[Congressional Record (Bound Edition), Volume 155 (2009), Part 21]
[Senate]
[Pages 28635-28690]
[From the U.S. Government Publishing Office, www.gpo.gov]




   SERVICE MEMBERS HOME OWNERSHIP TAX ACT OF 2009--MOTION TO PROCEED

  The ACTING PRESIDENT pro tempore. Under the previous order, the 
Senate will resume consideration of the motion to proceed to H.R. 3590, 
which the clerk will report.
  The assistant legislative clerk read as follows:

       Motion to Proceed to H.R. 3590, to amend the Internal 
     Revenue Code of 1986 to modify the first-time homebuyers 
     credit in the case of members of the Armed Forces and certain 
     other Federal employees, and for other purposes.

  The ACTING PRESIDENT pro tempore. Under the previous order, there 
will be debate until 10 p.m., the time controlled in alternating 1-hour 
blocks, the majority controlling the first hour.
  The Senator from New Mexico is recognized.
  Mr. BINGAMAN. Mr. President, I rise to speak for a few minutes about 
the health care legislation that has now been proposed by the majority 
leader and that we will be hopefully proceeding to for serious 
discussion, deliberation, and opportunity for amendment. Let me talk 
first about where we are today without health care legislation.
  What are the circumstances faced by the average American family 
without enactment of health care legislation? The cost of medical care 
is rising. In fact, it is unaffordable for many individuals and 
businesses. In addition, there are 46 million who are uninsured in the 
country. That number continues to grow. I have been in the Senate and 
continued to watch that number grow for the last decade at least. Those 
most in need of health insurance often are denied coverage. Many others 
worry about whether they are one diagnosis away from financial ruin 
because of their lack of adequate coverage and their lack of ability to 
afford adequate coverage.
  We are working in the Senate to craft a national health reform 
proposal that would remedy the situation and would do so by reducing 
the growth in the cost of health care. Let me be clear. We are not 
saying the cost of health care is going down substantially. We are 
talking about the growth in the cost of health care. That is what we 
are trying to moderate as part of this legislation.
  We are also providing insurance to everyone in the country, 
regardless of their health status and medical condition. This health 
reform proposal is designed to lower health care costs, lower than what 
they otherwise will be in the future. This health reform legislation 
caps what insurance companies can force patients to pay in their out-
of-pocket expenses and in their deductibles. The legislation would let 
small businesses and individuals join purchasing pools and give them 
the lower costs that benefit larger groups today. I have heard from 
hundreds of small business owners in my State over the years who have 
complained that the cost of health care to them and their employees is 
so much higher than the cost of health care to large employers and 
their employees. We would solve that. We would create a system that 
helps to prevent illness and disease instead of just treating it when 
it is too late and when the cost is excessive.
  This health reform proposal will reduce health care fraud and waste 
and abuse and overpayment to insurance companies. It is estimated by 
most experts to be in the range of $60 billion per year under the 
current health care delivery system. This legislation would eliminate 
most of the cost of uncompensated care. This is a substantial part of 
the premium people with health insurance are required to pay. They are 
not only paying for their own health care when they pay their premium, 
they are paying for the uncompensated care that hospitals, physicians, 
and others are providing to people who don't have insurance. That is 
the 46 million uninsured figure I mentioned before.
  This legislation reduces the growth in the cost of public programs 
such as Medicare and Medicaid and helps to rein in the Federal deficit. 
We have the unusual circumstance that many of the individuals who 
opposed the establishment of Medicare and claimed it was socialized 
medicine are now resisting any effort to put it on a sounder financial 
footing and doing so purportedly in the name of defending the 
beneficiaries of Medicare. We need to speak the truth to the American 
people and say: Medicare and Medicaid are going to continue. There are 
going to have to be reductions in the growth of those programs in the 
future, the growth of the cost of those programs, and some of those 
changes are incorporated in this legislation. That is a good thing for 
Medicare beneficiaries. That is a good thing for people who are going 
to be dependent upon Medicare in the future. They will know Medicare is 
there. They will know Medicare is solvent and will benefit accordingly.
  Health reform will also ensure all Americans have access to quality 
and affordable insurance. We prevent insurance companies from the 
current practices in which they are engaged. One of

[[Page 28636]]

the worst of those practices is the practice of denying health coverage 
for preexisting medical conditions. If one has a preexisting medical 
condition and is able to buy a policy, perhaps, the policy in its own 
language will exclude them from getting medical treatment that might 
result from that preexisting medical condition. This legislation would 
end that. It would end the discrimination of charges that currently 
exist where the charge for health care is based on one's health status 
or gender.
  During the course of this year and the last few years, while we have 
been studying the health care delivery system, I have come to a new 
understanding of what the word ``underwriting'' means. I used to think 
I knew what the word ``underwriting'' meant in insurance. What I have 
found it means is the screening out of people who might actually need 
the insurance that is being sold. So much of the effort of the health 
insurance industry today is not focused on assisting the patient or the 
policyholder; it is focused on screening out those individuals who 
might, in fact, wind up sick and might need health care. We try to end 
that in this legislation, and we do so effectively.
  The legislation provides tax credits to middle-class families to make 
sure they can afford quality coverage. There are many middle-class 
families in my State who, frankly, cannot afford adequate and quality 
coverage for the parents and the children.
  This legislation strengthens employer-based health care by offering 
small businesses a tax credit so that employers can offer competitive, 
affordable rates to their employees, if they choose to do so.
  It creates incentives that reward doctors for healthy outcomes, not 
only for more and more procedures. We have the unfortunate circumstance 
today, for which this Congress and this administration and previous 
Congresses and previous administrations are responsible, where we have 
set up a system of payment, under Medicare in particular, where the 
amount the health care provider receives depends on how many procedures 
they perform, not on whether the patient gets better, not on whether 
they have done the right thing to assist that patient. We are trying to 
begin changing that with this legislation. This will result in better 
health care for all Americans.
  Health reform is also designed to improve the choices people have 
when they go out to obtain coverage or to obtain health care itself. 
Most Americans get their insurance through an employer. Many are 
satisfied with the plans they currently have. They are satisfied with 
the physician or the doctor they currently have. It is clear in the 
legislation we are considering that this legislation does not require 
them to change that. This legislation says they can keep that policy. 
They can renew that policy. They can add family members to that policy 
if they choose to do so. But this health reform also provides security 
that ensures that families always will have guaranteed choices of 
quality, affordable health care. That is even when a person loses their 
job, when a person switches jobs, when a person gets sick, or a person 
decides to move from one community to another. This legislation will 
ensure that they have access to health care even in those 
circumstances.
  It creates a health insurance exchange. This exchange would be a 
place where families and businesses could easily compare insurance 
plans and prices and make a judgment based on that comparison. This 
puts families, rather than insurance companies or government 
bureaucrats, in charge of their own health care. It helps people to 
decide which quality, affordable insurance option is right for them and 
for their family.
  It keeps government and insurance bureaucrats, because there are 
bureaucrats working for insurance companies just as there are 
bureaucrats working for the government, both from coming between each 
individual and his or her doctor by simplifying insurance paperwork, by 
cutting out the pages of fine print, by eliminating all of the 
``gotcha'' clauses people discover once they get sick. They find out 
they were not covered for whatever it is that now afflicts them.
  By promoting computerized medical records, this legislation will 
dramatically improve efficiency in our health care system and, through 
that effort, also reduce cost.
  Let me talk a little bit about the impact of this legislation on my 
State. I represent New Mexico. Frankly, this legislation is critically 
important to my State. This chart is a depiction of what is projected 
by the experts about the cost of health care in New Mexico. Without 
health care reform, my State is expected to experience the largest 
increase in health insurance premiums of any State in the Union. For 
example, the average employer-sponsored insurance premium for a family 
in New Mexico in the year 2000 was $6,000. By 2006, that had almost 
doubled to $11,000 for a family of four. By 2016, the expected increase 
goes to an astonishing $28,000.
  In addition, this third chart highlights the health insurance 
premiums and the percentage those premiums represent of the income of 
the average New Mexico family. It is higher in my State, unfortunately, 
than in any other State in the Union. Today, 31 percent of a family's 
income is going to pay for health care. That is for the folks who have 
coverage today in New Mexico. That is expected to grow to an astounding 
56 percent. Over 56 percent of a family's income is expected to be 
consumed just paying premiums for health care by 2016. That is totally 
unsustainable and unaffordable.
  The health reform proposal that has been developed by the majority 
leader, based on the work of the Finance and HELP Committees, intends 
to slow the growth of health care costs around the Nation. The 
nonpartisan Congressional Budget Office forecasts that the legislation 
would not add to the Federal deficit. In fact, it would reduce the 
deficit by $130 billion by 2019 and by more than $400 billion by 2029.
  Most experts believe these reductions also will drive down the cost 
in the private health insurance market. Thus this legislation is 
critically important to my State because it will help to curb increases 
in health care costs for all New Mexicans.
  Let me show you a fourth chart. This one is a chart based on--I guess 
this is data from the Census Bureau. It is a chart that was developed 
by the Commonwealth Fund. It is the percent of adults ages 18 to 64 who 
are uninsured by State. It has two maps shown on it. The first is for 
1999 through 2000 and the second is 2007 through 2008.
  You can see what has happened just in that relatively short period. 
In 1999 to 2000, there were two States that had more than 23 percent of 
its population uninsured, and those two States were Texas and New 
Mexico. The only State in the Union that has a higher uninsured rate 
than we do in New Mexico is Texas. That was the case then, in 1999 
through 2000. It is still the case today, I would point out.
  But what you can see from this map on the right of the chart for 2007 
to 2008 is that many other States--particularly the States shown in 
dark blue across the South and California--many other States have 
joined the ranks of States that have over 23 percent of their 
population uninsured. Their aged 18-to-64 population was uninsured. 
This is a very serious problem.
  I think my State has the lowest rate of employer-sponsored insurance 
in the Nation. We also have the highest rate of uninsured among 
employed individuals in the Nation.
  Let me show you this next chart, this fifth chart I have in the 
Chamber. This is a pie chart that shows what the current status of 
folks in New Mexico is. I know it is difficult to read from a distance, 
but let me explain what it is.
  We generally think of most people having private health insurance 
coverage. In New Mexico, 38 percent of our population has private 
health insurance coverage. So it is not a majority; it is 38 percent. 
We have 14 percent who are covered by Medicare. We have 22 percent who 
are covered by Medicaid and the Children's Health Insurance Program. We 
have 4 percent who are undocumented immigrants in our State, estimated 
at about 80,000 individuals. They do not have coverage

[[Page 28637]]

today, and they will not have coverage once this legislation becomes 
law, if we are able to pass this legislation and the President is able 
to sign it.
  Then this large red area shown down here at the bottom of the chart 
is 22 percent, and that represents individuals who have no coverage, 
excluding undocumented immigrants. So we have the undocumented 
immigrants, at 4 percent. Then we have 22 percent without coverage. 
These are folks who are here legally. Most of them are citizens. They 
do not have coverage. This gets back to the point I was making before 
about people's premiums today are covering not only the cost of their 
own health care needs, but they are covering the cost of the 
uncompensated care that is provided to this large red wedge of people 
shown down here on the chart. So it is a serious problem that needs 
attention.
  New Mexico will benefit from this legislation in very important ways. 
The legislation will provide new Federal tax credits for private 
insurance, and it will also expand the Medicaid Program for individuals 
with incomes of up to 133 percent of poverty.
  This is a very important provision for my State: It is projected that 
insurance market reform and Federal tax credits may reduce the cost of 
coverage in the individual/private market for the average family in my 
State by as much as 40 percent. So this last chart tries to take the 
previous information and say what would likely occur by 2019--10 years 
from now--if, in fact, we are able to enact this legislation.
  You can see what the two biggest changes in the legislation are. The 
green wedge in the pie chart shows that we will have more people 
covered by Medicaid and CHIP. We would have 29 percent rather than the 
22 percent we had before. It shows we will have many more people 
covered by private insurance. I believe for the first time in the 
history of our State, we will have over 50 percent of our population--
exactly 53 percent is what is estimated--who will be covered by private 
insurance and have an insurance policy they can depend upon.
  So this would still leave undocumented immigrants--which is still 
estimated to be 4 percent of the population--without any guaranteed 
source of coverage. But we would have about 124,000 New Mexicans newly 
eligible for Medicaid coverage, and covered by Medicaid, we would hope. 
We would have an additional 238,000 New Mexicans who would be eligible 
for private coverage through the exchange or from their employers if 
their employers chose to provide that coverage.
  We will have a lot of opportunity over the next few weeks to debate 
particular parts of this legislation. I look forward to that debate. I 
think the more the American people understand what is in this 
legislation, the more wholeheartedly they will support us moving ahead 
and enacting this legislation.
  This debate has been a long time in coming. In the 27 years I have 
been in the Senate, we have not gotten to this point previously, where 
we were beginning a serious debate that might actually result in the 
passage of legislation, major comprehensive reform legislation. But I 
think we are to that point.
  This is legislation that is currently available for anyone to review 
on the Internet, and I encourage people to do that. I encourage people 
to study the issue and follow the debate. As I say, the more people do 
study the issue and follow the debate, the more people will conclude 
this is worth doing, this is important to do.
  So I very much urge my colleagues to rally around this effort. I 
hope, frankly, we will get some Republican support for this 
legislation. I think it is very unfortunate we are going into this 
debate with reports that all Republicans are agreeing to oppose health 
care reform. That is not the way to move our country forward. If there 
are amendments they would like to offer, obviously, they will have 
every opportunity to offer those, and some of them may prevail.
  That certainly was the case in the Finance Committee when we marked 
up the legislation. That certainly was the case in the HELP Committee 
when we marked up the legislation. Amendments were offered from 
Republican members, and some were adopted. But to just say no, to just 
say: We are opposed to reform, is not a good option. I think the 
American people deserve better than that. I hope we will have a 
serious, substantive discussion about what the elements of health care 
reform should be.
  I compliment the majority leader for putting together a very credible 
proposal that will move this country very far toward meeting the health 
care needs of all Americans. I hope by the end of this year we are able 
to enact that legislation or pass it through the Senate and go to 
conference with the House of Representatives.
  Mr. President, I see my colleague is in the Chamber to speak on this 
issue, and I will yield the floor at this time.
  The ACTING PRESIDENT pro tempore. The Senator from Ohio.
  Mr. BROWN. Mr. President, I appreciate following Senator Bingaman. 
Senator Bingaman perhaps knows more about this issue than anybody in 
the Senate. He was the only Democratic Senator to be on both committees 
that wrote this bill and did such great work both in the Finance 
Committee and the Health, Education, Labor, and Pensions Committee.
  I would follow up his words by pointing out that this process--I was 
on a C-SPAN show this morning, and I heard the previous Senator who was 
on the show, a Republican, say this bill was written behind closed 
doors and that it is a partisan bill.
  I went through this process, as did the Acting President pro tempore 
from Oregon, and we sat through 11 days of markup in the Health, 
Education, Labor, and Pensions Committee--all televised, all public, 
with hundreds of amendments. We accepted 160 Republican-sponsored 
amendments. The Senator from Oregon and I and Senator Bingaman and 
Senator Murray, also on that committee, voted for most of those 160 
amendments. This bill had a lot of bipartisanship.
  But on the big issues, the issues such as the public option, such as 
issues on how we are going to pay for it--some of the big issues--there 
is a clear philosophical disagreement. We can go back to 1965, when 
Medicare passed. Republicans opposed it in those days because they had 
a different view of the world. Their philosophy is government will 
never do anything right. Our philosophy is Medicare has been a pretty 
darn good program and has lifted a whole lot of seniors out of poverty, 
and so has Social Security. Medicare, in fact, has given people longer, 
healthier lives as a result.
  So this issue is not so much partisan--although my friends on the 
other side of the aisle made it that--it really is a difference in 
philosophy. They wanted to continue--my friends on the other side of 
the aisle pretty typically do the bidding of the insurance industry. We 
cannot have health care reform and do it the insurance companies' way 
or there will be no health care reform.
  We stood on the Senate floor--Senator Merkley and I, and Senator 
Kaufman and Senator Whitehouse and Senator Tom Udall and others--
talking about some of the things insurance companies have done, such as 
having preexisting condition exclusions, where someone who has an 
illness cannot get insurance.
  When I was on the C-SPAN show today, a gentleman from Indiana called. 
He is 63 years old. He has a preexisting condition, and he cannot get 
insurance. He has 2 years to wait to get on Medicare. But he knows when 
he is on Medicare, Medicare will not take away his coverage, exclude 
his coverage because of a preexisting condition. Neither will the 
public option exclude him from coverage because of a preexisting 
condition.
  But you know Cigna does, you know Aetna does, you know WellPoint 
does, you know Blue Cross--the insurance industry so often excludes 
them because of a preexisting condition. That is why they can afford to 
pay their CEO at Aetna $24 million a year. That is why insurance 
company profits have gone up 400 percent over the last 7 years--because 
the insurance companies deny care for so many people, so

