[Congressional Record (Bound Edition), Volume 155 (2009), Part 18]
[Senate]
[Pages 25073-25077]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           HEALTH CARE REFORM

  Mr. KYL. Mr. President, I believe my colleague, Senator Thune from 
South Dakota, will be here in a few minutes. Until he arrives, I 
thought this might be of interest. I promised my constituents I would 
tell my colleagues what they told me to tell them. I think it would be 
of interest to share some of these remarks.
  I went to a meeting on Saturday morning that I thought was going to 
be a rather staid affair with folks who were primarily senior citizens, 
but not all of them were. It turned out to be a little bit reminiscent 
of some of those townhall meetings we saw on television during August 
because the subject most people wanted to talk about was health care. 
They weren't happy with what they were hearing the Senate was about to 
do. Among other things, they wanted to get it clear with me right off 
that I would pass on their concerns about this to my colleagues. I 
promised that I would. So let me summarize what some of them had to say 
and what I think the clear consensus of the group was.
  First of all, they have a hard time understanding how Senators would 
pass a bill before we read it or even know how much it costs. I assured 
them that the procedure we would follow in the Senate was that we would 
have at least 72 hours after the bill had been finally written and 
after the Congressional Budget Office had scored the bill--that is to 
say, told us how much it would cost in all of its component parts and 
the ways it would be paid for. The reason I can feel fairly certain 
that will happen is because a number of colleagues on both sides of the 
aisle have either written to the majority leader or made it clear to 
him that they will not support a motion to proceed to a bill until we 
have had an opportunity to, in effect, read it and see how much it 
costs. That process could take some time, I told my friends. The 
Congressional Budget Office Director told the members of the Finance 
Committee, on which I sit, that it can take 2 to 3 weeks after the bill 
is written to come up with all of these calculations.
  You will hear many people say we need to move this process on, even 
before we have the numbers. But I think that given the fact that most 
of us are committed to ensuring we have the numbers and can digest them 
and share them with our constituents before we debate and amend the 
bill, I assume the process will unfold in the Senate in such a way that 
we do know what it costs, and that means after the final CBO report is 
provided to us.
  The next thing they wanted me to convey was that they were very 
worried about--in fact, maybe that would be a euphemism. They were more 
than concerned about the degree of government involvement in health 
care once this process is over. They fail to understand why we had to 
have what amounts to a government takeover of insurance in this country 
and dictating everything from what kind of insurance policy you have to 
have, to how doctors and hospitals are paid, in order to solve the two 
key problems that exist: No. 1, there are some Americans who need help 
buying insurance; second, that the costs of health care premiums 
continue to go up every year, and it is especially hard for small 
businesses to provide coverage for employees.
  They asked me: Why do we have to change the entire system, with the 
government essentially taking it over?
  I happen to believe we don't. I provided the two basic alternatives 
to them. One is a step-by-step approach that targets specific problems 
we have and matches up specific solutions to the problems, on the one 
hand, which is the approach I favor; on the other hand, essentially 
changing the insurance we all have today, creating a new insurance 
exchange, and all insurance would have to go through there. Even if you 
like your policy, it will change, and you are not going to be able to 
keep it.
  Estimates are that, as a result of all of this, in an effort to cover 
18 or 20 million more people with insurance, it is going to cost us 
close to a trillion dollars. It will raise taxes, it will raise 
insurance premiums, and it will require deep cuts in Medicare. They 
didn't like that. I guess that brings up the third thing.
  With regard to Medicare, they were pretty perceptive in asking me the 
following basic question. One person said: One of two things is going 
to happen. Either it will be business as usual where we say we will 
make cuts in Medicare, but the Senate and the House never have the 
courage to do that, in which case this bill is going to cost a lot of 
money that is not offset by concomitant savings, or the savings are 
going to be made, and when they are made, it is going to deeply cut our 
benefits under Medicare.
  That person was right. One of those two things is true, and neither 
one is a good result.
  I remember a few years ago when we tried to reduce the growth in 
Medicare by about $10 billion. Republicans and President Bush were 
excoriated; we were going to ruin Medicare, and our colleagues on the 
Democratic side took great glee in the public reaction to that proposal 
to decrease the growth in Medicare by $10 billion.
