is likely to reduce costs?
  Mr. THUNE. I think that is the big question about all of these 
various pieces of legislation we have had in front of us. What do they 
do to reduce costs? Even the Congressional Budget Office has said 
repeatedly, in this bill in particular, the Baucus bill, the most 
recent version of a health care reform proposal here, there is a $1.7 
trillion cost over 10 years when fully implemented.
  If you actually look at what it does for most people in this country, 
they are going to see their health care costs not go down but go up. 
The premiums are actually going to increase. The reason for that is 
many of the taxes imposed in the bill to help pay for the cost of the 
$1.7 trillion expansion are going to get passed on. So the people who 
get hurt by this are hard-working Americans who are expecting, if 
Congress is actually reforming health care, that would mean health care 
costs, the costs people pay for premiums for their health care 
coverage, would actually go down. The Congressional Budget Office, 
under questions that were raised yesterday by some of our colleagues, 
responded that dollar for dollar, those additional--those taxes that 
would be imposed to pay for this would actually be passed on and you 
would see higher health care costs.
  So there has not been anything in this entire debate yet, or any of 
the bills that have been put before various committees or that 
eventually we assume will be considered on the floor here in the Senate 
and in the House of Representatives, that has actually impacted costs 
in a way that they go down, that reduces the overall cost for the 
people in this country.
  Furthermore--and I talked about this with the Senator from Tennessee; 
we had this discussion on the floor yesterday--many Americans, those I 
heard from in my State of South Dakota during the month of August in 
the many conversations I had out there, are very concerned. They are 
really concerned about two issues: one is control, one is cost. Who is 
going to control their health care? Is the Federal Government going to 
do it, the bureaucrat in Washington, DC? In this country, are we ceding 
one-sixth of our economy, more and more control to the people in 
Washington, DC? The Baucus bill, inasmuch as it doesn't at this moment 
contain the government plan, still assumes a high level of government 
involvement, government intervention. The government would determine 
which health care plans it would have to approve, which would meet the 
standards the government set. So you have a high level of government 
intervention with this plan as you have had with all the other plans.
  But perhaps even more important--and this is the issue I think most 
Americans are really homing in on--is the cost. What is the cost to me 
as a taxpayer? In this case, $1.7 trillion over a 10-year period when 
fully implemented. And does it reduce my cost of