[[Page 28638]]

they cannot get covered, they cannot get insurance. Then they turn down 
so many claims. Thirty percent of insurance company claims are turned 
down initially by the insurer. So even if you eventually appeal and get 
your claim covered, get your claim paid for from the company that you 
have paid premiums to--if you ultimately get your claim paid for--why 
should you have to get on the phone day after day and call your 
insurance company and complain and complain and cajole and persuade and 
finally get it paid? That is not how our reform will work. That is not 
how the public option will work.
  Mr. President, I know Senator Murray is here to speak in a moment. I 
just want to, as I have done many times on the Senate floor in the last 
3 months, share three or four letters from Ohioans who have written me 
about this health insurance bill. What has come through in these 
letters I have gotten is a couple things--or maybe three things.
  No. 1, I have found that most of the people who have written these 
letters--if I met them a year ago and asked them: Are you satisfied 
with your health insurance, most of them would have said: Yes. But then 
something happened. They lost their job or they got sick, and it was 
very expensive and they lost their insurance because they got cancer or 
they had a child born with a preexisting condition. They cannot get 
insurance. So they once were happy with their insurance--until they 
needed it. That has happened too many times.
  The second thing I see over and over in these letters from the 
people--similar to the man from Indiana I mentioned earlier--is people 
who are 61, 62, 63 years old, maybe 59 years old, who are sick or they 
are not sure about their health and they cannot get insurance, they 
just say: I wish I was 65. I cannot wait until I am 65 so I can get 
covered because I know Medicare is stable and will not cut me off their 
plan.
  What kind of health care system do we have when a 61-year-old writes 
a letter to their Senator saying: I cannot wait until I am 65 so I have 
health care protection, I have health care security? There is something 
wrong with that. We fix that too.
  The third thing I hear in these letters--then I will read them 
briefly--is people call for the public option because they know a 
public option will help them, will help discipline insurance companies 
and make them behave, make them more honest. The public option will 
save money because they will compete.
  In southwest Ohio, Cincinnati--in Hamilton and the three adjoining 
counties to Hamilton: Clermont, Warren, and Butler; those four 
counties--two insurance companies in those four counties control 85 
percent of the insurance policies. Obviously, with that lack of 
competition, the quality is low and the cost is high for that 
insurance. Injecting a public option will inject confidence. The 
existence of a public option will inject competition and make those 
insurance companies work better.
  This first letter is from Patricia from Hamilton County:

       I am a senior who has been on Medicare for several years 
     now. I also have a supplemental insurance plan with 
     reasonable premiums and copays, but that has continued to 
     rise over the last two years. Therefore, I don't have any 
     problems accessing the care I need now. However, I have 
     multiple sclerosis and when I was younger and living in 
     another state, I was subjected to the preexisting condition 
     exclusion. Fortunately, I was employed by the state which 
     allowed me to obtain a reasonable health plan. But I know a 
     lot of people are not as fortunate as I am. It is our 
     responsibility as citizens to make sure all of our people 
     have good health care coverage. A public option is essential 
     to making sure this happens.

  Patricia understands the public option will--again, whether you 
choose Aetna, whether you choose the public option, or a not-for-profit 
in Ohio called Medical Mutual, you have that option, and the public 
option is, in fact, an option that will give people that opportunity.
  Joyce from Lawrence County, sort of straight southern Ohio along the 
Ohio River near the Ironton area of the State, writes:

       I have been notified that any Medicare Part D monthly 
     premiums will increase 25 percent in 2010. I simply cannot 
     afford this increase and I need my medications. I am a 
     senior, live on fixed income, and suffer from multiple 
     sclerosis. I do not know how to handle this situation except 
     give up my drug therapy and live with frequent episodes that 
     require hospitalization. I support your efforts for health 
     reform that includes a public option.

  One of the things that will happen under our health care bill is that 
the doughnut hole that keeps people such as Joyce around Ohio and 
around the State and around the country who don't--it means people pay 
so much out of pocket for their prescription drugs coverage, we will 
close--initially, we will close it by half, and we are going to offer 
some four amendments to close the doughnut hole entirely so that people 
don't get hit so hard by drug costs.
  Karen from Morrow County up near where I grew up in the Mount Gillian 
area, sort of north-central Ohio--Karen writes:

       Please vote for health care reform for all that includes a 
     public option. As a middle-aged female small business owner 
     in rural Ohio, I am tired of seeing my community ravaged by 
     the loss of affordable and accessible health care. With a 
     preexisting condition, I have no option but to stay with my 
     present provider and cross my fingers each year on my 
     birthday that I won't be dropped.

  This is a small business owner.
  One of the things we knew right away and that Senator Murray and 
Senator Merkley and I worked on in the HELP Committee was to make sure 
there were good, strong incentives for small businesses to be able to 
afford health insurance for their employees. Whether it is in Olympia 
or Spokane or Portland or Eugene or Cleveland or Toledo, we have all 
been in similar situations where we have small business owners approach 
us all the time.

       I have 20 employees. One of them got cancer. It costs so 
     much for this one employee that they are either dropping my 
     small business coverage or the cost has spiked so much that 
     we can no longer afford it. What are we going to do?

  Our bill will bend the cost curve for them and will give them tax 
credits so they can buy insurance and allow them to go into the 
exchange so they are in a larger pool. So 1 or 2 illnesses in a company 
of 20 or 30 people won't cause the price spikes that a larger pool of 
insurance will be able to blunt.
  The last letter--and then I will turn it over to Senator Murray--is 
from Gail from Belmont County, which is eastern Ohio near St. 
Clairsville, Flushing, that area of the State. Gail writes:

       I am a teacher and my husband is retired. In March 2009 I 
     was diagnosed with cancer and began treatment soon after. I 
     had surgeries, radiation therapy, and chemotherapy. I have an 
     employer based plan, but it doesn't cover the entire costs of 
     some of my expensive drugs which can cost thousands of 
     dollars. How does someone without insurance afford such 
     treatment? The fact is, they can't. I really didn't realize 
     how expensive health care had gotten until I got sick.

  Which is kind of the situation with all of us.

       One of my sons is a veteran and has coverage that way. One 
     son is in college and is still covered under my insurance. 
     But my third son works seasonally and is not covered at all. 
     He had an appendectomy several years ago and the resulting 
     medical bills destroyed his credit. I don't know what will 
     happen if he ever gets sick again. It is not right to leave 
     the poor to flounder without proper medical coverage. It is 
     time to end the greed of insurance and drug companies and 
     have them face fair competition.

  That is really all we are saying here. We want to create a system 
with consumer protections so that insurance companies can't drop people 
for preexisting conditions; can't put a limit on their coverage so that 
when they get sick they lose their insurance; can't discriminate 
against women, whom they usually charge more for premium costs for 
their insurance policies than they charge men; can't discriminate based 
on geography or disability. We want to give incentives to small 
businesses so they can insure more of their employees, and we want to 
bring competition into the system so insurance companies have to 
compete better than they have, driving prices down. That is what this 
legislation does, not to mention a lot in prevention and wellness. 
Prevention is in the bill, which really will help keep

[[Page 28639]]

people out of hospitals and live longer and healthier lives. That is 
our mission.
  This Congress has tried to do this for seven decades. Tomorrow will 
be a historic moment when we vote in the evening to move this bill to 
the floor of the Senate so we can begin this process. It is the most 
important thing professionally I have ever done in my life. I feel 
privileged to have the opportunity to be a part of this and to fight 
for 11 million Ohioans. I know this isn't a bill just for uninsured 
Ohioans; it is a bill to make businesses more competitive, to help 
small businesses, to give consumer protections to those who are happy 
with their insurance and want to keep it, and to help Medicare 
beneficiaries by closing the doughnut hole and bringing some of their 
out-of-pocket costs down so they can live healthier, longer lives.
  Mr. President, I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Washington is 
recognized.
  Mrs. MURRAY. Mr. President, I wish to thank the Senator from Ohio for 
sharing those stories. It tells the compelling reasons why tomorrow 
night's vote to move to this bill is so important, and we are all 
honored to be a part of that.
  After a lot of hard work, it is amazing that our country really is 
now closer than we have been in decades to passing a real health 
insurance reform bill that will help provide our families and our 
businesses with affordable and stable health insurance coverage. There 
is a lot of debate and there is a lot of work still ahead of us, but it 
should not go unnoticed that this is a big moment for our country, and 
you know what. It couldn't come soon enough.
  Our economy is hurting. Americans across the country are so worried 
about keeping their jobs and making their mortgage payments. The last 
stress people need today is to worry about the cost of getting sick or 
being dropped from their insurance plan or opening the mail and seeing 
yet another premium increase.
  Health insurance premiums for families in my home State of Washington 
have more than doubled in the last 10 years, and they are rising at a 
rate that is five times faster than people's salaries. Families and 
small business owners are paying more and more for their coverage, and 
often they are getting less and less in return. These numbers 
demonstrate clearly what families and small business owners across my 
State of Washington understand all too well. The status quo in the 
health insurance system is unsustainable and the cost of inaction is 
just too high for them to bear.
  The news we got back from the Congressional Budget Office on 
Wednesday is encouraging. It shows the American people that our bill, 
our legislation will save money while protecting Medicare, and it 
ensures that families and businesses can take back control over their 
own health care choices.
  If we do not pass this bill, health insurance premiums are going to 
continue to skyrocket. If we fail to act, health insurance companies 
will continue to deny patients coverage simply because they are sick. 
And if we let another year go by without reform, more and more families 
are going to lose their coverage and more and more businesses are going 
to collapse under the growing burden of the cost of health insurance. 
It doesn't have to be this way. We have been talking about reforming 
our health insurance system for a very long time here. Now we owe it to 
the American people to give them more than just talk; to give them, 
finally, the stability and security of a health insurance system that 
will be there for them when they need it and that cannot be taken away 
from them if they get sick or if they lose their jobs.
  Six months ago, I sent a letter to my constituents asking them for 
their stories and their thoughts on health insurance reform, and the 
response I got was overwhelming. I received over 10,000 letters and e-
mails from people across Washington State sharing their health care 
stories with me. Those stories came from small business owners, from 
employees, from moms and dads who told me how they are struggling with 
the cost of care today. So many of them cannot afford the status quo 
and deserve health insurance reform that allows them to keep coverage 
if they like it, gives them additional options if they don't, makes 
their care more affordable, and guarantees, finally, stable coverage 
that cannot be taken away when it is needed the most.
  I have come to the floor many times over the last several months as 
we have worked to put together our Senate bills and I have shared some 
of these stories on the floor. Now that we have a plan on the table, I 
wish to tell two of these stories once more to really demonstrate the 
desperate need for us to move quickly and to get this bill passed.
  Chris Brandt, from Spokane, WA, told me a story about his problems 
finding coverage. Chris told me he is a healthy young man who works for 
a small business that cannot afford to provide coverage to its 
employees, so Chris, as do a lot of Americans, had to find coverage on 
his own through the individual market. He told me that after paying his 
mortgage, his car payment, and his student loans, the only insurance he 
could afford is a catastrophic plan that might keep him out of 
bankruptcy if he gets sick. But even the cost of that plan has 
doubled--has more than doubled in the last 2 years.
  So here is a man named Chris who wants insurance. He doesn't want to 
be a burden to anybody else if he gets sick, but he cannot keep up with 
the rising cost. We have to have a system that encourages people such 
as Chris to get high-quality insurance that covers preventive care so 
that those small, inexpensive medical problems can be treated before 
they become large, expensive medical problems. That is what will keep 
our families healthy, and it will save money in the system in the long 
run.
  I also received a very compelling story from a woman named Patricia 
Jackson who lives in Woodinville, WA. Like a lot of working families, 
the Jacksons told me they have insurance through their employer and 
they pay their premiums each month directly through Patricia's 
paycheck. But also like a lot of our families, the burden of those 
premium payments is rising too quickly. Patricia told me that to care 
for her family of four, she paid $840 a month in 2007--$840 a month. In 
2008, her payments jumped to $900 a month. This year, Patricia paid 
$1,186 a month. Now, before this year is even over, she got a new bill 
and her rates have been hiked to $1,400 a month. That is an increase of 
over 66 percent for her premiums in just 3 years.
  Patricia, not surprisingly, told me she and her family can no longer 
afford to pay this, and she is not alone. Family health care coverage 
rose over 86 percent between 2000 and 2007. That is an increase in my 
State of over $5,600 per family. Wages during that time period only 
grew 16 percent.
  The largest private insurance company in my State sent out a letter 
in August to all of the people who get insurance through them and told 
them they were raising rates by 17 percent--17 percent. Some of my 
small business owners are telling me premium increases are going up 40 
percent. This makes families and businesses have to make choices about 
what they can pay.
  Families are really struggling today in this tough economic climate. 
It is the worst since the Great Depression. They cannot afford these 
cost increases. So the bill we are about to bring to the floor will 
finally--finally--make insurers compete for the business of the 
American people. That is what families and small business owners in my 
State and across the country want and need, and it is what they 
deserve.
  The bill we are going to bring before the Senate will make health 
insurance more stable. It will end the unfair and deceptive insurance 
company practices such as cherry-picking and cancelling coverage 
because of preexisting conditions. It is going to reward what works in 
this system and change what doesn't. Finally, it will start reining in 
those costs so that health care can become more affordable. It is going 
to allow people such as Chris to get high-quality coverage, and it is 
going to rein in the costs for people such as Patricia.

[[Page 28640]]

This is more important now than ever before as our economy struggles 
and the cost of that care continues to rise.
  We have been talking about health insurance reform for a long time, 
and while we were talking, families and small businesses have suffered. 
It is now time to end the politics and end the partisanship and come 
together to bring our families and our small business owners the health 
insurance reforms they deserve.
  As we move forward in this debate, I am going to be working very hard 
to make sure that the needs and priorities of Washington State families 
and businesses are preserved and that we move forward in a way that 
ensures that the future health of our families and the strength of our 
economy is there. So I urge all of our colleagues to work with us now 
in a very constructive way over the next several weeks as we debate 
this bill. and to rise above the partisanship. Let's make health 
insurance work for our families, our economy, and for our country. That 
is what this debate is about.
  Mr. President, 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. DURBIN. Mr. President, 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. DURBIN. Mr. President, we gather on the floor today at a time 
that is historic. It is hard to imagine, to put it in the appropriate 
context, but this debate over health care reform is remarkably similar 
to the national debate over the creation of Social Security, or the 
creation of Medicare. It is that historic. It affects that many 
Americans and their futures. That is why it is important that all of us 
come forward to understand what this debate is about, the important 
issues that are before us.
  The starting place for those who want to get into it is, of course, a 
Web site in today's technology and reality. The Web site is 
democrats.senate.gov/reform. If you visit that Web site, you will be 
able to see the bill that will be before Congress in its entirety. You 
will have your chance to read it, though it will be challenging. It is 
difficult not having all of the Federal statutes before you. But most 
of it is fairly clear in terms of what we are trying to achieve.
  There have been critics of the bill who have come to the floor and 
argued that this bill should be defeated because it is too long, too 
many pages. They bring to the floor more than a copy of the Senate 
bill; they bring the House bill and the Senate bill and stack them up 
here to say how long this is. Well, of course, we are not going to vote 
on the House bill; it is the Senate bill. That is a bit of an 
exaggeration, but it is a long bill, over 2,000 pages. I won't talk 
about whether it is small or large print, but it is 2,000 pages plus.
  You may ask, why does it take so many words to address this? But wait 
a minute, this is about health care in America. One out of every six 
dollars in our economy is spent on health care. It affects every single 
American citizen, and it will be challenged in court by the health 
insurance companies that want to stop this health care reform. We have 
to make sure this is carefully and well written, perhaps erring on the 
side of adding more language so there is no question as to our intent. 
But that is it.
  The obvious question I ask back to the critics on the Republican side 
of the aisle, who say we should vote against this bill because there 
are too many pages in it, is: Where is your bill? Where is the 
Republican health care reform bill?
  I know that in a few moments--in about 10 minutes--Republican 
Senators will come to the floor to talk about this important issue. I 
welcome that. I wish we could come to the floor at the same time. We 
might get close to something called ``debate,'' which would be an 
interesting phenomenon in the Senate, as it is something we have gotten 
away from. When they come to the floor, I hope the first Senator who 
stands up will do what I did. I hope the first Republican Senator will 
read a Web site where the American people can go to to read the 
Republican health care reform proposal. Again, ours is 
democrats.senate.gov/reform. What is the Republican Web site? Where can 
we find the Republican bill? I know the answer. There is no Web site 
where you can find the Republican health care reform bill--at least not 
today. I hope it will come soon. They have spent their time criticizing 
our efforts to change this system. That is healthy in a political 
system like ours, but at some point criticizing isn't enough. Stand and 
tell us what you are for, what you are going to propose.
  If we start moving on this, as we expect to tomorrow, the procedures 
will take us to the consideration of the Senate Democratic amendment 
offered by Senator Harry Reid. I want to suggest and heartily recommend 
to the Republican side of the aisle--I see my friend, Senator John 
Barrasso, of Wyoming, who is here. He is a medical doctor, an 
orthopedic surgeon. We are friends. We may disagree on this issue, but 
we agree on many other issues. I hope he will encourage his leadership 
to produce a bill, show us what they believe. It would even be good if 
they send it to the CBO, as we did, and let us know what it would cost 
for the Republican plan for health care reform.
  I will tell you what we have received from the Republican side of the 
aisle. It is three pages long. If you are looking for brevity, it is a 
very brief analysis of the health care reform issue in America. It is a 
press release from Senator Mitch McConnell, where, as of yesterday, 
Senator McConnell laid out everything--maybe not everything but most of 
the things he thought were wrong in the Senate Democratic approach. It 
is all negative. There is not one positive in here in terms of what the 
Republicans would do. Are they sensitive to the reality of health care 
in America today? Do they know the cost of health care insurance 
premiums have gone up three times faster than wages, that fewer 
businesses are offering health insurance coverage to their employees, 
and that more and more Americans have no health insurance protection 
because of unemployment and because of the cost of health insurance 
today? Are they aware that two out of three people filing for 
bankruptcy today are doing so because of medical bills--two out of 
three--and that 75 percent of them have health insurance that isn't any 
good? And they are in bankruptcy court. Are they aware of this cost 
challenge? If so, what will the Republicans do about it?
  They will show us a stack of paper that Senator Barrasso will show 
when he speaks, but they won't show us the Republican alternative. What 
is it? How much does it cost? How many people will it cover?
  I hope my friend from Wyoming is the first Republican Senator who 
will come to the floor and join us in at least saying there is one 
thing we agree on--that health insurance companies are running 
roughshod over consumers and families of America. I hope this Senator 
from Wyoming, and other Republican Senators, will say there is one 
thing we can agree on with the Democrats: We should stop these abuses 
by health insurance companies. We should not allow these health 
insurance companies to turn you down for a preexisting condition when 
you get sick. We should demand that the health insurance companies 
cover our children beyond the age of 23.
  My wife and I have been through this with our kids, and a lot of 
others have, too. Here comes your son or daughter, fresh out of college 
and looking for a job--oops, he or she is 23 years old, so now they 
need their own health insurance. Our bill moves that age to 26. Could 
the Republicans endorse that idea? It would be great if they did.
  Would they endorse the idea that your health insurance would stay 
with you if you lose your job, and that we should not put caps on the 
coverage of a catastrophic illness so it won't wipe out a family? I 
hope they will join us in health care reform.
  Of all the criticisms, I have yet to hear the first Republican 
Senator take