  Now we are talking about cutting Medicare by--I said $500 billion. 
The Finance Committee money is actually $450 billion. So let's be 
accurate. If that

[[Page 25074]]

is the way this bill comes out, $450 billion, $120 billion of that is 
reduction of benefits under Medicare Advantage. So when people say: You 
would not have your benefits cut, that first $120 billion is a direct 
cut in benefits, and in my State a lot of seniors have Medicare 
Advantage policies.
  The other way in which Medicare is cut--there are basically two 
things. One is reducing the amount of money we pay doctors and 
hospitals, and that cannot help but reduce the care we get. The final 
mechanism is a Medicare Commission is being established to provide--I 
think it is every year; maybe every 2 years, but let's say every year--
an amount of money that will have to be cut and will automatically be 
cut from Medicare unless the Congress finds a different way to do it, 
but Congress would still have to cut the same amount. So we either do 
it the way we want to do it or we do it the way the commission 
recommends it. In any event, their recommendation automatically goes 
into effect if Congress does not act.
  I have a couple thoughts about that point. We have never been able to 
effect these cuts in the past because seniors know that it cuts deeply 
into their care, and they have told us and we have reacted by saying: 
OK, we will not do it. We could react that way again, in which case all 
of the savings, or at least a great deal of the savings, that were 
supposed to result and offset the costs of the bill would not be there. 
So now the bill is no longer deficit neutral. Now it is not balanced. 
Now it does add to the deficit and to the debt. If we do allow those 
cuts to go into effect, seniors are clobbered by deep reductions in the 
care they receive all the way from nursing homes to physicians to 
hospitals to hospice, medical devices--you name it. As I said, neither 
of these results is a good result.
  There were several people who wanted me to convey their thoughts in 
that regard. I happen to agree with them, so I could do that.
  I met, after visiting with this group, with a group of spinal 
surgeons from all over the country and, in fact, from outside this 
country. I saw the agenda of their meeting. I was the last speaker. For 
a layman, such as you and I, Mr. President, it was daunting to read 
through that agenda--all of the latest techniques in using new laser 
and stints and all kinds of things that I did not understand, but it 
was the very latest technology and techniques for treating spinal 
diseases and conditions.
  What they told me was--I was the last person to make a presentation--
all of these great things we are doing for our patients we are not 
going to be able to do under this legislation, first of all, because it 
will be presumed to cost too much; second, because it will take the FDA 
and the other government agencies way too long to authorize its use for 
treating Medicare patients, for example; and, third, because the 
comparative effectiveness research which has in the past been used by 
these doctors to help them appreciate the best way, clinically, to 
treat someone is now going to be used to decide what Medicare can 
afford to pay. A lot of the more leading-edge techniques and 
technologies are not going to be approved for that purpose.
  Their point was that people in China and Europe are going to be 
treated with the latest techniques more than Americans will because the 
American system of health care is going to deny people such as these 
experts the ability to do what they do.
  One way this is being accomplished is by taking money away from 
specialists and giving it to general practitioners. There is a 
rationale for paying general practitioners--family doctors--more money. 
They are not making enough, and they are the first place most of us 
enter the medical world. If we have something that does not feel right, 
we go to our doctor. It is usually a family doctor. Frequently, he can 
help us, but frequently he says: I think there is something about what 
you have here that tells me I have to send you to a specialist. We go 
to the specialist then and he orders some specialized tests and he 
examines them and he may end up having to provide some kind of very 
specialized treatment and care that is probably going to cost more 
money.
  While the family doctor needs to be paid more, we don't solve that 
problem by taking money away from the specialists. If we have to add 
money to the system to ensure that we have enough doctors who can 
provide quality care, then there is no free lunch and we have to pay 
for what we get. We should not make it a zero-sum game and take it from 
Dr. B in order to pay Dr. A. That was another strong message of these 
specialists.
  I also happened to meet on Friday afternoon with a group of 
physicians in Phoenix from all different practices--from specialists to 
generalists, hospital physicians to others. To a person, they had this 
question for me. The way they asked it was, Why isn't anybody talking 
about medical malpractice reform?
  I said: I am talking about medical malpractice reform.
  They said: You are not getting through.