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health care? They are going to look at it two different ways. One is, 
what am I going to have to owe in the form of higher taxes to finance 
this; and second, how is it going to impact the cost of health care for 
me in terms of the premiums I pay? I think it is fair to say--it is not 
what we are saying, it is what the Congressional Budget Office has 
determined--that actually the cost of health care for a lot of 
Americans, under this proposal, the Baucus proposal, is going to go up.
  Mr. ALEXANDER. Senator Thune, I see the Senator from Kansas is here. 
I wonder if Senator Brownback from Kansas or you from South Dakota have 
been hearing from your constituents about the possibility of shifting 
costs from Washington to the States when, because we in Washington say 
it is a great idea to expand Medicaid, then we shift some of the cost 
of that to the State, the State taxes go up or State services go down. 
I wonder if you have heard anything from the people of Kansas about 
that, Senator Brownback?
  Mr. BROWNBACK. I certainly have. I appreciate the Senator from 
Tennessee leading this discussion and also asking that question. As a 
former Governor, he has dealt with these issues. He knows that when 
Washington dictates something--or too often Washington will dangle a 
little bit of money out here and say: We would like the State to do 
this, and here is a little money to get it started. Then 3 years in the 
program, 5 years in the program, the money is pulled away at the 
Federal level and the State is left with trying to fund this.
  It is on two levels that I get it at the State level: No. 1, trying 
to drive so many more people into Medicaid; that is, by raising the 
amount of coverage of people in Medicaid, it then gets a big price tag 
with it--at the Federal level initially and at the State level as 
well--and State budgets are really strapped right now. I was just 
talking with some State legislators yesterday, and they are looking at 
a multiple hundreds of millions of dollars hole next year--that alone, 
without adding additional Medicaid requirements from the Federal 
Government on top of that. It is clearly a huge problem for them if you 
are going to add a cost at a time when they don't have the funds.
  The Federal Government, much of it, is saying: We are going to pay 
for it initially, and the proposals under Baucus are to pay for most of 
it initially, but I don't think there is any question that then, over 
time, the State is going to have to assume a bigger role of that, and 
that is going to be up to State responsibility.
  Mr. ALEXANDER. I believe the National Governors Association chairman, 
of Vermont, said that all Democratic Governors as well as all 
Republican Governors said: Don't shift it to us. If you want to expand 
Medicaid from Washington, pay for it from Washington.
  Mr. BROWNBACK. Pay for it and pay for it completely. But this is also 
a more pernicious piece of this, and that is we have 40 percent of our 
physicians in Kansas saying they are not taking more Medicaid patients. 
That is 40 percent now. Now you are talking about expanding Medicaid, 
the number of people in Medicaid, when 40 percent of your doctors are 
saying: We aren't taking them. You are saying: Why won't the doctors 
take it? It is not that they don't want to have Medicaid patients, but 
it is the reimbursement ratios they get. Listen to these numbers from 
MedPAC saying that Medicare provider reimbursement rates are about 80 
percent of private insurance. So private insurance, and then 80 percent 
of that is Medicare, and then Medicaid is 72 percent of Medicare. So 
you are cutting it back even further, to the point that physicians are 
saying: I just can't afford to take more.
  Mr. ALEXANDER. Medicaid is the largest government program we have 
today, bigger than Medicare; it has low-income Americans in every 
State. I believe the Baucus proposal plans to add about 11 million more 
low-income Americans to this plan that 40 percent of doctors will not 
see patients for?
  Mr. BROWNBACK. They won't see them. Now what you are doing is driving 
people into a system that is a very low reimbursement system, that 
physicians are, almost half, saying: We won't take any more.
  My concern here is that you are going to drive people in this system 
where you are not going to be able to get health care; they are not 
going to be able to get health care at all because of these 
reimbursement rates, because of the reimbursement rates physicians are 
having under Medicaid.
  So I think that is a deadly piece of this overall proposal. It is the 
cost to the States, and then it is also that you are driving people 
into an area where providers are fleeing and heading out of.
  Mr. ALEXANDER. We have 5 minutes left. We will go to Senator Thune 
and let Senator Brownback wrap up our time.
  But ``Medicare cuts,'' those are scary words to most Americans. And 
some people say: Well, you Republicans are trying to scare the seniors 
of America when you say the words ``Medicare cuts.''
  But is it not a fact that the Baucus plan would cut Medicare by about 
$500 billion and use it for a different program instead of shoring up 
the Medicare Program?
  Mr. THUNE. We know for a fact that the Medicare trustees have said 
the Medicare Program is destined to be bankrupt in the year 2017. So 
Medicare is already on an unsustainable path. It needs to be shored up. 
And what we are talking about doing is getting savings, if you want to 
call them that, or ``cuts,'' I would say out of Medicare to create a 
whole new entitlement program here in Washington, instead of fixing and 
making more sustainable a Medicare Program that, as I said, is destined 
for bankruptcy by the year 2017.
  I think most seniors and most providers around the country are going 
to be very concerned about the idea of having cuts in the Medicare 
Program, $500 billion, as the Senator from Tennessee has mentioned, go 
to paying for this new entitlement program which, as I said earlier, 
over a 10-year period is going to cost $1.7 trillion.
  So I think you are not only going to have, as the Senator mentioned, 
a lot of providers very concerned about cuts, I think you are going to 
have an awful lot of seniors who are concerned about how their Medicare 
benefits are going to be impacted by this proposal. I would add to what 
the Senator has already talked about, and I know the Senator from 
Tennessee's Governor has called some of these Medicaid expansions ``the 
mother of all unfunded mandates.''
  I have had numerous conservations with my Governor in my State of 
South Dakota about this. It would cost our State about $45 million a 
year, new revenues they would have to raise, to meet the matching 
requirements under this expansion of Medicaid.
  In my State of South Dakota, that is real money. I know that does not 
sound like a lot out here in Washington. But that really is. My Govenor 
is very concerned, as are all Governors, about the impacts not just on 
Federal budgets but on State budgets.
  Of course, as the Senator from Tennessee and the Senator from Kansas 
have pointed out, Medicare--and I might add, I love the quote from the 
CEO of Mayo, which the Senator from Tennessee has mentioned, ``If the 
public plan looks like Medicare, I think the country would go broke 
almost overnight,'' because Medicare is already proposed to go broke by 
2015 to 2017.
  I think that is the problem we run into when we try and build upon a 
foundation that is already crumbling. The Medicare Program is destined 
to go bankrupt. We are talking about adding a whole new entitlement. 
Instead of trying to figure out how to plow some of these savings back 
into Medicare and make it sustainable, we are actually adding to and 
building upon a foundation that is already crumbling.
  Mr. ALEXANDER. We have about a minute and a half left in our time. I 
wonder if Senator Brownback would conclude.
  Mr. BROWNBACK. Mr. President, I think to put it in Kansas-type terms, 
if you are talking about taking savings from Medicare to start a whole 
new

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health care entitlement program, that is like writing a big fat check 
on a completely overdrawn bank account to buy a new car.
  You are going: Now, well, who would do something like that? When you 
are saying: Well, that is what the Federal Government is looking at 
doing in this proposal that Senator Baucus has put forward.
  Medicare is not sustainable. It is not fiscally sound. You are going 
to write an overdraft check on that to start a whole new program that 
you do not have the wherewithal to do, that most Americans do not want 
to see you do because they want to see you fix the current program and 
get it on a sustainable basis.
  It does not make sense. It is out of the stream of thought of the 
American public. We ought to back up, stop, and go at this in 
incremental changes, to get costs down and more people covered, that do 
not drive costs up, that do not do a big federal takeover of the 
system.
  Mr. ALEXANDER. I thank Senators Thune and Brownback.
  Obviously, we believe that instead of a 1,000-page bill, we should do 
what Senator Brownback said. We should go step by step to re-earn the 
trust of the American people. For example, permitting small business 
plans to pool their resources to offer more insurance to a million 
people; buying insurance across State lines; stopping runaway junk 
lawsuits against doctors; signing up those people already eligible for 
Medicaid and SCHIP; and encouraging technology.
  All of those are steps we can agree on and reduce costs, without 
running trillions of dollars of new debt, more taxes, and Medicare 
cuts. I thank the Senators from South Dakota and Kansas for 
participating in our colloquy.
  I yield the floor.

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