[[Page 28641]]

on the health insurance companies. That is what this battle is about. 
Who will win? Will it be the American people or the health insurance 
companies? I hope our friends on the Republican side of the aisle will 
join us in saying that it is clear it will be the American people.
  Finally, this bill will expand coverage to 30 million more Americans. 
How many more Americans will be covered by the Republican health care 
reform plan? I am sorry to say I can't tell you. No one can tell you, 
because they have not produced a plan. We don't know what they are 
planning on doing.
  This bill we are bringing before the Senate tomorrow for a procedural 
vote and to start the debate is a bill that is not perfect. I would 
have written it a lot differently. But it is a bill that we are working 
toward a working majority on. That means concessions. Some of these 
concessions are painful, from my personal point of view, but they are 
necessary. It would be great to have one Republican Senator cross the 
aisle tomorrow night and say, all right, I may not agree with 
everything in your bill, but I do believe this is an important national 
issue; the Senate should debate it, and this Republican Senator will 
join the Democrats in saying let's proceed to the issue, proceed to the 
debate. I don't think that is too much to ask. In fact, I think most 
Americans would say: Why wouldn't they want to debate it? Tomorrow 
night, they will have a chance to vote on that cloture motion on the 
motion to proceed to that debate. I hope they will join us at that 
point.
  I will address one particular issue raised by one Republican Senator 
yesterday. Senator Coburn of Oklahoma, a medical doctor, said of the 
Democratic health care reform bill that there is a 5-percent tax on 
cosmetic surgery. He went on to say that this bill would cover breast 
reconstruction surgery after a mastectomy--in other words, imposing a 
tax on a surgery for breast reconstruction. I want to respond to him 
and say he is wrong and inaccurate. I want to make sure the record is 
clear. The bill we are proposing says the surgery is not a cosmetic 
surgery if it is ``necessary to ameliorate a deformity arising from, or 
directly related to . . . disfiguring disease.'' That is in the bill.
  The bill points to the current definition for deductible medical 
expenses for the interpretation of this language. The IRS has already 
dealt with this. IRS publication 502 specifically states that breast 
reconstruction surgery following a mastectomy for cancer is deductible. 
It is clearly not taxable under our bill.
  That statement on the floor by Senator Coburn was inaccurate. I 
wanted to make that clear. The Senator was mistaken. Breast 
reconstruction surgery is not elective cosmetic surgery for the purpose 
of this bill and is not subject to the bill's 5 percent excise tax on 
elective surgery.
  I know we have a limited amount of time before the other side of the 
aisle has a chance to speak. I will save my remarks I had planned 
relating to some people in my home area back in Illinois, who are 
battling health insurance companies. On the Senate floor, I told the 
story of Danny Callahan, a baseball coach at Southern Illinois 
University who is fighting cancer. WellPoint has turned down the drug 
he was using, which his doctor recommended, to fight cancer and said 
they won't pay for it. It is a good drug for him, but it is expensive. 
It stopped the spread of cancer. His doctor said this drug works, but 
the health insurance company won't pay for it. The drug costs $12,000 a 
month. Danny Callahan cannot afford that. He will get a couple more 
treatments, but that is it. At the first of the year, the health 
insurance company is cutting him off from this lifesaving drug that is 
attacking the cancer in his body. They made that decision. His doctor 
said it was the wrong decision. He is another of many Americans who are 
at the mercy of the health insurance companies when you need help the 
most.
  Can we change this? Can we give the American people a fighting chance 
when it comes to these situations? I think we can. But we won't do it 
by saying no. That is what we have heard from the other side of the 
aisle--no to everything. I hope that after 11 o'clock today, on Friday, 
November 20, the first Republican speaker will say: Here is the 
Republican health care reform bill. You can find it on the Web site. 
You can read it and compare it to the Democrats' bill. Again, the 
Democratic version is available at democrats.senate.gov/reform. Read 
it.
  The ACTING PRESIDENT pro tempore. The majority's time has expired.
  Mr. DURBIN. Mr. President, I am looking forward to reading their 
bill.
  I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Wyoming.
  Mr. ENZI. Mr. President, I ask unanimous consent that the Republican 
Senators, during their hour, be permitted to engage in a colloquy with 
fellow Republican colleagues.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. ENZI. Mr. President, I rise to talk about the health care reform 
bill. This country needs health care reform. The status quo in health 
care is unacceptable. Health care costs are skyrocketing, insurance 
premiums are increasing, and too many small businesses can no longer 
afford to offer health insurance to their workers. No one on either 
side of the aisle denies we need health care reform.
  We need to enact reforms to bring down costs so everyone will have 
access to quality, affordable health care. We need to take a step-by-
step approach to reduce health care costs and lower insurance premiums 
for individuals and employers. We need to eliminate discrimination 
based on preexisting conditions and ensure that people can take their 
insurance with them from job to job. I support commonsense reforms that 
would achieve all these goals.
  Unfortunately, this 2,074-page Reid bill fails to address these 
issues. Instead, this bill would raise taxes by $493 billion. It would 
cut another $464 billion from the Medicare Program. The bill would 
reduce wages and eliminate the jobs of millions of Americans. It would 
actually drive up health insurance premiums for many more Americans and 
still leave 24 million people without insurance coverage. We need to do 
better than that, and I think we can.
  Our country currently faces one of the worst economies in a 
generation. Our unemployment rate is 10.2 percent, which means there 
are 15.7 million Americans without jobs.
  At the same time, the bill we are debating, or will be debating when 
we actually get to the real thing, would impose $28 billion in new 
taxes on employers. This new tax will eliminate millions of American 
jobs and reduce wages for millions of American workers.
  When employers struggle with extra costs, workers and their families 
feel the impact. American workers depend on a strong economy to create 
jobs that help them feed their families and build their dreams. 
Unfortunately, the policies being pushed by the majority will only make 
it more difficult for America's businesses to hire workers or pay 
current employees more.
  The Congressional Budget Office, health researchers, and nationally 
recognized economists all agree that Senator Reid's new job-killing, 
employer tax will mean one thing: More Americans will be out of work if 
this bill becomes law.
  As I mentioned, this bill will raise taxes by $\1/2\ trillion--$\1/2\ 
trillion. The authors of the bill truly believe the greatest problem in 
our health care system is that we do not pay enough taxes for our 
health care.
  Under this flawed bill, if you take a prescription drug, you will pay 
a new tax. If you use any medical devices or equipment, ranging from 
walkers to wheelchairs, you will pay a new tax. If you do not have 
health insurance, you will pay a new tax. If you do have health 
insurance, you will also pay a new tax. If the government decides your 
health insurance is too expensive, there will be a new tax for that as 
well.
  The problem with our current health system is not that we don't pay 
enough

[[Page 28642]]

taxes. Americans actually want to lower their health care costs--that 
is the message--not just pay more taxes to the Federal Government. All 
these taxes will only increase costs, making health care even more 
unaffordable.
  The third major problem with this bill is it will actually increase 
the cost of health insurance for millions of Americans. The bill 
mandates that insurance premiums for younger, healthier workers be 
tightly tied to the costs for older, sicker individuals. This will 
immediately drive up costs for the young, healthy individuals who, 
coincidentally, make up a significant portion of our current uninsured 
population.
  The bill also eliminates consumer choices, requiring Americans to buy 
richer types of plans that cover more of the deductibles and cover more 
out-of-pocket expenses. These plans typically have much higher 
premiums.
  Taken together, these insurance changes will increase costs for 
millions of Americans. In looking at more modest provisions included in 
the Senate Finance bill, nationally recognized accounting and business 
consulting firms found these changes would increase insurance premiums 
by 20 to 50 percent.
  The practical effect of this bill is, Washington could dictate to 
every single American, even those who have insurance they now like, the 
coverage they would need to purchase. Washington will tell you what is 
good enough coverage. The bill does not give people affordable options, 
and it penalizes those who do not purchase high-end, expensive plans, 
regardless of what they want, need or can afford.
  Before I was a Senator, I was a small businessman. My wife and I 
owned three shoe stores. When I was showing someone a shoe and he said 
he did didn't like it or couldn't afford it, I didn't try another sales 
pitch. I knew it was time to find another shoe, one he liked and could 
afford. If the customer is complaining, get something else to show. The 
customers are complaining. The voices of August are still out there, 
and they know this bill is just more of the same.
  There is a lesson in that story when it comes to reforming health 
care. It is time to listen to our customers and find an alternative 
they want and can afford. The intensity of the country's disapproval is 
apparent in townhall meetings, letters to newspaper editors, citizen 
protests, constituent calls, and letters from all across the Nation. I 
received some of those that said: My Senator is not listening but you 
are.
  I wish to find solutions. Ask most of my colleagues and they will 
tell you, time and time again, I have been known to work across the 
aisle on commonsense reforms on all kinds of issues. I have fought for 
years to enact commonsense reforms that will help slow health care cost 
growth and make the insurance market work better for small businesses.
  I worked closely with Senator Ben Nelson from Nebraska on a bill that 
would allow small businesses to combine their purchasing power across 
State lines, even nationwide, and collaboratively buy health insurance 
at discounted rates.
  I worked closely with the late Senator Ted Kennedy on a bill to 
reform the drug approval process at the Food and Drug Administration.
  I worked closely with then-Senator Clinton on a bill to save lives 
and decrease costs by promoting greater use of electronic medical 
records.
  Time after time, I have advocated that we set partisan differences 
aside and work on the 80 percent of the issue that will make a 
difference for most people.
  Unfortunately, rather than working with Republicans to develop a 
commonsense solution, the majority drafted a flawed bill that spends 
too much, does too little to cut health care costs, and puts seniors' 
benefits on the chopping block.
  The White House and Democratic leaders should have responded to these 
concerns with alternative ideas that actually address the health care 
issues that most Americans care about--their cost. Unfortunately, they 
decided to simply try a more aggressive sales pitch. As a result, 
opposition to it will only continue to grow.
  If this bill continues to move forward, in spite of what most 
Americans are telling us, I am going to keep offering amendments geared 
to bringing down health care costs for American families, scaling back 
total health care spending, and protecting seniors.
  I yield the floor to my colleague from Wyoming who has copies of the 
bills.
  The ACTING PRESIDENT pro tempore. The Senator from Wyoming.
  Mr. BARRASSO. Mr. President, in joining my colleague from Wyoming, he 
and I had a townhall meeting together in Gillette, WY, his hometown, a 
wonderful community. I was just there last week for a Veterans Day 
parade. What Senator Enzi knows and I know is when we talk to the 
people of Wyoming, they want commonsense solutions.
  As I am here with the House-passed bill and the Senate bill we are 
now looking at, people of Wyoming are astonished at the amount of pages 
in this sort of thing, how to deal with this, how to comprehend it. 
What does it mean? What if I like something on page 208 but don't like 
something on page 1,200?
  We ought to be using a step-by-step process. My colleague has a 
wonderful program, a 10-point plan to improve our health care, and any 
one of those would be a positive step to actually helping American 
families, helping them get the health care they would like and they 
need. But not these bills--one through the House, one through the 
Senate.
  I don't know if my colleague wants to join me in discussing the 
townhall meetings, where people said: We want health care reform; we 
want things that are going to make life better but to help keep down 
our premiums, help keep down the cost of our care. Eighty-five percent 
of Americans have health care coverage. They are just not happy with 
the cost. What I heard for the last hour from my colleagues on the 
other side of the aisle is we need to cover more people; we need to 
cover more people. That is only part of it. We need to keep down the 
cost of care for the 85 percent of people who like the care they have.
  That is what happens when we get together with groups of people from 
around the State of Wyoming who come out for our townhall meetings to 
discuss the issues, to listen. We are there mostly to listen; they are 
there mostly to talk.
  I ask my colleague, is that not exactly what we heard: We need 
changes but not this?
  Mr. ENZI. Absolutely and not just townhall meetings. That is how the 
letters, e-mails, and phone calls are coming in, greatly in response to 
what they anticipated they were going to get, which was going to be 
lower costs. They don't mind helping other people to have insurance and 
subsidizing that insurance or in some cases providing it for free. But 
they expected to get something out of it themselves. We miss the mark 
on this. You can tell they missed the mark. The bill that has been 
brought up to be voted on is just a little 2-page bill. Why didn't they 
put up the House bill? Because they couldn't get 60 votes for the House 
bill. They know that is wrong. This is a whole lot different from the 
House bill. It is different. I give them some credit for that. They 
couldn't put this bill up because they can't get 60 votes, and they 
have to get 60 votes to move on to debate.
  They brought up the Service Members Home Ownership Tax Act of 2009, 
which is actually two pages and a summary. So there is not much to that 
bill. Their hope is they can get the 60 votes and people will not 
concentrate on the fact of what is in this bill.
  I appreciate all the efforts of the Senator from Wyoming. He has been 
involved in the health care industry as a provider for a long time and 
a real student of what is in these bills. He has looked at these bills 
in detail, so he knows a lot of the flaws. I appreciate him taking the 
time to point those out.
  Mr. BARRASSO. Mr. President, there are a lot of flaws in these bills 
because what Senator Enzi and I both hear when we go to townhall 
meetings--but also I had a telephone townhall meeting the other day--
is: Don't cut my Medicare. Yet when we take a look at the details of 
these bills, it is going to cut $500 billion--$500 billion--from our