  I said: The problem is there are a bunch of folks on the other side 
of the aisle who don't want medical malpractice reform, and you know 
why. And, yes, they understood the answer why.
  I remind friends who might not have remembered, Howard Dean, a former 
Governor of Vermont and a former Democratic candidate for President and 
a former Democratic Party chairman was very candid in a townhall 
meeting in Northern Virginia on August 17 with Representative Moran 
where he told the group assembled there that the reason medical 
malpractice reform was not in the legislation is because they did not 
want to take on the trial lawyers.
  That is true, but it does not make it right. Maybe somebody should 
take on the trial lawyers because there are a lot of estimates of how 
much money could be saved through meaningful medical malpractice 
reform. This jackpot justice system of ours that pays trial lawyers and 
requires physicians to pay as much as $200,000 a year in liability 
insurance premiums--all of which, of course, have to be passed on to 
the cost of our care, and perhaps even worse than that, practice what 
is called defensive medicine--raises the cost of our health care. 
Defensive medicine is having all kinds of tests performed and maybe 
putting someone in the hospital an extra day or two all in order to 
protect from a liability claim that their doctor did not do everything 
he could to take care of this poor patient and, as a result, the 
patient got sicker and something bad happened.
  There are a lot of estimates. First, one estimate is from a study 
that says 10 cents on every dollar spent on health care is paid in 
insurance premiums by physicians. Obviously, some of that will still 
have to be paid with medical malpractice reform, but it could be 
reduced as has been the experience in the State of Arizona and the 
State of Texas, which is the reason Senator Cornyn from Texas and I 
have introduced legislation that will provide modest reforms to the 
tort system by putting some modest caps on noneconomic damages awards 
and providing that expert witnesses who testify have to be really 
expert witnesses in the area of the alleged malpractice.
  These two things have saved enormous amounts of money. In Arizona, we 
don't even have caps on damages, but the Requirement that expert 
witnesses really be expert has ended up saving millions of dollars and 
reducing the malpractice premiums for physicians in the State of 
Arizona.
  This is a reform we could accomplish on a bipartisan basis that not 
only would not cost anything, it would actually reap financial 
benefits. The Congressional Budget Office says just the savings to the 
U.S. Government--because we provide care under Medicaid, Medicare, and 
to our veterans--would save $54 billion. There are a lot of estimates 
that are higher than that. There is one estimate that is over $100 
billion a year.
  The Director of CBO acknowledged to people of the Finance Committee 
when we asked that $54 billion savings would actually be approximately 
doubled if we take into account the private sector as well. In other 
words, not only the Federal Government would save that much money, 
which pays about half of

[[Page 25075]]

all health care dollars in the United States, the private sector, which 
pays the other half, could save a like amount of money.
  These constituents wanted to know why doesn't anybody ever talk about 
it. I had to tell them we are talking about it. It is just that nobody 
is listening.
  That kind of brings up the last point I want to pass on. After 
meeting with these three different groups in Phoenix and talking with 
people elsewhere I went over the weekend, it is pretty clear to me 
people are becoming very frustrated with their government, and this is 
not good. They don't think their government is listening to them. We 
are elected to be their representatives, to bring their ideas to 
Washington. Since they can't all study up on the issues as thoroughly 
as we are supposed to do, they trust us to not just to do what they 
want, not what they say, but to use our best judgment. But they do want 
us to listen to what they are saying and translate that into action.
  What I hear them saying and what public opinion polls verify is they 
are very worried about the breadth and the depth of this proposed 
health care reform. They say it costs too much money; it is going to 
get us in debt; it will raise taxes which are going to be passed 
through to them; it is going to raise insurance premiums; and it is 
going to involve a massive government intrusion into what is primarily 
a private matter between them and their physician, with their insurance 
company added into the mix. They see this along the same lines as the 
government takeover of banks and insurance companies and car companies 
and everything else, and they don't like it.
  One of the reasons they don't like it is because they see their own 
health care being delayed or denied as a result. They appreciate the 
fact that if the government gets so involved that it can begin to tell 
insurance companies what they can pay for and tell doctors what they 
can do for patients, that the next thing that will happen is their care 
will be delayed and denied and ultimately rationed.