[[Page 28643]]

seniors who depend on Medicare for their health care.
  They also say: Don't raise my taxes. But taxes are going to go up 
across the board. Every family is going to notice an increase in their 
costs, whether through taxes, premiums, an increase in the cost of 
their lives in terms of how it is going to impact the care they are 
going to receive. They say: Don't make my family pay more for health 
care. But across the board, people look at this and say they are going 
to end up having to pay more.
  When Senator Reid brought this bill out, he said: Of all the bills I 
have seen, it is the best. To me, it is the best of the worst bills I 
could ever see. It raises taxes. It is not just me speaking. If you 
read what the people who had a chance to read the bill say--the 
Associated Press, the Washington Post, the New York Times, others 
throughout the country, our e-mails from home--there are higher payroll 
taxes, companies would pay a fee, rely primarily on new taxes, new 
fees, and then cuts in Medicare. It is beyond me that this Senate--that 
this Senate, the Senate of the United States--is ready to tell the 
seniors of this country they are going to cut $500 billion from the 
care these seniors get from Medicare. That is a growing number of 
people. Year after year, more people are on Medicare but yet the cuts 
are going to be there.
  The gimmicks, the budget gimmicks are astonishing. The advertised 
pricetag is an astonishingly large number, over $800 billion. To get 
down to that astonishingly high number, they have used quite a few 
gimmicks. You get taxes, you get Medicare cuts, and then you get the 
gimmicks.
  I visited with Senator Gregg from the Budget Committee earlier today. 
He is going to be on the floor to discuss the gimmicks. One of the 
things they have done is basically hidden the true cost of the bill. 
The true cost of the bill is going to be close to $2.5 trillion over a 
10-year span. They have done it by putting in a whole new program 
called the Community Living Assistant Services and Support Act. It is a 
new Federal long-term care program.
  What happens in these long-term care programs? They take in the money 
early on and then they do not spend it until many years later. But in 
the way they count money around here--they do kind of a 10-year score, 
they call it. For the first 10 years they are going to be taking in all 
of this money, and then when it is time to pay the money out, that 
money is not going to be there anymore because they will have spent it 
on the increased cost of medical care because these bills do nothing to 
get the cost of care down.
  Kent Conrad, Democratic Senator from North Dakota, do you know what 
he called this part of the bill, the Democratic bill on which we are 
going to be asked to vote? He called it a Ponzi scheme of the first 
order. He said it is the kind of thing that Bernie Madoff would be 
proud of. That is a Democrat talking about what is in this bill.
  What has the Washington Post said? ``It's a gimmick. These are not 
savings that can honestly be counted on the balance sheet of reform.''
  Do we need reform? Yes. Do we need health care reform? Do we need to 
change the system? Absolutely. But this is not the way to go.
  Senator Enzi is here. He has done a remarkable job as a member of 
both the Finance Committee and the HELP committee, and he has been part 
of the markups for both of the bills. He has focused relentlessly on 
trying to get the costs down so the premiums for the American people 
will not go up, and he has offered amendment after amendment, and they 
have been rejected time and time again.
  Then Senator Reid gets these two bills--one from the HELP committee, 
one from the Finance Committee--tries to stitch them together behind 
closed doors, and there is an amendment that Senator Enzi had put into 
the bill, one of the bills--it was voted on and approved--and then it 
magically disappeared without the knowledge of any members of the 
committee. It was something intended to help the American people, but 
that got taken out and thrown away in the dead of night.
  I don't know if Senator Enzi would like to comment on that, but this 
is a Senator who was working to improve the lives and health and 
pocketbooks of the American people, and his great idea is thrown away.
  Mr. ENZI. I would like to comment on that, in some way, unprecedented 
action by a committee. We agreed in committee on some amendments. Then 
when the bill was actually printed, which was not done for 2 months--
which was, I think, so people couldn't actually look at it during the 
August recess, during that 2 months--when it was finally printed, some 
of the things that were agreed to were left out. One of the big ones 
was an actual wellness program, one that worked for Safeway, that 
helped cut their cost in the first year by 8 percent.
  Have you heard of anybody cutting their costs in health care? Their 
program did. Since that time it has been held level because of what 
they were able to do with wellness programs. We got that wellness 
program approved. We didn't get much approved when we were doing that 
bill, but we got that approved.
  But when the bill was printed, that was left out. Staff, without 
talking to any one of the Members, had taken it out. I think that is 
unprecedented around here. But that was not the only instance either. I 
would like to direct the attention of Senators to the costs on this 
bill, which the Senator from Wyoming has mentioned. As an accountant, I 
look at those. They say they are going to reduce the deficit in the 
first 10 years and even more in the second 10 years. There are two ways 
they can do that. One of them is to raise taxes. The other is to steal 
money from other people, which is what they are doing from Medicare. 
That, maybe, means they are overtaxing? So that might mean they want to 
stick in some other things that will be spending. Is there anybody out 
there who thinks you can do a $1 trillion new program and it will not 
cost a dime?
  I hope people are taking a look at matters such as the Wednesday 
editorial by the president of Harvard who made some comments about how 
things are working. I hope everybody reads that. This is a good way for 
our Nation to go broke. We are not in very good shape right now, but 
that is a good way to go broke, and there are a lot of gimmicks in this 
bill too.
  I appreciate the Senator from Wyoming pointing that out, and I assume 
the Senator from New Hampshire, who is the chairman--ranking member on 
the Budget Committee now--and has a handle on a lot of these gimmicks 
will share some of those too.
  Mr. GREGG. If I could join this colloquy with my colleagues from 
Wyoming--what a great State to have two such exceptional Senators. 
First off, I want to make this point: Obviously, a lot of folks are 
pointing at this bill which I have right here--the Senator from Wyoming 
has one, and the other Senator from Wyoming has one--because it is 
real. Up until now most of the debate that has been occurring around 
here has been media. A lot of it has been theater. Some of it has been 
good theater, I hope, but it has been theater to a large degree.
  Now we are dealing with something that is extremely real. Every page 
of this 2,074-page bill will have an impact on Americans. Every page of 
this bill will make a decision and direct a policy that will affect the 
health care of every American everywhere.
  It is an extraordinarily intrusive and expensive bill. The Senators 
from Wyoming have been alluding to this, but it really is historic. The 
colleagues on the other side say this is a historic bill. It is 
historic. Never in my experience, and I don't think in any experience, 
has the Congress taken up a bill which is essentially going to 
restructure and fundamentally change the way that 16 to 20 percent of 
the national economy is going to be affected in such an immediate and 
intrusive way.
  Essentially, the Federal Government will affect every decision that 
has to do with health care as a result of this legislation, every 
decision that has to do with health care.

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  The cost this is going to create in the area of increasing the size 
of the government is astronomical. We have heard this number, that this 
is a $890 billion bill. That is pretty big. I suspect that would run 
the State of Wyoming for a few years, maybe a century. I think the 
State of New Hampshire would probably run for pretty close to a 
century--in fact, more than a century, to be honest with you. I don't 
think our budget is $8 billion yet. So that is a lot of money, $800 
billion plus. But that is not the real number. That is a phony number. 
That is a bait-and-switch number.
  That number is arrived at by claiming, over a 10-year period, that 
the programs that are initiated in this bill--which is a massive new 
entitlement--will not start until the fourth and fifth year. In fact, 
the House bill was at least a little more honest than the Senate bill. 
It started in the fourth year. The Senate bill starts in the fifth year 
with most of the spending. But the taxes which the Senator from 
Wyoming, the senior Senator from Wyoming was just talking about, and 
the fees and the reductions in Medicare, they start pretty much in the 
first year.
  So they have taken 10 years of taxes, fees, and cuts in Medicare, and 
they have matched them against 4 or 5 years of actual spending and 
claimed that they are in budget balance and that the bill only costs 
$890 billion--only.
  In fact, CBO has scored this over the real period, when all the 
programs are in place. Over that period, over that 10-year window when 
all the programs are functioning that are created under this bill--all 
of them being Federal programs, brandnew entitlements, extraordinarily 
expensive initiatives--when that occurs, this bill costs, by CBO's 
estimate, $2.5 trillion. In order to pay for that we would have to cut 
Medicare by over $1 trillion. In order to pay for that we would have to 
raise taxes, fees, by over $1.5 trillion. This is a massive increase in 
the size of government, a massive increase in tax burden, a massive 
effect on Medicare.
  The Senator from Wyoming mentioned there are a few gimmicks in here 
on top of the huge gimmick, that it is a bait-and-switch, that this is 
a $800 billion bill when in fact it is a $2.5 trillion bill. There are 
a lot of other games in here that deal with budgeting. I found one of 
the more entertaining ones: the fact they take credit in this bill for 
creating a new program, the CLASS Act, a massive new program, a long-
term care program. They take credit in this bill as that being a budget 
surplus item. How do they figure that out? Because on a long-term care 
program, basically people in their twenties, their thirties, their 
forties, even into their fifties, pay into it. It is like buying 
insurance under this plan, so that money comes into the Federal 
Treasury.
  What they do not account for is when those folks go into their long-
term care facility and the money goes out, the money goes out at an 
incredibly fast rate, and the program balloons radically in its costs. 
They do not account for that. They just account for the years when 
people are paying in, and they claim that as surplus money they apply 
to try to reduce the cost of the bill. So they spend the money.
  This is classic. First, they take in the money and claim it as an 
adjustment against the debt they are running up, and then they spend it 
so it will not even be available to pay for the program they claim they 
are going to fund with it. It is just inconceivable.
  Bernie Madoff is in jail. Whoever thought up this program and scored 
it in this bill, Bernie Madoff would be proud of that person. He would 
say: My type of guy. That is the way you do accounting--fake it.
  It is unbelievable. There are a whole series of these types of games 
in here. The States are going to be taken to the cleaners by this bill. 
The allegation that we are going to expand Medicaid by 20 to 30 million 
people, and the States are not going to end up paying a huge bill as a 
result of that? Absurd on its face. It is absolutely absurd on its 
face.
  More importantly, when we expand Medicaid by 20 or 30 million people, 
the doctor will tell you, back here, the reason Medicaid is in such 
dire straits is because doctors will not see Medicaid patients. Why? 
Because they are reimbursed at 60 percent of the costs. Who pays the 
other 40 percent, by the way, for the present Medicaid recipients? Who 
pays the other 40 percent? I will tell you who pays. Mary and Joe 
Jones, who are working down at the local restaurant who have health 
insurance, they pay it with their premium. Bob and Marie Black, who are 
working over at the local software company, they pay it with their 
health care premium. The 40 percent of Medicaid that is not paid for by 
the government is paid for by people who are in private insurance. 
Their insurance premiums go up because they are subsidizing Medicaid 
reimbursements because the hospitals have to get paid for the cost, and 
they are only getting 60 percent of it from the government and the 
other 40 percent is being picked up by the private sector.
  When we expand Medicaid by another 20 or 30 million people, we are 
inevitably going to drive up the costs of private insurance again. So 
the private insurance policies go up. What does that do? It does what 
this bill is basically intended to do: it will force employers to drop 
private insurance and move people over on to the public plan. That, 
when you get down to it, is what this is all about. This is an exercise 
in having the Federal Government get control over all health care. It 
is being done in an incremental way. They are setting up a scenario 
that will not be immediately apparent to people. But as we move through 
the years it will become apparent because what will happen is the costs 
of private health care will go up so much that private employers will 
start to drop their health care. They will take the penalty, which is 
not that high in this bill compared to what they have to pay in health 
care costs, and move their people, and say: Sorry, I am not going to 
give health care anymore--or never did--and go get this government 
plan.
  Then down the road Congress will change this government plan a little 
bit, and they will start to put price controls in, just like they want 
to do in Medicaid. Basically, that will mean people will get fewer 
products because as you put price controls in you will have less 
innovation, fewer drugs. Fewer devices will be developed because people 
will not be getting a return on their investments because these will be 
price-controlled events.
  You will find delays because that is what happens when you move to a 
government program that controls costs. The government can only control 
cost by controlling price. That creates delays in access which is what 
happens in England and Canada. So the quality of the health care system 
goes down.
  I ask my colleague from Wyoming, who is uniquely qualified to comment 
on this because he is a doctor and he has experienced the problems of 
dealing with Medicaid, is this not a reasonably accurate reflection of 
what will happen if we move another 20 or 30 million people into the 
Medicaid Program? Doesn't that mean that private insurance policies 
have to go up, fewer doctors will see fewer people, and inevitably we 
will end up with a cost shift which forces private insurers to drop 
insurance?
  Mr. BARRASSO. Mr. President, that is exactly what is going to happen. 
No. 1, we will get this huge push of an unfunded government mandate 
onto the States, a mandate that both Republican and Democratic 
Governors have called the mother of unfunded mandates, and they are 
across the board opposed. This is the way that Washington, with its 
wisdom, will say: We keep the price down, but what we will do is make 
the American people pay for it in a roundabout way. The more people you 
have on Medicaid, the program to aid the poor--and we have seen this in 
Massachusetts with their health care plan; there are not enough doctors 
to take care of everyone so the system is swamped, which is why it is 
taking now up to 9 weeks to get an appointment to see a doctor in 
Massachusetts, but also about 40 percent of doctors do not see Medicaid 
patients because the reimbursement rate is so low.
  What you said, 60 percent of the cost, that is exactly right. It 
doesn't cover

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the cost of seeing the patient. We are talking about hiring a nurse, 
turning the lights on, paying the rent on the office, doing all of 
those things, the medical charts, the liability insurance, the whole 
list of the costs of having an office opened. You cannot keep the 
office open if all of your patients are Medicaid patients. As a result, 
physicians--and I saw every Medicaid patient who wanted to see me. My 
partners and I have the same program where anyone can call and get an 
appointment, regardless of the ability to pay. But we know 40 percent 
of the doctors don't see patients on Medicaid.
  Mr. GREGG. If I may ask a question on that point, this is an 
important point. As a practicing physician, if all your patients had 
been Medicaid, would you have been able to pay your bills?
  Mr. BARRASSO. The answer is no. Doctors' offices cannot stay open at 
the rate that Medicaid reimburses, and no hospital in the country can 
stay open if they are getting paid across the board at Medicaid rates. 
You have to have other people who are paying more to make up for the 
underpayment by the government on Medicaid.
  Mr. GREGG. If I might follow up, doesn't that inevitably mean that 
the people who are paying more are in the private sector, which means 
premiums for people in the private sector go up, which means fewer 
people are willing to give that type of coverage because the cost is 
too high for the business to cover; right?
  Mr. BARRASSO. The people who have private insurance end up paying 
more for their insurance premiums to help make up the difference 
because the government has across the board been the greatest deadbeat 
payer. Washington is a deadbeat when it comes to paying for health care 
costs, both for Medicare as well as Medicaid across the board. That has 
been the long tradition of Washington and health care. The other people 
who are penalized under this situation are people who have no health 
insurance, because they are being charged at a higher rate. The person 
who works hard and says, I will kind of self-insure in case something 
happens, I get sick and I have to pay the full bill, they pay the full 
bill to cover themselves as well as more to help for the underpayment 
done by Washington.
  That is how, when you have more and more people on the Medicaid 
rolls, more and more people forced onto that through Washington's 
wisdom, it is going to be harder on people who have insurance through 
their jobs. Insurance premiums, for people who have insurance and like 
their insurance, those rates are going to go up. It is going to make it 
harder for American families and for small businesses that want to hire 
someone, because the rates of insurance will go higher. It will make it 
harder for small businesses to provide health insurance for their 
workers, and those who continue to provide health insurance will not be 
able to give raises because the costs are going to go up.
  This whole approach to health care reform was supposed to be designed 
to help keep the cost of care down. That is what the President and the 
Senate promised all through the year. But it does not. It drives prices 
up.
  When I hear my colleague from New Hampshire talk about all of the 
gimmicks being used in an effort to claim this is a good bill, I refer 
to this morning's column ``Health Bill Hoax.'' Only Bernie Madoff could 
believe the Senate's health care bill will expand coverage to 31 
million while cutting the deficit by $127 billion over 10 years. It 
would be the first profitable entitlement. Kind of like when the 
President of the Senate, at an AARP townhall meeting this year, said: 
We have to spend money to keep from going bankrupt. On its face, we 
know how absolutely ridiculous that sounds. You can't do that. This is 
an incredible expense: taxes galore, all over the place. The word 
``tax'' is used in the Senate bill 183 times; ``taxable,'' 164 times; 
``taxes,'' 17 times; ``fee,'' 152 times; ``penalty,'' 115 times.
  For people who believe this will keep down the cost of care, it will 
not. As my colleague from Wyoming said earlier, I advise Members to 
take a look at an editorial by the dean of Harvard Medical School, 
living in a State where they have the Massachusetts health care plan, 
which is government-forced insurance, government-mandated care, 
government-run care. According to the dean of Harvard Medical School in 
an editorial this week, the health debate deserves a failing grade. The 
plan is wrong and those who support it are living in collective denial. 
This is what is wrong with this. This will markedly accelerate national 
health care spending rather than restrain it. It will do nothing or 
little to improve the quality of care.
  That is what we started with at the beginning--to improve quality, 
improve access, and lessen the cost. What we have is a bill which, if 
passed into law and signed by the President, will decrease quality, 
increase cost, and lessen the access of Americans to health care 
providers.
  I appreciate my colleague's comments. The numbers are so high. These 
are staggering figures. How do you communicate to the folks back home 
how astonishingly large these numbers are? Because people say: We do 
want you to fix things, but don't cut Medicare, don't raise our taxes. 
Drive down the cost of medical care. Improve access to providers. 
Create more choices. As I look at this, to me this is going to mean 
higher health insurance costs, higher taxes, Medicare cuts and then, 
unfortunately, more government control over health care decisions.
  Mr. GREGG. I thank the Senator from Wyoming. He has a unique 
perspective which we should listen to, as a practicing physician for 
how many years?
  Mr. BARRASSO. I have 24 years practicing orthopedic surgery, taking 
care of the families of Wyoming.
  Mr. GREGG. That is impressive. He understands this whole issue and 
the point on cost. It is very hard to conceptualize that this is a $2.5 
trillion bill when honestly scored. When honestly scored, it is a $2.5 
trillion bill.
  This page right here, page No. 1, cost the American people $2 
billion. You could pick almost any page in this bill. And I don't think 
they are worth $2 billion a page. This page here, what does that say? I 
don't know. I am just picking this out: Transfer to the Secretary of 
Treasury a list of individuals who are issued a certification under 
subparagraph (h), including the name and taxpayer identification number 
for each individual, the name and taxpayer identification number of 
each individual who was an employee of an employer but who was 
determined to be eligible for the premium tax credit under section 
36(b) of the Internal Revenue Code of 1986 because, A, the employer did 
not provide essential coverage, and B, the employer provided such 
minimum essential coverage, but it was determined under section--and on 
it goes--section 36 (b)(c)(2)(c).
  I don't understand what that said. We now will have about 72 hours to 
figure it out. But I know this much: When a bill costs $2 billion a 
page and when it includes language such as that, it is something we 
should spend some time on. This bill is being rushed. It should not be 
rushed. This vote that will occur tomorrow at 8 o'clock at night, after 
having this size of a bill on our desks for less than 2, 3 days, is 
very serious. We are firing real bullets here. This is no longer 
theater. It is no longer political media. This is the passage of a 
piece of legislation, the potential passage of a piece of legislation. 
Tomorrow's vote is a critical vote because it basically will mean we 
are on the road to passage. In fact, 97 percent of the bills that come 
to the floor of the Senate under a motion to proceed pass.
  So this piece of legislation is serious. It is real bullets at $2 
billion a page. Tomorrow's vote is something we need to look at as a 
vote that is not some sort of a procedural vote. It is a substantive 
vote on whether we are going to fundamentally change the way health 
care is delivered, cause the size of this government to grow by 
trillions and trillions of dollars, and put the Federal Government 
virtually into every decision that has anything to do with health care. 
With the way you choose a doctor, the way you get your insurance, with 
the type of procedures you get, with the type of drugs you can obtain--
the Federal Government will