  I read a chapter in a book by our former colleague, former majority 
leader of the Senate, Dr. Bill Frist, a renowned heart surgeon. I 
talked with former Senator Frist about it last week. He actually served 
for about a year in England under their health system. He makes the 
point in his book that there are some good things about their health 
system. He said the bad thing is that if someone has a serious 
condition, unless they are at the top of the list, they run the risk of 
never having their serious condition dealt with.
  He gave an example of a list of 100 patients who needed heart 
surgery. He said they would do two a day and gradually work down the 
list. He said what he found was that after a few weeks, peoples' names 
were being taken off the list. They didn't need the surgery anymore 
because they had died. He said that would never happen in America. He 
said if we have 100 people who need heart surgery in America, we would 
figure out a way to get that heart surgery for them right away, and we 
wouldn't do two a day until we ran out of time and they ran out of 
life. He said that is really the difference in a system in which we are 
controlled by the amount of money the government chooses to put into 
the system every day versus the kind of system we have that takes care 
of people and worries about the cost later. That is why it is possible 
for us to say that even people without insurance get cared for. No one 
in this country should die because they don't have insurance because we 
will take care of them.
  Obviously, having insurance makes the delivery of care easier, more 
timely, and much more cost-effective, which is why at the end of the 
day we want to see that everybody is insured.
  The bottom line is that we do not need to throw out the baby with the 
bathwater, get rid of the system we have that currently takes care of 
most people very well in order to insure that last group of folks who 
don't have insurance. We can provide a voucher or subsidy to them and 
get them coverage.
  The other thing we have to do is help to bring down the costs. 
Republicans have offered numerous solutions on how to do that without 
having the government take over the system. I mentioned one: Medical 
malpractice reform. It does not cost a dime, it will save billions of 
dollars, and it is good policy besides. So why don't we do it? Because 
there is a vested special interest that does not want it done. It will 
take money out of their pockets. That is wrong.
  My question to all of my colleagues is, When are we going to stand up 
to the special interests? Everybody likes to whack at the insurance 
companies. How about taking a good hard look at the trial lawyers? And, 
by the way, while we are talking about insurance companies, Republicans 
offered several ideas on how to add more competition for the insurance 
companies so in those situations where they have it good, if we provide 
for certain reforms that we have offered, such as association health 
plans, small business plans, more flexible HSAs, interstate sales of 
insurance, all these things would provide more competition for the 
insurance companies and force them to lower their rates. This would 
make health care more affordable because it would help small businesses 
in providing health care for their employees.
  All these things came up during these meetings. As I said, I promised 
my constituents I would be sure to pass their ideas on to my 
colleagues, and I make these comments in that spirit, hoping that we 
will listen to our constituents not just in Arizona but in South Dakota 
and everywhere else around the country. And as a result of listening to 
a bunch of pretty commonsense folks, perhaps we will make wiser 
decisions here than we otherwise would have.
  I see my colleague from South Dakota is here. He had some very 
erudite comments to make on one of the television shows on Sunday, and 
I am happy to yield the floor for Senator Thune.
  The ACTING PRESIDENT pro tempore. The Senator from South Dakota.
  Mr. THUNE. Mr. President, I thank my colleague for yielding the 
floor, and I appreciate listening to his observations about the current 
state of the health care debate.
  Mr. President, I ask unanimous consent that I be allowed to speak for 
up to 20 minutes.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. THUNE. Mr. President, as my friend from Arizona noted, there are 
many things about the current debate that I think raise questions with 
the American people. He was discussing what he had heard back in his 
State of Arizona regarding the current debate that is before the 
Congress and the concerns people have, the anxiety, the frustration, 
and, frankly, the fear that I think a lot of Americans have about what 
happens and what the ultimate result may be. For instance, will this 
health care reform effort lead to higher costs for them? Will it lead 
to questions about whether they will be able to retain that 
fundamental, essential relationship between the patient and the doctor?
  Those are, I think, very valid questions. Frankly, we don't have 
answers to them because, one, we don't have a bill. We haven't seen a 
bill. That bill is being written, we are told, in the majority leader's 
office. There will be a handful of people in that room. There will not 
be input from our side, let alone from many Democrats in the Senate. It 
is going to be basically cranked out and at some point we will have a 
bill that will be put on the floor before the entire Senate. Having 
said that, it is interesting to me that this week we are going to have 
a vote in the Senate on an issue which, frankly, is very much a part of 
the debate over health care reform and yet that vote is being separated 
out. I think there is a reason for that, which I will come back to in a 
moment.