[[Page 28646]]

be involved. How much it costs, the Federal Government will be 
involved. And with the type of debt that will be passed on to our 
children. This bill will play a major role.
  Remember something about the Federal Government: Once you give the 
Federal Government power, you don't get it back. This bill is all about 
moving power here to Washington. That is what this legislation is 
about, about centralizing the decision process, the national decision 
process on health care. In the end, the goal, as openly stated by some 
of my colleagues on the other side of the aisle--and I appreciate the 
fact that they are forthright--is to have a single-payer system where 
the government essentially runs health care top to bottom, much as it 
does in Canada and England. I believe that fundamentally undermines 
quality and is fundamentally unaffordable. It passes on debt to our 
kids which we obviously don't want. In the process, it will take 
Medicare, which is already in serious trouble--there is already a $55 
trillion unfunded liability in Medicare--it will take Medicare's 
problems and aggravate them dramatically. To the extent savings are 
taken out of Medicare and used to create this new entitlement, which 
has nothing to do with Medicare or Medicare recipients but is going to 
be funded by Medicare both on the tax side with the HI tax in here and 
in the cuts in Medicare benefits with the elimination basically of 
Medicare Advantage, all of that is Medicare money that should be going, 
if you are going to do those things, to making Medicare more solvent 
for seniors, not to creating a new entitlement.
  I see the Senator from North Carolina wants to jump in here.
  Mr. BURR. I thank my colleagues from New Hampshire and Wyoming. Let 
me say on the same note, an $800 billion-plus bill, when you ask 
anybody in America, do you think this will increase the deficit, 
everybody's hand goes up. But the claim is that this is deficit 
neutral, that there is no no continuation of increasing the debt. Let 
me pick three areas, one you were just talking about, Medicare. This 
bill proposes that we shift $464 billion over 10 years to pay for this 
new program.
  Mr. GREGG. Fully phased in, it is a trillion dollars.
  Mr. BURR. But in that 10-year period, if you took Medicare, the 
proposal to shift over, if you face the reality that we will not cut 
doctor reimbursements 23 percent, which is another $246 billion worth 
of revenue, and the creation of a new program called the CLASS Act 
actually has people paying in for 20 years before the first person 
might take out a benefit, those three items alone come to $700 billion 
of the $800 billion we are paying for it with. Most Members would agree 
there are cuts that probably will never happen. On the face, it says it 
is going to contribute to the deficit. It will continue to add to the 
deficit at greater numbers, as the ranking member of the Budget 
Committee has stated.
  But let me try to point out something I know my colleagues 
understand. This is a bill about coverage expansion. This is not a bill 
about health care reform. There are very few reforms, if any, in this 
bill. The Senator from Wyoming was talking earlier about Medicaid. One 
of the fundamental reforms that has to be made in health care is that 
we have to eliminate cost shifting where an individual who is uninsured 
goes in, receives a service, does not pay, and the cost is shifted to 
the private side, with people who pay out of pocket, people who have 
insurance. For the underinsured, the person goes in and receives a 
service, but the reimbursement is less than the cost of the service, 
and what is left over is shifted. Usually that is where the debate 
stops.
  But under Medicaid, the current system, we reimburse 72 cents of 
every $1 provided, meaning 28 cents is shifted to the private pay side, 
out-of-pocket and insured side. In this reform package, we are 
increasing the rolls of Medicaid by 15 million Americans. We are taking 
a program today where, if the attempt is to eliminate cost shift--which 
it should be in health care reform--we would be eliminating Medicaid 
and we would be putting the Medicaid beneficiaries in a program that 
actually provided them a medical home, provided them an opportunity at 
prevention, wellness, and chronic disease management.
  But, no, we are keeping Medicaid intact. And in the bill it says to 
the States: You cannot change your program. You have a maintenance of 
effort. You may find a more efficient way to do it, but if that 
efficiency means you are cutting any benefit, you are asking them to 
select where they choose health care differently, you cannot do that, 
States. We are locking you in for 10 years. And we are going to 
increase the rolls in Medicaid by 15 million Americans. We are actually 
exacerbating the problem we are trying to solve, which is, either 
shifting from people who do not pay or where there are reimbursements 
that underreimburse for a service. We are increasing the rolls by 15 
million Americans.
  Forget the fact, as the good doctor from Wyoming knows, that when you 
lock them into Medicaid, you have locked them out of having a medical 
home. You have locked them into a system that is there to treat them 
when they get sick and not to spend a dime on trying to keep them well. 
The truth is, health care reform, in large measure, is about our 
ability to change the lifestyles of the American people so we make 
healthier choices.
  In part, you do that by creating a medical home. It is the reason 
most of us, if not all of us, have argued that everybody should be 
covered in some fashion. Health care should be accessible and 
affordable. The debate is over: where and what type. And, more 
importantly, should the American people have the ability to have 
choice? Should the American people have the ability to construct a 
health care plan that meets their age, their income, and their health 
conditions?
  What we are doing is, we are taking on a one-size-fits-all government 
approach to say: If you do not like what is out there, we are not going 
to let what is out there change. We will give you an option, and it is 
to be insured and to be managed and to be run by the Federal 
Government.
  I am not sure how others in other States have found it. In North 
Carolina, it has been overwhelmingly rejected by the population. I 
daresay, I think we have the greatest health care delivery system in 
North Carolina, both public and private, some based in academia. I 
think what North Carolina says is: Do not hurt my quality of care. If 
we are going to talk about reforms, let's talk about how we increase 
the quality of care, not decrease it.
  Unfortunately, this misses the boat on reform. It is the most 
expensive approach to coverage expansion that anybody could ever 
imagine. The question is, if we took some time, if we worked in a 
bipartisan way, could we find a way to do this more efficiently and 
more effectively for quality of care, where the outcome was different?
  This is a town obsessed with process, as my colleagues know. This is 
a product where we should be focused on outcome, not process. Because 
at the end of the day, there is an American family who is going to be 
the recipient of the rules, the regulations, and also the outcome of 
what this produces.
  Mr. GREGG. The Senator has made a very good point, which is how you 
do health care correctly. You do not create a massive new Federal 
entitlement. You do not spend $2.5 trillion we do not have. There are a 
couple things you could do, though, on a step-by-step basis.
  One of them--and I would be interested to know if the Senator 
understands why it is not in here--one of them is to correct lawsuit 
abuse. It is estimated $250 billion a year of medical expenditure is 
defensive medicine which doctors order and hospitals undertake simply 
to avoid the potential of a lawsuit being filed. CBO estimates it would 
be a $50 billion savings if we would adopt the proposals they use in 
Texas, California. That is one approach.
  Another approach would be to allow employers to pay employees more 
who live healthy lifestyles, such as employees who stop smoking or 
employees who get the tests they need--whether it is mammograms or 
colonoscopies--

[[Page 28647]]

when they should have them or employers who live healthy lifestyles and 
lose weight. Under the bill that is not allowed, other than what 
present law is, which is very restrictive. That would save a lot of 
money, by the way.
  The first proposal, as I understand, was opposed by the trial 
lawyers. Do you think that is why it is not in this bill--saving $54 
billion on abusive lawsuits?
  The second proposal--allowing employers to pay a differential and pay 
employees who are living a healthy lifestyle more--is opposed by the 
big labor unions here in Washington. Do you think that is why it is not 
in this bill?
  I wonder whether maybe the Senator from North Carolina has some 
thoughts on those two approaches as to whether they would help the 
health care system in this country, and why they did not find their way 
into a 2,000-page bill, since we seem to have a lot of room in this 
bill for things.
  Mr. BURR. I think the Senator makes a good point. I think many in the 
Congress who have worked on health care for a period of time have seen 
private businesses across this country reach new efficiencies in health 
care. Why? Because they have self-insured their employees. Where have 
they focused? They have focused on exactly what the Senator has talked 
about: prevention, wellness, chronic disease management, paying 
employees to enroll in chronic disease management courses, working with 
dietitians to make sure they lose weight, having cessation programs 
that are offered for free.
  The things we have seen in private companies across the country that 
have brought down health care costs are absent in this piece of 
legislation. It is as though they have come to Washington and shared 
their tremendous experience, and we have ignored it when we sat down to 
write the bill.
  Mr. GREGG. That is because we would have to change something called 
HIPAA.
  Mr. BURR. That is exactly right.
  Mr. GREGG. It is a technical term, but it basically allows companies 
to pay an employee who lives a healthy lifestyle more than other 
employees, and that is opposed, as I understand it. It was originally 
in one draft, and it got dropped somewhere.
  Mr. BURR. Well, the Senator makes a tremendous point about the 
rational, reasonable reforms that the American people are looking for, 
and saying: Why can't we purchase insurance across State lines if that 
creates competition? Why can't we have insurance reform that allows us 
to construct the products? Why does the Federal Government have to 
mandate: Here is what the structure is?
  Many Americans have chosen over the past several years to have 
flexible spending accounts, to have the ability to put their money in 
to take care of their health care needs. What does this bill do? It 
basically reduces the ability to fund flexible spending accounts at the 
amounts that are sufficient to let them continue to access their health 
care, in many cases with their own money. In fact, that is going 
backwards from what we have learned.
  The Senator from New Hampshire mentioned earlier this shift of money 
from Medicare to this new program. Think about our Nation's seniors, 
those who are relying on Medicare for their health care, and the next 
generation that is getting ready to go in--some of us in this room. 
Well, when you shift $464 billion, you are shifting $1,063 per senior 
per year. Over the 10-year life of this score, we are going to shift 
$10,363 per senior, per beneficiary on Medicare today.
  Is that fair to our country's seniors who have paid a lifetime of 
premiums into Medicare to receive a benefit, that because of fiscal 
irresponsibility that benefit may be cut in the future or the premium 
may go up for the next generation? And, thank goodness, the current 
beneficiaries in Medicare are screaming as loud as anybody because they 
understand the ramifications of what we are getting ready to do.
  As the Senator from New Hampshire said, this is all going to happen 
tomorrow. This is going to happen at 8 o'clock Saturday night. People 
are going to come to the floor and they are going to vote on a bill, 
2,074 pages--one that, at best, takes a team of people reading and a 
computer searching words in hopes you can identify everything of 
importance that is in the bill.
  Mr. BARRASSO. The Senator from North Carolina, who has been a 
champion of early detection, early treatment, and prevention of 
disease, did see a preview of rationing this past week when this 
Preventive Services Task Force made a decision and recommendation about 
breast cancer.
  The Senator talked about our seniors. I worry about rationing of 
care, delaying care, denying care. They said for women under 50 they 
should not have mammograms anymore. They should not do a breast self-
exam. They said for women over 75, they should not have a mammogram 
anymore.
  I will tell you that my wife is a breast cancer survivor, and she was 
diagnosed by a mammogram under the age of 50. And they cannot say that 
mammograms are not helpful. What they are saying is that the number of 
mammograms done per life saved is not cost effective.
  I know both of the Senators who are on the floor, from New Hampshire 
as well as from North Carolina, have talked about early detection, 
early treatment, not using cost as the issue on comparative 
effectiveness research. We say let's use some clinical judgment. Let's 
see what we can learn. But, no, because for women under 50, they have 
to do 1,900 mammograms to save a life. For women over 50, it drops down 
to 1,300 mammograms to save a life. So that is what they are putting 
the cost of a life at: a 600-mammogram difference.
  But for my wife--who is alive today, after three operations, and two 
full bouts of chemotherapy, and is now 6 years cancer free--having that 
mammogram under the age of 50 meant the difference between life and 
death.
  That is what this bill has to do with. It is the difference between 
life and death for people. If you get into rationing care, delayed 
care--that is why people come to the United States for their care. It 
is the best care in the world. That is why Canadians and Europeans come 
here, because they have to wait too long. That is why our techniques 
and our treatments and our survival for cancer is so much better in the 
United States than these other countries. Because the Senator from 
North Carolina knows it is that early treatment that makes a big 
difference.
  Mr. BURR. I think the Senator from Wyoming, being a medical 
professional, would probably agree with this: that every disease that 
can be detected at an early stage provides, one, more treatment 
options, greater survivability and, in the long run, less expensive 
cost to treat that disease.
  It troubles me we have these determinations being made on cost that 
are not true costs because they are not putting into the calculation 
the treatment cost. But, more importantly, incorporated in this bill we 
are putting fees on medical device companies, we are putting fees on 
pharmaceutical companies, we are putting fees on health care equipment 
companies. Why? Because they have to pay for them.
  We are replicating the same thing. We are disregarding the fact that 
when an innovative drug comes off the research bench, there is a 
likelihood we could cure disease versus maintaining, that we might have 
a new treatment option that cuts down on the cost.
  As the Senator knows, even though he is an orthopedic surgeon, we 
have cholesterol-busting drugs that now people take who would have been 
in line for bypass surgery. And after that, we got stents that we put 
in, in place of bypass surgery, and that bypasses the last resort.
  Sure, the creation of those blockbuster drugs was expensive. As they 
go off patent, generic competition comes in, and they become very 
inexpensive. But when compared to the $70,000-plus of bypass surgery, 
those drugs all of a sudden look inexpensive. But, more importantly, 
when you look at the quality of the care, where a patient did not have 
their chest cracked, they did not have rehab time, they did not have a

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hospital cost, we save a tremendous amount of money in the health care 
system.
  Mr. GREGG. If I could jump in at this point.
  I think the Senator has touched on something that is important; that 
is, when you start putting these major fees on things such as medical 
devices and drugs, you reduce the willingness of people to invest in 
creating the next device, and not only do you end up with a device 
being priced out of the market or maybe not being produced, but----
  The ACTING PRESIDENT pro tempore. The Republican time has expired.
  Mr. GREGG. Then I will yield the floor.
  Mr. President, I ask unanimous consent we be allowed to speak for an 
additional minute each, so we may wrap up our time.
  The ACTING PRESIDENT pro tempore. Is there objection?
  The Chair hears none, and it is so ordered.
  Mr. GREGG. My point is, this bill fundamentally undermines 
innovation, and innovation has been at the essence of what has made 
American medicine better than the rest of the medicine in the world. We 
are the most innovative country in the world in the areas of drugs and 
medical devices and procedures. I think this bill undermines that.
  Mr. BURR. I might add, that level of innovation is what makes the 
U.S. health care system unique to the rest of the world. We may not do 
primary care very well, and I think we have all admitted that, but if 
you get sick, where do you want to be treated? Right here in the United 
States of America because of the innovation that takes place.
  Mr. BARRASSO. Mr. President, there are improvements that need to be 
done to the system. There are simple things we can do to keep down the 
cost of care, such as allowing people to buy insurance across State 
lines as well as giving individuals the same tax breaks big companies 
get, ending lawsuit abuse and dealing with what is needed to be done in 
terms of incentives to help people stay healthy so they have 
opportunities to save money themselves, and allowing small businesses 
to join together.
  The bill we are looking at here is going to raise premiums for people 
who already have insurance. It is going to raise taxes on all 
Americans. It is going to cut Medicare--cut Medicare--for our seniors 
who depend upon Medicare for their health care needs. And while they 
are doing it, they are going to fund a whole new program rather than 
save Medicare--a system we know is going to go bankrupt.
  Thank you, Mr. President. I yield the floor and note the absence of a 
quorum.
  The ACTING PRESIDENT pro tempore. The clerk will call the roll.
  The bill clerk proceeded to call the roll.
  Ms. STABENOW. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER (Mr. Kaufman). Without objection, it is so 
ordered.
  Ms. STABENOW. Mr. President, I am very proud to be here with 
colleagues of mine who have today joined me on the floor. Senator 
Merkley from Oregon and Senator Mark Begich from Alaska are such 
strong, passionate voices for people in this health care debate, for 
what we need to do to stop the insurance abuses and to save lives and 
save money. I am so pleased they are both here with me. Let me take a 
moment before turning it over to them to talk about what this is really 
all about for us.
  Right now, the bill in front of us basically saves lives and saves 
money. We save lives through making sure that the 47,000 people who 
lost their lives last year because they couldn't find affordable health 
insurance to be able to see a doctor--making sure we change that; by 
focusing on prevention, also, so people have early detection and people 
can find out earlier when they have cancer and get the treatments they 
need to save their lives. There are so many ways in which this bill in 
front of us literally will save lives.
  We save money. We save money for individuals and small businesses 
that are currently having a difficult time finding affordable 
insurance. If you have your insurance through an employer, as do about 
60 percent of the people in my State, and if you are a large employer, 
then you can get a better rate because you have a large group plan. If 
you are a small business, you don't get that same treatment today. If 
you are an individual, if you are, like many people today, operating 
out of your home as a businessperson, a single entrepreneur, or maybe 
you are creating that next great invention in your garage and you are 
trying to find health insurance as a single individual for yourself and 
your family, you can't do that right now in a very affordable way.
  So we want to fill in the gaps in a system that has worked well for 
many people with employer insurance and certainly for people in 
Medicare and our veterans with the VA and our military personnel and 
others. But we have a little less than 20 percent of the public right 
now that is left out there without a way to get affordable insurance, 
so we want to bring down their costs. We want to bring down the costs 
for our bigger businesses as well.
  We want to make sure we are stopping people from using emergency 
rooms inappropriately and raising the cost on everybody with insurance 
and instead give everyone the opportunity to see their own doctor, 
their family doctor, and make sure their children and their families 
get the care they deserve.
  We know this also saves money for the Federal Government, for States, 
for our economy as a whole, and we know what the numbers are in terms 
of inaction, the fact that we need to bring down costs across the 
board.
  This bill protects Medicare. We know we would not have the AARP 
endorsing the House plan and hopefully supporting ours as well--I know 
they are still looking through the specifics, but they certainly 
support health care reform, and we welcome their support. They want 
health care reform. They have said certain things that I think are very 
important that debunk what we have heard from the other side of the 
aisle.
  We have heard over and over that health care reform will hurt 
Medicare. The AARP Web site has up on its site: Myth: Health care 
reform will hurt Medicare. And then it says--not from us but from the 
AARP, a champion for senior citizens in this country--Fact: None of the 
health care reform proposals being considered by Congress would cut 
Medicare benefits or increase your out-of-pocket costs for Medicare 
services. None of the proposals we have introduced as the Democratic 
majority, supported by President Obama, would do that.
  Fact: Health care reform will lower prescription drug costs for 
people in the Medicare Part D coverage gap, or what has now been dubbed 
the ``doughnut hole,'' so that they can get the better, affordable 
drugs they need.
  Fact: Rather than weaken Medicare, health care reform will strengthen 
the financial status of the Medicare Program--strengthen it for the 
future.
  We know Medicare has been a great American success story, and we want 
to make sure it is on strong financial footing to go forward for all of 
us who are baby boomers and beyond, to our children. This comes from 
the AARP Web site. So we strengthen Medicare. We protect Medicare.
  Then we focus like a laser on stopping insurance abuses. We have 
heard so many times, unfortunately, story after story about families 
who cannot find insurance because someone in the family has a 
preexisting condition of some kind--a child who has leukemia, someone 
who is a diabetic. Even for women, pregnancy has been used as a 
preexisting condition. We want to make sure all Americans have the 
opportunity to find affordable insurance. We want to make sure that if 
you have insurance you have paid for your whole life, you have paid the 
premiums, you feel confident that because you have health insurance, 
when somebody in the family gets sick, the companies can't drop you on 
a technicality.
  So we have a number of areas in which we want to stop abuses and,

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frankly, strengthen the system. We want your children to be able to 
stay on your policy until age 26 if they need that. That is something I 
have often said that I wish had been in place a couple of years ago 
because I know what it is like to have a son or daughter come out of 
college and that first job doesn't have health insurance.
  We want to make sure early retirees get the health care they need and 
are able to afford their health insurance with the Federal reinsurance 
plan, to help businesses keep costs down for people who--frankly, many 
have been forced to retire at age 55 or age 60 and don't yet qualify 
for Medicare.
  So this is the bottom line: We are saving lives, we are saving money, 
we protect Medicare, and we stop insurance abuses.
  I wish to focus for a moment on something else we are doing that is 
absolutely critical to me and, I know, to colleagues across the 
country, because this plan will also save jobs. Folks have said to us: 
Well, don't talk about health care; let's talk about jobs. Lowering the 
cost of health care is about jobs. It is about jobs. We lose jobs 
overseas to other countries that have lower health care costs than we 
do. We have seen plants--in fact, in Michigan--go across a river that 
you could swim across, the Detroit River, from Michigan into Canada, 
everything else being equal--a unionized labor force, environmental 
standards--everything else equal but one thing: the health care costs 
are less. So this is about jobs, and it is about keeping jobs in 
America.
  We know our plan will allow big employers to save $9 billion over the 
next 10 years--$9 billion. What will they do with that? They will put 
that back in, reinvesting in equipment, building other plants, hiring 
more people.
  Health care reform is about jobs.
  Small businesses are estimated to save 25 percent in their costs over 
the next 10 years with the tax credits we have in the bill--the ways we 
create the ability to buy through a large pool, to be able to lower 
costs, and with the tax cuts in the bill to small business. There are 
tax credits to help all the companies that don't have insurance to be 
able to find affordable insurance.
  The bottom line is, it is estimated that if we do nothing, the costs 
to businesses will double, and we will lose 3.5 million jobs. We can 
turn this ship around and begin to bring down costs. It is estimated we 
can save 3.5 million jobs.
  People in America understand we have to focus on jobs and the 
economy. They also know the one-two punch is that when you lose your 
job, you lose your health care. So in our bill, we specifically create 
policies that make sure that if you lose your job, you don't lose your 
health care.
  We want businesses, large and small, to be able to redirect the 
spending on ballooning health care costs and premiums, to be able to 
redirect that on hiring people and doing what we know how to do best, 
which is making things in America and putting people to work.
  This is about jobs. It is saving lives and saving money and saving 
jobs in this country. I will conclude by saying that what are we 
hearing from our colleagues on the other side is the same kind of 
tactics that were argued in the 1960s before Medicare. You can take 
some of the same arguments and lift them right from the pages of the 
Congressional Record and you would think it was today's debate, but it 
was actually back in 1964, 1965, with Medicare. We know the arguments 
they used then about destroying the economy, about costs going up, 
about people losing access to doctors, and about how this would hurt 
businesses--it didn't happen then. We know it will not happen now. But 
what we are hearing is: Just wait, wait, wait, wait--that is all we 
heard in the Finance Committee. Don't do it now. What is the rush?
  Well, if you are not getting those premium increases in the mail, 
maybe you don't feel the rush. If you are not losing your job and 
health care, maybe you don't feel the rush. But we have been talking 
about this for 100 years. We are tired of waiting. The American people 
are tired of waiting. They are saying business as usual for insurance 
companies: Let the insurance companies decide whether we are going to 
have maternity care covered under basic insurance. That is not 
necessary. It is an option. Let them decide whether we are going to 
focus on prenatal care.
  We are 29th in the world in the number of babies who live through the 
first year of life--below Third World countries. Right now, 70 percent 
of the insurance companies in the individual market don't offer 
maternity care as basic health care. They say let the insurance 
companies decide. Let them be the ones between you and your doctor. 
When a doctor says what he wants to do when you are sick, what is the 
first call they make? To the insurance company. They say that is OK, 
let the insurance companies be the ones deciding what you are going to 
pay or get, whether you are going to be able to find coverage. Let them 
stand between you and your doctor. We say: No, we have had enough of 
that.
  Finally, they say higher costs for middle-class families and small 
businesses are OK. Higher costs are OK because they are willing to 
allow this craziness to continue. Mr. President, we are not.
  Let me emphasize, again, the bottom line: This is about saving lives, 
about saving money, and it is about protecting Medicare and stopping 
insurance abuses. We are committed to doing those things, getting 
through all the misinformation. All those who make so much money off 
the current system are just flailing and saying anything right now to 
try to stop us from getting control of the system and bringing costs 
down and making health care available. We are committed to getting this 
done for the American people.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Alaska is recognized.
  Mr. BEGICH. Mr. President, I thank Senator Stabenow for her 
leadership. Last night, I had the honor of presiding while she spoke. I 
heard her first comment after she heard the other side describe the 
bill, saying it is so big they cannot read it, but they had great 
detail, for some reason. She even said she wouldn't support a bill as 
they described it. I agree with her. After hearing the last hour and 
what they described, I wouldn't support it either.
  But that is not what this bill is about. This bill is about saving 
lives and saving money, protecting Medicare and stopping insurance 
companies and their abuse. I sat here for a few days--and I preside 
quite a bit, and I enjoy the opportunity to watch. I see the props 
brought out by our opponents. They always bring out the bill. It is 
almost always taller than they are. It is interesting that the prop is 
not realistic. The American public should know that. They make it look 
like it is such a large bill that they are incapable of studying it and 
reading it in a fashion--something that drives one-sixth of our 
economy. I learned one thing. In the last 11 months, I have gotten so 
many different books on different issues, and it is amazing. I took the 
bill--one of the pages out, page 114, and I was curious and thought, if 
we converted this into a regular book page similar to the ones we read 
on a regular basis--or all the books I get that people want me to 
read--I said, how big would it be? Well, it is just about as big as the 
book I have here. It is not hard. If you want to do it--and former 
Senator Martinez, who left us recently, I took his book, and it is an 
easy read. Maybe you would have to read it twice. It is not as they 
describe--like it is some complicated, huge document that is bigger and 
taller than they are. It is not a fair representation of what we are 
doing.
  As you know, we have lots of pages here who work hard every day. I 
know they were surprised when I grabbed one of their textbooks for just 
one subject matter that they are required to study in order to be 
proficient. If you converted it into bill language, it would be four 
times the size of that document that they stack next to them. We ask 
our young people to be well educated, to learn the topics, and 
understand what they are referring to when they are tested. It is a 
simple thing.
  I encourage our colleagues on the other side to not be so extreme in 
the

[[Page 28650]]

way they display the bill. It is not accurate. I think it is important 
to recognize that. This book is short. Probably people cannot see this 
book because it is so low on this table.
  The other thing, as a new Member, I am learning the elements of the 
process here. I heard some colleagues on the other side talk about the 
process. The motion to proceed is a simple issue. It is an issue of are 
we going to debate this in earnest. Are we going to put ideas on the 
table rather than just talk about it and talk about it? We tried this a 
few weeks ago on the Medicare fix. The idea was a motion to proceed so 
we could move forward and debate how we were going to pay for it. The 
Medicare fix is critical to Alaskans. We have Alaskan seniors who want 
to make sure the reimbursement rate is the right one to ensure long-
term coverage. But they didn't want to move on the motion to proceed. 
Therefore, we never debated how to pay for it. We couldn't get there 
with the amendments that many of my colleagues on the Democratic side 
were anxious to put forward. That is where it is.
  To the American public and for folks listening to this forum here, it 
is important we keep to the facts, and they are very simple. This bill 
saves lives, money, protects Medicare, and stops insurance abuses. It 
is proconsumer, pro-patient. It creates more affordable access to 
health care. It strengthens Medicare, as I said. It is fiscally 
responsible. We have a long way to go. I hear, again, my colleagues on 
the other side say rush, rush, rush or, as the Senator from Michigan 
said, they always want to wait, wait, wait. The fact is, we are going 
to have weeks of debate, and there are items I will bring forward to 
improve this, similar to many of my colleagues on both sides who will 
bring forth amendments. That is what we should let happen in the 
process--debate it, discuss it, and end up with a product that will 
improve the health care system of this country. That is the goal.
  When I hear, on the other side, that somehow this bill will be 
rationing, delaying, and denying care--I don't know about you, but I 
get letters every single day about people who have been denied care by 
their insurance company, who have been rationed out because they have 
preexisting conditions. They cannot get coverage because of the delay 
of the private insurance companies and the techniques being utilized.
  It is important to know the debate on this side of the aisle on this 
bill is about ensuring that we will no longer have insurance companies 
denying or dropping coverage. We are asking insurance companies in this 
bill not to place limits on your coverage and ration your care. As I 
said, there will be no discrimination for preexisting conditions, and 
there will be preventive care, making sure people can access their 
health care and their insurance.
  As was said by Senator Stabenow, who clearly understands the job 
issues because of the struggle in her State, there is a report--I will 
cite a few things, and I know Senator Merkley from Oregon has many 
items, because as we have sat here as freshmen talking about health 
care, I know he has more to share from the small business perspective.
  My wife has been a small businessperson for many decades. A report 
was done by the Small Business Majority, working with MIT. Here is the 
basic data. The largest employers in this country are small 
businesspeople. Small businesses will pay $2.4 trillion over the next 
10 years for health care costs for their workers. With minor reform, I 
believe that is what we are offering, at minimum. It will save them as 
much as $855 billion. That is not me or a bunch of politicians coming 
up with this; it is people in the small business community working with 
folks to do the research who determined this. That means more small 
business can employ people and raise capital, expand employment, create 
new jobs. As described earlier, it saves real money for small 
businesspeople.
  I can tell you my brother-in-law who owns and manages one of my 
wife's operations has diabetes, a preexisting condition, and he has a 
$15,000 deductible. He pays an enormous amount each month, with no 
preventive care or chronic maintenance. It is a program that will not 
do much for him until he ends up in a hospital in a severe condition.
  This bill is not just about making sure the insurance companies are 
held accountable and do the right thing for people who buy and have 
insurance today; it is also about creating jobs and making sure the 
private sector continues to grow.
  The last thing I will mention right now--and we talked about this--is 
protecting Medicare. This bill protects Medicare. Why I know this is 
because I have looked at that component of the bill and, most recently, 
I had to explain this to my mother who is on Medicare; she is 71 years 
old. She discussed this with me just this week, as I visited her at her 
home in Carson City, NV. She described her sister, my Aunt Audrey, who 
has a disease. She is in the doughnut hole, where she has to pay for 
prescription drugs that she had no idea she would have to pay for. 
Today, this bill is trying to rectify and fix that problem and make 
sure seniors who are struggling out there don't end up having enormous 
out-of-pocket expenses. This issue around Medicare is not real. What we 
are trying to do is solve the problem and make sure to extend its 
length of stability but making sure seniors get more. They have earned 
it and they deserve it. This bill moves it forward.
  Again, I wish to reemphasize the point that this bill reduces the 
deficit. It has a positive impact for this generation and future 
generations--$127 billion in the first 10 years, $650 billion in the 
next 10 years. That is what it does.
  You will hear all kinds of numbers--and I am sure people who watch 
this get confused, as I do at times, listening to all these numbers 
they throw out. But that is the fact. That is not decided by us as 
Democrats or Republicans; that is the independent office of CBO that 
made that determination. They determined that is the positive impact to 
the deficit.
  We need to push aside all the debate and rhetoric that is out there 
that is not factual and focus on what is right. Again, as we move 
forward on health care and insurance reform, there will be a lot of 
stuff put on the table. There will be items I will put on the table to 
work to improve health care and to protect Alaskans--yes, I will be 
parochial at times--but also look to the greater picture for America. 
This will be a great debate. It won't end Saturday at 8 o'clock; it 
will continue on and on, probably to some folks' dismay because it will 
be longer than people want.
  The fact is, we will debate this issue. We will struggle with it. We 
will struggle with it within our own caucus of what the right decision 
is. But when done, our focus is the American people, improving the 
system--the status quo is not acceptable--and ensuring that we save 
lives, save money, improve Medicare, and hold our insurance companies 
accountable for their actions.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. MERKLEY. Mr. President, it has been a pleasure to listen to the 
comments of my colleagues from Michigan and Alaska, Senators Stabenow 
and Begich.
  The bill before us saves lives, saves money, saves jobs, strengthens 
Medicare, and ends insurance abuse. You wouldn't have known that is the 
case if you were tuning in earlier to the Republican discussion in the 
last hour because what we had were a series of interesting arguments 
ranging from the plain silly to the flat wrong.
  On the plain-silly end, we had a stack of paper about the complexity 
of a bill that addresses one-sixth of our economy and quality of life 
for every single American. My friend from Alaska has pointed out that 
if you put it in a normal size print, that is about equal to a normal 
book. I think we ought to realize that with a topic as serious as 
health care reform, which is touching the lives of every American, you 
are going to want to be thoughtful enough to address it in that detail.
  We also had in the last hour a conversation about how much does the 
bill cost per page. Senator Gregg from New

[[Page 28651]]