  I think it is important and telling that the first vote on health 
care reform here in the Senate is going to be to add a quarter of a 
trillion dollars to the Federal debt. That is right, $250 billion--or 
$247 billion, to be precise--is going to be added to the Federal debt

[[Page 25076]]

because what the majority leader has decided to do is to bring 
legislation to the floor this week that would address the physician 
reimbursement issue. We all believe that needs to be addressed. There 
is no one on our side of the aisle who doesn't believe we need to 
address the challenge that we will face in January of this coming year. 
Physicians across this country, if we don't take steps, are going to be 
subjected to a 21\1/2\ percent pay cut. That is not something anybody I 
know of in this Chamber is willing to abide.
  But we have a fundamental difference about whether that ought to be 
addressed in a way that is paid for, that actually doesn't borrow $250 
billion from future generations. The reason I say it should have been 
in the health care reform bill, but wasn't, is because it is a part of 
that debate. In fact, the House of Representatives included the 
physician reimbursement issue in their version of health care reform 
and put it out of balance, but at least they were honest. They dealt 
with it in the context of health care reform, because it is fundamental 
to addressing the health care issues we have in this country. The 
reason I think it was left out of the Finance Committee bill, the 
Baucus bill, is because they knew if they put that in the bill, it 
would put their bill out of balance, and we had the big proclamation 
that had come out about how this is deficit neutral, that it is going 
to add $81 billion in surplus, that it is actually going to save money 
in the long run.
  Obviously, if you back out $250 billion, you can make your books 
balance in the near term. But what you are doing is adding a quarter of 
a trillion dollars to the debt, which this year was $1.4 trillion--
three times what we have ever seen here in the last 40 years or so. The 
last time we have seen debt of this magnitude in terms of a percentage 
of our gross domestic product was right after World War II. But the 
debt this year is three times what we have seen in recent history--at 
least in this last decade.
  I think the first point I would make is that the first vote out of 
the gate on health care reform should not be to add a quarter of a 
trillion dollars to the Federal debt and to pile this burden on future 
generations of Americans. In fact, there is a bumper sticker going 
around right now, which I think is perhaps pretty descriptive of what 
is happening in Washington, and it says something to the effect: 
``Don't tell those people out in Washington, DC what comes after a 
trillion dollars.'' I think the American people are sitting out there 
wondering, when we talk about billions and billions and billions, and 
now we are talking trillions and trillions and trillions, what comes 
after that? And yet we continue to spend and borrow as if there is no 
tomorrow. I think the American people are picking up on that, and 
obviously they want to see a government that lives within its means 
just as they have to every single day in their personal lives, in their 
businesses, and most people who have to live within balanced budgets.
  It is a lesson I think Washington could learn. It is essential that 
we don't continue to pile this burden of debt on future generations of 
Americans. The deficit last year was $1.4 trillion. It is estimated if 
we stay on the current trajectory that we will double the Federal debt 
in 5 years, triple it in 10 years, and at the end of the 10-year 
period, the average part that each household in this country will own 
of that entire Federal debt obligation is $188,000. So if you are a 
family in America today or say you are a young couple who has just 
gotten married, and looking at your life ahead of you and planning for 
your future, you are going to get a wedding gift from the Federal 
Government--a big old IOU for $188,000. That will be everyone's share 
of the Federal debt.
  What we do here with the first vote out of the gate on health care 
reform is add a quarter of a trillion dollars to that Federal debt. A 
quarter of a trillion dollars used to be a lot of money in this town. 
When you start talking about $1.4 trillion deficits, maybe it doesn't 
seem like that anymore. I think that is why the American people are 
asking, and probably fairly so, what comes after a trillion dollars. 
When you add a quarter of a trillion dollars to the debt, the total 
interest payment on that amount over the 10-year period, if you can 
believe this, is $136 billion. So we are adding $136 billion in 
additional interest payments that we are going to have to make over the 
course of the next 10 years by borrowing an additional quarter of a 
trillion dollars to address the physician reimbursement issue.
  I say all that because I think it bears on the bigger question of 
health care reform and the fact that right now we have competing bills: 
One in the House, called the tricommittee bill, if you will, which does 
spend, over a 10-year period, about $2.4 trillion; the Senate HELP 
Committee bill, which over a 10-year period spends $2.2 trillion; and 
the Senate Finance Committee bill, which over a 10-year time period 
spends $1.8 trillion--until now. When we add in this $250 billion for 
physician reimbursements, that now pushes the number on that particular 
bill up to about $2 trillion as well.
  So what we have is a whole new expansion, a whole bunch of new 
spending on health care by the taxpayers in this country. Obviously, it 
has to be paid for somehow. Most of it is paid for by cuts to Medicare 
reimbursements that providers in this country would receive, paid for 
in the form of higher taxes that would be borne by small businesses, by 
individuals, and would ultimately lead to the final outcome of this big 
debate, which is higher premiums. The whole purpose of this was to 
reduce the cost of health care for people in this country by reducing 
and driving down what they paid for health insurance. But as has been 
pointed out, I think over and over now in response to questions posed 
by members of the Senate Finance Committee in answers from the CBO 
Director, these tax increases--roughly dollar for dollar--will be 
passed on in the form of higher taxes. In fact, some of the taxes in 
the House bill hit squarely at small businesses and hit squarely at 
individuals. The CBO and the Joint Tax Committee, which looked at the 
Finance Committee bill, concluded that 90 percent--87 percent, I should 
say, as far as the Joint Tax Committee and 89 percent was the CBO 
estimate--of the tax burden would fall on taxpayers--on wage earners--
making less than $250,000 a year. In fact, the Joint Tax Committee went 
so far as to say a little over 50 percent of that tax burden would fall 
on wage earners making less than $100,000 a year.
  So the tax burden is going to be borne by people who were promised 
they wouldn't pay higher taxes in the health care reform proposals, and 
it was stated by the President and others that we wouldn't tax people 
who make less than $250,000 a year. That is clearly not the case. There 
is a 5.4 percent surcharge on high-income earners in the House bill 
which would be borne largely by small businesses, many of whom file, 
because of the way they are organized, on their individual tax returns. 
So you are going to have higher taxes on small businesses, higher taxes 
on middle-class Americans, and this explosion and expansion of Federal 
Government here in Washington to the tune of $2 trillion.
  You would hope then that you would see that would have some positive 
impact on health insurance premiums. The reality is, as I said earlier, 
it does not. I think as the debate broadens and we become engaged on 
health care reform, the American people are going to come to that 
conclusion, which is why I think they are very concerned about what is 
happening here in Washington.
  The other point I will make is that one of the objectives of health 
care reform--in fact, to me, health care reform ought to be about 
driving health care costs down, not increasing them, which is what all 
these bills do--was that it was designed to cover people who aren't 
currently covered, to provide access to more Americans. What we are 
seeing now with all these various bills is there are lots of people who 
get left out. Under what they call the House bill--the tricommittee 
bill--17 million Americans still would not have health insurance. Under 
the Senate HELP Committee bill, that number is

[[Page 25077]]

much higher. It is 34 million who would still not be covered. But there 
is an assumption there, although it wasn't included in the bill, that 
Medicaid would be expanded. That would cover more people. So that 
number may be overstated. But the Senate Finance Committee assumes 25 
million people will be without health insurance.
  So you will have higher taxes, a tremendous amount of higher 
spending--up to about $2 trillion under any of these bills--and an 
expansion of government here in Washington, DC, cuts to Medicare 
reimbursements--to seniors--across this country, and all for what? 
Higher premiums for most Americans, for people who currently have 
insurance, to hopefully cover some Americans. When you are spending $2 
trillion, there ought to be some advantage to that, but clearly a lot 
of Americans are still going to be without health insurance when this 
is all said and done.