Hampshire said the bill is going to cost $2 trillion and there are 
2,000 pages, so it costs $2 billion a page. Last I checked with my 
schoolchildren, 2 divided by 2 is 1, not 2 divided by 2 is 2. But that 
is not the point. The point is, health care reform is not an issue to 
be played with hysterics, to be played with phony visuals, to be played 
with phony math. This is about our future, a future in which our 
businesses can compete around the world and in which our small 
businesses are able to provide health care. In fact, this is about 
quality of life for every single American.
  In the course of my colleagues from across the aisle discussing the 
bill, they actually made a pretty good case for it. Let me start with 
Senator Burr.
  Senator Burr said health care reform should be about choice but this 
bill takes one-size-fits-all. Boy, I thought, he is absolutely right. 
Health care reform should be about choice, and this bill before us is 
about choice.
  Right now in America, we have one dominant player in most major 
health care markets. Even if we have more than one, we have antitrust 
exemptions that enable the health care companies to collaborate and 
cooperate. So you don't have real choice in the marketplace today.
  What does this bill do? This bill says we are going to give every 
American the same type of choice Federal employees have. I became a 
Federal employee in January after I was elected and sworn in. I was 
told to go to a Web site and look at all the choices I had. My wife and 
I sat down and looked at the situation facing our family, and we chose 
the health care plan we thought would be best for us. We had that 
choice. What this bill does is it creates a health care exchange or 
health care marketplace that creates those choices and puts them in 
front of every family.
  I will tell you that right now it is very hard for an insurance 
company to go into a new market. Why is that the case? Because in 
health care, unlike in life insurance, you have to do contracts with 
the providers. You cannot sell health insurance if you don't have 
arrangements with the hospitals and the doctors. It is very expensive 
to do. You don't yet have any customers. So it is very hard to break 
into a new market. But now, if you have a computer marketplace that 
citizens who go to the exchange are going to see and have a chance to 
change plans every year, you have automatic access to the customers and 
you can then afford to make contracts with the hospitals and 
physicians. It encourages competition across State lines. Take Oregon. 
You may have a company operating in Washington, Idaho, or California 
now say: Yes, we want to be on that exchange in Oregon.
  I say to my colleague from North Carolina, he is right, reform should 
be about choice, and this bill is about choice.
  My colleague, Senator Barrasso, told a poignant story. He told a 
story about his wife having breast cancer and how fortunate he was and 
she was and their family was that it was detected by a mammogram and 
how important that type of preventive care is. I couldn't agree with 
him more. But millions of Americans--45 million, 47 million, one report 
says 50 million--do not have health care, and therefore they cannot get 
those preventive tests. They cannot get that mammogram if they are a 
woman. They cannot get that prostate checked if they are a man.
  Senator Barrasso makes a very good point about why we need to expand 
health care coverage throughout this Nation. The bill Senator Reid has 
put before us will reach between 94 to 98 percent of all Americans.
  The question came up: Why not 100 percent? Because Americans move a 
lot. Americans have crises and may not be paying attention when they 
are supposed to sign up. There will always be a small part of the 
population that is not signed up for health care. That is why it is a 
few percentage points. Let's put it this way: 100 percent of Americans 
will have the opportunity to have affordable, accessible health care. 
That is what this bill is about.
  Returning to my colleague from North Carolina, he made the point that 
the bill before us is not about reform and that it should be about 
reform, about insurance reform. I have good news, good tidings for my 
colleague from North Carolina. Embedded in this bill are all kinds of 
reforms that are important for every person who has insurance in the 
United States of America.
  First of all, guaranteed issue. You cannot be turned down because you 
have a preexisting condition if we pass this bill. I cannot tell you 
how many Oregonians--and I am sure it is true in North Carolina--have 
been turned down for health care insurance because of some health care 
problem they had in the past, maybe in the far past of their life.
  This bill says you cannot have a lifetime limit. What kind of 
insurance do you really have if you have a $50,000 or $100,000 lifetime 
limit? After 20 years of paying your premiums, you get sick and, as you 
all know, you can wipe out $50,000 or $100,000 in a week or two. And 
now you are informed--you paid health care insurance for 20 years, you 
have been in the hospital for 2 weeks--sorry, you are on your own now. 
What kind of insurance is that when it is not there when you need it? 
This bill reforms that.
  This bill adds nondiscrimination for gender, which is a fundamental 
value I think all Americans share.
  This bill says you cannot be dumped off your insurance when you get 
sick or you have an accident. How many Americans have paid health care 
insurance premiums for years, paid those premiums month after month, 
are very healthy, rarely go to the hospital, rarely go to the doctor, 
but then they have a car accident and are seriously injured or they 
have bad news and have gotten a serious disease and they get that 
letter from their insurance company saying: Sorry, we are not renewing 
your insurance; you are on your own. So now, because preexisting 
conditions are not allowed, they cannot get insurance from anybody else 
either. They truly are on their own. This bill reforms that.
  I am glad to let my colleague from North Carolina know that this bill 
is about reform.
  Senator Enzi noted the story of selling shoes, that he had three 
shoestores and that when a customer came in and he showed him a shoe 
and that customer said that shoe is too expensive, he knew he shouldn't 
keep pushing the same shoe, he should not keep trying to sell it. No, 
he should show him a different shoe. That is exactly what the public 
option does in this bill.
  Those who are in support of the status quo and don't want reform, 
they want to keep sending the same shoe, keep saying: Americans, you 
have only one choice or maybe a couple choices. But within a situation 
where there are no antitrust provisions, you just have to keep going 
back to that private company--no new shoe for you; no different product 
for you. But this bill says: No, if you are not happy with that, there 
is another alternative. In fact, this bill not only gives you one new 
shoe, it gives you two. Nonprofit co-ops can be set up--a provision 
that came to us through the Finance Committee--and it gives you a 
strong public option, a plan dedicated to healing, not dedicated to 
profits. So if you are not satisfied with the insurance you have, you 
have some alternative choices.
  I think my colleagues across the aisle made a very good case--maybe 
better than the case I could make--for the fact that we need health 
care reform. We need it for large businesses so they can compete around 
the world, and we need it for our small businesses so they can afford 
to provide health care to their employees. We need it for our families 
because health care is about the biggest stress families face in 
America. If you have health care, you are worried about losing it, and 
if you don't have it, you are worried about getting sick. We need 
health care reform today.
  The PRESIDING OFFICER. The Senator from Michigan.
  Ms. STABENOW. Mr. President, I wish to take a few moments and 
continue this discussion and then turn it over to the distinguished 
Senator from New Mexico, Mr. Udall. We are so

[[Page 28652]]

pleased to have him. We served together in the House. We are pleased to 
have him as a colleague in the Senate. They are a terrific team of 
people who are so smart, who care so much and have such great 
experience. Our previous speaker, coming from Oregon as the leader in 
the State legislature, and Senator Begich, as a leader, as a mayor--we 
bring a wealth of experience of people who have been serving, problem-
solving, trying to make government work, make the right decisions at 
various levels of government. It is wonderful to be working with them 
today.
  I wish to take a moment because I understand that the Republican 
leadership, our colleagues, are currently holding a press conference 
talking about what we are doing is somehow rationing care. This is the 
same argument, by the way, used back in the sixties with Medicare. 
Somehow seniors would not be able to get care, it would be rationed, 
which, of course, is the exact opposite of what happened.
  Now people hold their breath if they retire early and don't have 
insurance, just waiting to turn 65 so they can get Medicare and they 
can see whatever doctor they want, not the one the insurance company 
says they can see but the doctor they believe they need to see, the 
specialist they believe they need to see.
  We know that for too many people in this country, there is the 
ultimate in rationing. Over 45,000 people lost their lives last year 
because of the ultimate rationing. They couldn't find affordable health 
insurance. They couldn't see a doctor. They couldn't get the care they 
needed. Mr. President, 45,000 people in the greatest country in the 
world paid the ultimate price. Shame on us. We want to stop that. This 
legislation will head us in the direction to stop that, to say as a 
matter of principle in this country that it is not acceptable that any 
American would lose their life, any mom or dad would lose their child 
because they could not find affordable insurance in this great country.
  We also know that every year we push as hard as we can to increase 
the amount of money going to the National Institutes of Health to 
gather information, to do research to save lives--to save lives through 
research, through information. In this legislation we want to make sure 
as the NIH is doing more research, as we are looking at better 
prescription drugs or new cures, that we are giving physicians and 
patients the very best information.
  I am not scared of information. I want information for my family, for 
myself. I have been in a situation--I am sure that we all have--talking 
to my physicians, where they said according to the latest data we now 
think a little bit differently about a particular procedure or a 
particular medicine. And they make a different recommendation. I want 
my doctor to have that information. That is not rationing. In fact, we 
specifically say in this bill, we specifically prohibit the Secretary 
of Health and Human Services from denying coverage of treatment solely 
based on research, solely based on information. But we certainly want 
the information.
  I think it is kind of silly to even argue about whether we want 
medical research and information so our doctors have the very best 
information to be able to treat us. Right now, less than 1 percent of 
our health care spending goes to examining what treatments are most 
effective. We want to make sure the information is there for 
physicians. Physicians support that, by the way. This is something in 
the House bill, endorsed by the AMA, endorsed by medical professionals 
all across the country. We want our doctors to have more information to 
do a better job for us, not less.
  We are hearing, over and over, scare tactics. We know we are going to 
continue to hear that until we get to the end and pass this bill. But 
none of the groups--doctors, nurses, family groups, consumer groups, 
business groups--none of those who currently support this legislation 
would be doing so if they thought it was in fact doing the things the 
other side is claiming it is doing, and certainly not if it was 
rationing care. The ultimate rationing right now occurs when people 
arbitrarily get dropped because the insurance company doesn't want to 
pay the bill; when people cannot get the coverage they need because of 
a preexisting condition; or when they lose their life because they 
can't find affordable insurance. Our legislation is about saving lives 
and saving money.
  I wish now to turn the floor to my colleague from New Mexico.
  The PRESIDING OFFICER. The Senator from New Mexico is recognized.
  Mr. UDALL of New Mexico. Mr. President, I thank Senator Stabenow for 
that very good statement on what I think is a very important issue. As 
we speak, and as I have watched the floor, I hear my Republican friends 
talking, as Senator Stabenow said, about rationing. They are seeming to 
imply this legislation somehow would do that. They also look at this 
administration and see that a prevention task force report of some of 
the key experts in the country, trying to give us the very best 
science, the very best medicine--that somehow that could be rationing.
  My advice to women, listening to this debate, is that they should be 
consulting their doctors when it comes to things such as this. They 
should be listening to their doctors. Their doctors are up on the best 
research, they are up on the best science, they are up on the best 
medicine and get on top of it.
  I would say to the women of America: Listen to your doctors, not to 
Rush Limbaugh.
  Senator Begich from Alaska is on the floor. I am happy to join with 
him and Senator Merkley and Debbie Stabenow--with all these great 
Senators down here--to talk about this bill. But there is something 
that--I look on the other side and I see these huge stacks of paper. We 
should be a little bit truthful and talk to people in a truthful way 
about these stacks of paper. First of all, they are one-sided, so you 
only have print on one side, which is not even the way we print them up 
around here. I have had mine printed up on both sides so I use both 
sides of the paper. They have made an attempt here to make it look a 
lot higher than it is, as Senator Begich pointed out here earlier 
today, and if you take the type and reduce it to the regular type of a 
book, you come out with an average size book.
  We are doing a piece of health care legislation that is very 
important to this Nation, a significant part of our economy, and we 
want it to be something that will rein in these insurance companies, 
bring in competition, bring in more choices, so we have to be careful 
about what we put in it. I think we should focus on the substance 
rather than focus on the gimmicks. We are getting a lot of gimmicks 
from our friends on the Republican side with these big stacks of paper. 
Let's talk about the substance.
  I hope we are going to see someday in this debate an actual 
Republican bill and proposal so we can debate it back and forth. We 
have not seen that yet. We have just heard an awful lot of rhetoric.
  One of the things I want to talk about today is what is a very 
important part of this bill and that is the public option section. A 
public option would bring to the Nation more competition. What we want 
more than anything is to have more choices when it comes to insurance. 
We want to see as many choices out there in the marketplace.
  Sometimes I don't understand, when my Republican friends talk about 
this, because we are talking on their terms--about competition, about 
choice in the marketplace, giving people more choices. I don't 
understand why they are opposed to those kinds of solid principles that 
are the backing of this particular bill.
  The other thing a public option would do is keep insurance companies 
honest. That is tremendously important. We have these insurance 
companies out there, we know they are doing very well in terms of their 
profit making. I am going to be talking about that in a little bit. We 
know they have very high administrative costs. If you have a public 
option that is actually dedicated to providing health care

[[Page 28653]]

rather than to making a profit, then you are going to have something 
going on in the marketplace that will keep everybody honest.
  As you can see here, keeping the insurance companies honest, 
inserting competition into the market, and giving the uninsured access 
to affordable coverage--that is what we are talking about here. When we 
say a ``public option,'' we are not talking about subsidized by the 
government. This is going to be fully financed by premiums. The public 
option is not going to make a profit for its shareholders, it is going 
to focus on health care. It would have low administrative costs since 
it operates as a nonprofit. It would exert bargaining power to obtain 
discounts from providers. It would offer savings to its subscribers 
with lower premiums, greater benefits, or lower out-of-pocket expenses. 
It should follow the same insurance requirements as private plans. What 
you are going to see is the public option offering low cost and high 
value.
  I think at this point what I wish to talk a little bit about is what 
has happened with some of our major health care insurance companies in 
the last couple of months. We have reached the end of a quarter. You 
see Wall Street has completed its third quarter earnings. Two of the 
big health care companies, Humana and Cigna, released their reports a 
couple of weeks ago. Let's just say that both companies did very well 
last quarter.
  How well, you ask. Humana reported a 65-percent jump in profits over 
the same period. That is a big number. But, ironically, Humana's 
earnings seem positively restrained compared to Cigna's report. That is 
because Cigna reported a 92-percent increase in third quarter profits--
92 percent.
  Many companies right now are just getting back on their feet after 
the worst recession since the Great Depression. Although the economy is 
improving, times are still tough. When you take that into 
consideration, an earnings report with a 65-percent jump or a 92-
percent jump in profits makes you wonder how Humana and Cigna are doing 
so well in such tough economic times.
  I will tell you how they do it. They do it by putting profits above 
people. While Humana and Cigna touted earnings that are 
incomprehensible to the average person, or the average business for 
that matter--the average businesses, the business people I talk to say, 
are making 10 percent, 15 percent profit if they are doing well. Yet 
here these folks are making these huge profits.
  While these health insurance companies are doing that, 47 million 
Americans continue to struggle without health insurance. While Humana's 
total revenue jumped 8 percent to almost $8 billion, and Cigna 
predicted profits of more than $1 billion this year, small businesses 
began reporting that their premiums are expected to jump more than 15 
percent next year.
  Unfortunately, Humana and Cigna are not alone in their ``profits 
above people'' business model. Over the past 7 years, publicly traded 
health insurance companies, companies that include Humana and Cigna, 
saw a 428-percent increase in profits--428 percent increase in profits. 
While the companies were raking in the cash, so were their CEOs, who in 
2007 alone made $118 million between 10 of them. That is why health 
insurance premiums more than doubled over 9 years. Health insurance 
premiums doubling over 9 years, three times faster than wages 
increased.
  Giant insurance companies are happy with the status quo. For them it 
means little competition, skyrocketing profits and the ability to do 
just about whatever they want to do to boost their bottom lines. A 
public option would change all of this. It would keep insurance 
companies honest by putting much needed competition back into the 
market. It would provide real choice for Americans by giving them 
another option that best meets their needs. And it would help small 
businesses and the self-employed by making health insurance for their 
employees more affordable.
  I urge my colleagues on both sides of the aisle to pay close 
attention to these earnings reports. I urge them to take a hard look at 
the skyrocketing profits these health insurance companies have reported 
and ask themselves: Whose side am I on? The insurance companies that 
continue to put profits above people, or the people I was sent to 
Washington to represent?
  I know which side I am on. I know a public option is the right thing 
for Americans and the right thing for this country.
  One of the things we hear in this debate--all of us, as Senators, 
stay in constant contact with our constituents. We get mail, we get 
telephone calls, we get e-mails. My constituents in New Mexico have 
talked to me a lot about their health care problems. They have talked 
to me about their rising premiums. They have talked to me about losing 
their insurance. And they send me some very powerful stories I want to 
share.
  Here is a story from a woman in Placitas, NM. Here is what she wrote 
me in an e-mail.

       Dear Senator Udall: I own a small business--just me and my 
     secretary. I just got my notice from my insurer about the 
     rate increase for next year, which is between 9 and 10 
     percent. For two people I will now be asked to pay $2,300 per 
     month in premiums.
       We can't afford it. I am now faced with the likelihood of 
     having to drop insurance, which for two cancer survivors is 
     not the right answer.
       I know you support the public option and that you are a 
     reliable vote for reform. But if anyone on the Hill is 
     keeping a record of how the inanity of this debate is 
     actually affecting real people, please include this e-mail in 
     the log.