  I am concerned. I think a lot of our colleagues here in the Senate--
and not just on our side of the aisle, but I think a number on the 
other side too--have expressed concerns about starting the debate a 
quarter of a trillion dollars in the hole by putting a bill on the 
floor that is going to spend a quarter of a trillion dollars--$250 
billion--over the next 10 years that is not paid for. That puts any 
bill that is considered later completely out of balance, and it is a 
gimmick that is designed to allow the President and the Democratic 
majority to say our health care reform bill is deficit neutral. Well, 
sure, if you take the $250 billion and back it out, it is easy to say 
it is deficit neutral, when in fact now it is going to be $200 billion. 
They have about an $80 billion overage on the bill in the Finance 
Committee, but it is still going to be $200 billion out of balance when 
you do this, again, to be financed with more debt and more borrowing, 
which is exactly what I think we want to avoid, and particularly when 
you are running deficits as far the eye can see.
  This last year, about 43 cents out of every dollar that was spent 
here at the Federal level--in Washington, DC--was borrowed. There isn't 
anyplace in America where you can function like that and still be in 
business. If you are a person doing that in your personal household 
finances, you would be forced into bankruptcy. If you were a small 
business, you would be forced into bankruptcy. Frankly, were it not for 
the fact that other countries around the world are financing America's 
debt, we would be in bankruptcy. Because you can't borrow 43 cents of 
everything you spend, as we are doing here in Washington, DC. In fact, 
to put it in perspective--and a lot of Americans understand this--if 
you are a family with an annual income of $62,000, it would be the 
equivalent of spending $108,000. That is what we are doing here in 
Washington, DC. Of all the money we spend in a given year, 43 percent 
of that is borrowed. We cannot continue to sustain that.
  I hope that before this bill comes to the floor, we can reach an 
agreement about amendments that might be offered. I would say our side, 
the Republican side, has amendments it would like to offer to this bill 
that would help pay for it, help reduce the amount or perhaps entirely 
reduce the amount that would be borrowed in order to finance the 
physician reimbursement fix, on which we all agree. As I said, there is 
not anybody on this side who does not agree that needs to be done. In 
fact, Senator Cornyn offered an amendment to the bill that would 
provide a 2-year fix, a 2-year solution to the problem for physician 
reimbursement. It was voted down. It was defeated, that amendment, in 
the Senate Finance Committee.
  We are looking. We are proactive. We have to address this issue. This 
issue was created by the Balanced Budget Act back in 1987. I was a 
Member of the House of Representatives at the time. I voted for that 
balanced budget agreement, but it included what was called a 
sustainable growth rate formula by which physicians are reimbursed. As 
I said earlier, in January of this year, based upon that formula, 
physicians would receive a 21.5-percent reduction in their fees, in 
their reimbursements.
  Everybody here--I should not say everybody. I can't speak for 
everybody. But I think most Senators on both sides of the aisle 
acknowledge that issue has to be addressed. We need to fix that, but we 
have to do it in a way that is fiscally responsible. We want an 
opportunity to offer amendments that would allow us to do that.
  As of last week, that request was being rejected. There was going to 
be a cloture vote today, which I understand now has been vitiated, 
which means perhaps the leaders are working together on an agreement 
that would allow Senators on both sides to offer amendments to this 
legislation that would help pay for it.
  I think it is telling that there are Democrats who are uncomfortable 
with the idea of adding $\1/4\ trillion to the Federal debt with the 
very first vote we will cast on health care in the Senate Chamber.
  I hope we can reach an agreement. I hope the leaders will be able to 
do that and this will be an open process, that we debate, and there 
will not be any mad rush to try to cut off debate. Rather, Senators on 
our side would have an opportunity to fix the issue that is going to 
put a lot of physicians in a very uncomfortable position if we do not 
address it but do it in a way that also is fair to the American 
taxpayer and make sure we, as a nation, are honoring the responsibility 
we have, not just to fix this issue for today but to provide a better 
and brighter and more secure future for future generations of 
Americans. It is a future which, I would add, is very much in jeopardy 
and in peril if we continue to spend and borrow and tax at the rate 
that is contemplated in the health care reform bill but, more 
important, with the very first vote on that health care proposal, which 
is to add $250 billion to the Federal debt.
  I yield the floor.
  I suggest the absence of a quorum.
  The ACTING PRESIDENT pro tempore. The clerk will call the roll.
  The bill clerk proceeded to call the roll.
  Mr. CASEY. I ask unanimous consent that the order for the quorum call 
be rescinded.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.

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