  How would a public option help in that circumstance the woman just 
wrote in about? A public option would provide another, more affordable 
choice for small businesspeople such as this lady from Placitas, people 
who own their own businesses, who are doing the right thing, pursuing 
their own American dream. These folks cannot achieve that dream when 
they are paying outrageous costs for health coverage for themselves and 
their employees. A public option would help small businesses succeed by 
giving them another, more affordable choice in the insurance market.
  This is something we need to focus on. As we flip through the bill, 
as the American people look at this bill, ask themselves: Are you for 
the status quo, are you for keeping these premiums going up, are you 
for the insurance companies dominating the market or are you for 
competition? When it finally comes down and we look at the overall 
package, it is going to be clear.
  The PRESIDING OFFICER. The time of the majority has expired.
  The Senator from Florida.
  Mr. NELSON of Florida. Mr. President, I will vote for the motion to 
proceed. That gets us to the point at which we can have the bill before 
the Senate in order to debate and to amend the legislation. It is a 
debate we must have. It is a debate we cannot afford not to have.
  The PRESIDING OFFICER. The time of the majority has expired.
  Mr. NELSON of Florida. I ask unanimous consent that I be able to 
proceed for 2 minutes.
  Mr. ALEXANDER. That is OK as long as it is taken from the Democratic 
time.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. NELSON of Florida. I will vote for the motion to proceed to bring 
the legislation before the Senate. This is a debate we must have. It is 
a debate we cannot afford not to have. What is before us is to make 
health insurance available and affordable. The legislation that will 
come before us will prevent someone from being denied insurance because 
they have a preexisting condition. It will not allow the insurance 
companies to cancel policies because someone is sick. It will bring in 
millions of uninsured people who will then be able to have insurance 
and can afford it. By the way, that brings down the cost of all the 
rest of our premiums because they get health care at the emergency 
room, and guess who pays. All the rest of us do, to the tune of a 
national average of about $1,000 per policy. This legislation will 
reduce the deficit, $130 billion over the next 10 years and over $650 
billion in the second 10-year period. There is room for

[[Page 28654]]

improvement. That is why we need to debate it. That is why we need to 
amend it. I will be offering an amendment that will produce savings to 
the taxpayers of another $100 billion by lowering the cost of drugs to 
Medicare recipients. Let the debate begin. I look forward to it.
  The PRESIDING OFFICER. The Senator from Tennessee.
  Mr. ALEXANDER. Mr. President, the Republican side should now have 60 
minutes; correct?
  The PRESIDING OFFICER. The Senator is correct.
  Mr. ALEXANDER. That will extend until about 2:05.
  The PRESIDING OFFICER. The Senator is correct.
  Mr. ALEXANDER. Mr. President, the debate has begun. The debate is 
about reducing health care costs--the cost of premiums every American 
has or the cost to the government that every American has to be 
responsible for. The bill we have been presented goes in the opposite 
direction. It raises taxes. It means higher premiums. It cuts Medicare. 
It transfers major new costs to States which, in turn, will damage 
higher education and/or increase taxes or both.
  Our purpose on the Republican side is to take this next hour, as we 
intend to take several hours, all the hours allocated to us today and 
tomorrow, and help the American people have a chance to read the bill 
section by section, to understand what it costs and to understand how 
it affects them.
  In this next hour, the Senators from Georgia, Mr. Chambliss and Mr. 
Isakson, and the Senator from Kansas Mr. Brownback, will be focusing on 
tax increases. We will be referring specifically to page 348, title I, 
subtitle (f), part 2 of this 2,074-page bill, which has to do with the 
tax on employers. We believe a great many employers will look at this 
big bill, look at the tax on them, if they don't pay insurance, look at 
the new government program and say: It is going to be a lot easier for 
me to pay the fine and write a letter to the employees and say: 
Congratulations, I have written a check to the government. You are on 
the government plan.
  Then we will go to page 2,040 of the bill, which is the new Medicare 
payroll tax. That is a tax on hiring. You heard that right, a tax on 
hiring in the middle of a 10-percent unemployment situation. How is 
that going to create any jobs? We don't think it will.
  Then Senator Chambliss, especially, and Senator Isakson, because of 
his background as a small businessperson, will talk about what 
Republicans want to accomplish. If you are waiting for the Republican 
leader to roll in a wheelbarrow with a 2,074-page Republican version of 
health care reform, you will never see it. We don't believe in that. 
What we do believe in is identifying a goal--reducing the cost of your 
premium, reducing the cost to the government, and then going step by 
step toward that goal; for example, by reducing junk lawsuits, by 
allowing small businesses to pool their resources to purchase 
insurance, which we have offered but the Democrats will not allow to 
come forward, and by allowing people to purchase health insurance 
across State lines. Senator Chambliss and others of us will talk about 
this during the next hour.
  That is the Republican plan, to do what most Americans want done, to 
reduce the cost of premiums, and to not increase premiums and taxes, or 
cut Medicare.
  There is one hidden tax I wish to talk about because it is in the 
bill, and it is in the news. Most Americans may have seen that the 
University of California yesterday raised tuition 32 percent. There 
are, in our country, around 18 million students who are in higher 
education. What I wish to say to them is, if this bill passes, their 
tuition is going up. California's tuition is going up again. It is 
going up in Tennessee. It is going up in North Dakota, in Nebraska, in 
Georgia, everywhere there is a public college, university, or community 
college there are going to be new taxes or higher tuition or both.
  In California right now, they are pointing fingers at each other 
about the 32-percent tuition increase. But they should be pointing the 
finger at us, Washington, DC, Congress, because it is we who have 
allowed the Medicaid Program, the largest government-run program we 
have in the country, to go year after year with increases of 7 or 8 
percent. We require every State, if it opts in, to have a government-
approved Medicaid Program. In our State, it is called TennCare. That 
Medicaid Program is helping bankrupt the States.
  Here is a State of Tennessee headline: ``State looks at $1 billion in 
cuts.'' Part of that is from the recession. But part of that is because 
of the increased cost of Medicaid. What does this bill do? It sends to 
the States another $25 billion in increased Medicaid costs. What will 
that mean? Higher tuition rates, higher taxes, or both. The University 
of California has the reputation as the best public university in the 
world. It will not be that very long if the Congress of the United 
States doesn't rein in Medicaid and reduce its cost so Californians can 
afford to have both a health program and a fine university system. The 
Governor of Tennessee has said the same thing. He has been outspoken 
about this. He has talked about exactly the dollars it will cost us. In 
the House bill, it is $1.4 billion over 5 years. In my view, I don't 
see how the State of Tennessee can pay that without a big State tax 
increase or without damaging higher education or both.
  Someone might look at this and say: What does health care have to do 
with a 32-percent tuition increase in California? It has everything to 
do with it. Instead of reining in Medicaid, we are expanding Medicaid. 
By doing that, we are making it impossible for virtually every State to 
properly support higher education. The only choice they have, other 
than taxes, is raising tuition for 18 or 20 million students across the 
country. Californians, if this bill passes, your tuition is going up 
one more time.
  I call on the Senator from Georgia, Mr. Isakson. He spent a number of 
years as the leader of the Republicans in the Senate. He dealt with the 
Medicaid question. He dealt with the question of taxes. As a small 
businessman for most of his life, he understands well the impact of new 
taxes on hiring and mandates on businesses.
  Mr. ISAKSON. I thank the Senator from Tennessee.
  Mr. President, I am delighted to be a part of the debate for all the 
right reasons, to talk about things we can do but also talk about 
things that the proposed legislation, in fact, does do to the American 
people, to small business, and to our future.
  When I end my speeches in Georgia, I always end with the same line. I 
say: I am 65 years old. I have nine grandchildren; in fact, No. 9 was 
just born. His name is Hunter. He is 5 weeks old. I always say my life 
is about their lives. The rest of my life is about making their lives 
as rich, as prosperous, as safe, and as free as the one my parents left 
to me.
  Legislation such as this severely threatens that. I wish to talk 
about two ways in which it does.
  The heart and soul of America is the small businessman, as 73 percent 
of our employees are employed by small business. I ran one. I had 200 
employees and 800 independent contractors. By law, I could provide 
health insurance to the 200 employees, and I did. But contractors, 
because they are independent, the IRS will not let an employer provide 
that benefit. That is one of the reasons you have a large number of 
uninsured who are actually working--real estate agents, sole 
proprietors, contractors. The Senator from Tennessee and I and the 
Senator from Wyoming, Mr. Enzi, then as chairman of the HELP Committee, 
proposed a small business health care reform act, a Republican act 
proposed in this body to cover one-third of the uninsured without 
raising rates or without raising premiums or without raising taxes. We 
had to get to a cloture vote of 60, and we only got to 57. So 3 years 
ago we missed a chance to cover one-third of the uninsured by a change 
in our law which would make it more affordable and accessible for 
independent contractors. That is what we were for.
  Let me tell you what this bill does to a small businessperson. No. 1, 
if you have more than 50 employees and you

[[Page 28655]]

do not offer them health insurance, you have to pay a fine of $750 per 
employee for ad infinitum. If it is 500 or 51, you have to pay a $750 
fine. I ran a company for 20 years. When I ran that company, I did 
provide insurance to 200 employees. I paid about $3,200 a year for the 
company's expense of their group health insurance. They paid the 
balance. If this offer were before me as a small businessman, then I 
would have said: Well, I have a $750 fine if I don't insure them and a 
$3,200 cost if I do. What should I do? Well, as a businessman, you are 
going to elect not to provide insurance, to pay the less expensive 
cost, which is the $750-per-person fine, and drive them into a public 
option.
  This is not about a public option, it is about a public ultimatum, 
because as you look at the revenue-raising procedures, the tax-raising 
procedures, and the policy procedures, it basically drives people to a 
public option and drives small business away from providing that 
insurance.
  There is another way it hurts small business. It also says, if you do 
provide health insurance to an employee and the cost of their part of 
the premium exceeds 9.8 percent of their annual income, then you have 
to move them to the public option, and they get subsidized. But you get 
fined $3,000 a year for the rest of the number of years that person 
works for you because their cost to their insurance was more than 9.8 
percent of their income. You might say: Well, whose insurance would be 
more than that? Well, if you take a receptionist or someone like that 
today in a business, who may be making $25,000 or $30,000--an entry-
level job--9.8 percent of that is only $2,800, $2,900. It would be more 
than easy for their share of their premium to exceed 9.8 percent. So 
the company gets fined, the employee gets driven to a public plan, and 
more revenue goes to the government through an indirect tax of a fine.
  Mr. ALEXANDER. I wonder if the Senator would yield for a question?
  Mr. ISAKSON. Absolutely.
  Mr. ALEXANDER. If the employee were eligible for the Medicaid Program 
in Georgia and lost employer insurance and went into the Medicaid 
Program, isn't it true that the employee who went into the new 
government plan under this bill is likely to pay a higher premium and 
have a harder time finding a doctor?
  Mr. ISAKSON. There is no question. I say to the Senator, you are 
exactly right. To think that it actually benefits the employee by doing 
that is wrong. They will have fewer doctors providing the coverage, and 
their cost might, in fact, be higher.
  But I want to talk about one other thing on the small businessman 
before I yield to one of my other colleagues.
  There is another tax--and we have heard the business about taxing the 
rich. This bill provides a surtax on payroll--a payroll Medicare tax on 
any employer who makes more than $200,000 if they are an individual or 
$250,000 if they are a couple. The Medicare tax goes from 1.25 
percent--your share; the company matches it--to 1.95 percent.
  Now, $200,000 is a lot of money, and so is $250,000. But to a small 
business incorporated as an LLC, a sub S, or something like that, that 
pays taxes as an individual, that is 1.95 percent doubled, which will 
increase the tax to 3.9-percent on every dollar that company makes on 
gross, not profit, if they're above $200,000. It is a tax on their 
business for Medicare to pay for a public option, not for Medicare. And 
Medicare goes broke in 2017.
  So we are raising taxes on Medicare for the alleged rich, which 
really is most small businesspersons, all to pay for a program that 
does not benefit Medicare. The unintended consequences of this 
legislation are disastrous to small business, it is inappropriate in 
the way they are handled, and it is directed to drive people to an 
inevitable option to where there is no option at all.
  I thank the Senator from Tennessee for giving me the time. I know my 
colleague from Georgia, Senator Chambliss, has a few facts to add as 
well.
  Mr. CHAMBLISS. Mr. President, I thank both my colleagues from 
Tennessee and Georgia.
  I want to talk just for a minute about what Republicans are for. We 
have been criticized by the folks on the other side of the aisle for 
being just against what they are for, and that is not at all true. 
There are actually four other plans that were filed in both the HELP 
Committee and the Finance Committee, three of which were strictly 
Republican plans, one was a bipartisan plan, that never saw the light 
of day, simply because the folks on the other side of the aisle had 
their minds made up that they were going to have their plan with a 
government option, and they were going to do whatever they could to 
move us toward universal health care coverage.
  I want to say to those folks on the other side of the aisle who have 
stood up and said on the floor of this Senate: Yes, by putting a 
government option in place, our intention is for the government to take 
over health care--some of them have been very straightforward about 
that, and they have been honest. There have been others who have been 
not so honest about that. But that truly is the reason there is a 
government option in the plan we have up for a vote tomorrow night.
  But what are Republicans for? First of all, everybody in this body is 
in agreement that we want to drive down the cost of health care and we 
want to drive down the cost of insurance, and those are integrally 
linked. If you drive down the cost of health delivery, then you will 
drive down the cost of health insurance.
  There are a number of ways we can agree today to enact legislation 
that will help drive down the cost of health care. What are those 
things?
  Preventive health care. Well, there is some mention of preventive 
health care in Senator Reid's bill somewhere in these 2,074 pages. 
There is the mention of preventive health care, but there is not the 
incentive in place to encourage people to move toward preventive health 
care as was done in the private sector with Safeway, a grocery store 
chain where the CEO has visited both Republicans and Democrats and 
talked about the way Safeway was successful in doing that.
  We all want to make sure those who do not have insurance today are 
covered. We want to cover preexisting conditions. We want to make sure 
we put competition into the insurance market by allowing policies to be 
sold across State lines. All of those things will work in concert to 
drive down the cost of delivery, as well as the cost of insurance 
policies per se.
  There is another measure that will significantly improve the cost of 
delivery; that is, putting in some measure of tort reform. In this 
bill, with these 2,074 pages, that seeks to totally reform the health 
care industry in America today, there is not one mention of reforming 
the tort system in this country, the malpractice reform area. If you go 
to any doctor and you ask him what is the No. 1 issue on his mind when 
it comes to reducing the costs in his office, I bet in 99 percent of 
the cases--maybe 100 percent--they are going to tell you that tort 
reform must be implemented if we are ever going to hope to drive down 
the cost of the delivery of health insurance in this country.
  Senator Graham and I have an amendment we will be talking about that 
is a tort reform measure that is a loser-pays style of tort reform. It 
does not take away the right from anybody who is injured. Anybody who 
is injured ought to have the right to have their day in court. But it 
does eliminate the potential for the extensive, frivolous lawsuits that 
our docs and our hospitals have to deal with every single day that 
drive up the cost of health care.
  I want to talk, too, about one other measure we are for that has been 
talked about a lot today; that is, covering the uninsured. I think, 
without question, if you want to drive down the cost of delivery and 
the cost of health insurance, you need to cover those people in this 
country who need to be covered.
  We have a little disagreement with folks on the other side of the 
aisle as to the exact number they seek to cover with this 2,074-page 
bill. But there is

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one area where we do agree; that is, there are somewhere between 47 
million and 50 million people in America today who are truly in that 
uninsured category whom we all, as a body of 100, would like to see 
have affordable insurance available to them.
  Now, who are these uninsured? First of all, there are about 6 million 
people in this country today who are uninsured who are here illegally, 
and they are illegal, undocumented aliens.
  Folks on the other side--and there is some question about this when 
you look at the language in this 2,074-page bill, whether they cover 
those illegal aliens, but let's assume we all agree they ought not to 
be covered. There are another 14 million people in America today who 
have health insurance available to them from the Federal Government in 
one form or another. Either they are Medicaid eligible or they are 
eligible for some form of SCHIP, the State Children's Health Insurance 
Program. In Georgia, it is called PeachCare. For whatever reason, these 
14 million people have not taken the initiative to go out and sign up, 
for example, in Georgia, at the Department of Family and Children 
Services. I do not know what it is in Tennessee, I say to Senator 
Alexander, but there is a comparable office in all 50 States for that 
to be done. What do these 2,074 pages seek to promote as to the 14 
million people who have insurance available to them today to go in and 
take that insurance? Nothing. So these 14 million people are not even 
addressed.
  Then there are another 15 million people to whom Senator Isakson just 
referred. They are people who are either those independent contractors 
or they are employees who work for employers who do not provide health 
insurance, but all of them are gainfully employed, and they have the 
ability to purchase health insurance. Some of these people are dealt 
with in this 2,074-page bill. Some of them are not because if you are 
an employer with 50 or fewer employees, then you are exempt, you would 
not be covered, still, as a part of that 15 million.
  Then there are about another 12 million to 15 million whom I refer to 
as the hard-core uninsured. Those are the folks whom we really ought to 
try to reach, and those are the folks to whom the bulk of the $2.5 
trillion this bill is going to cost during the 10 years when it becomes 
fully implemented seeks to reach.
  I would simply say, if we are going to truly have a health reform 
bill, we need to start and take it step by step. If the folks on the 
other side of the aisle are serious about health care reform, we can 
get the appropriate committee chairmen together this afternoon, 
tomorrow, or whenever, and begin work on these issues I have just laid 
out about which there should be no disagreement. We could move forward 
with developing a true and meaningful health insurance reform package.
  I want to come back in a minute and talk about Medicare taxes and the 
way Medicare is going to be dealt with here. But I would simply throw 
it back to the Senator from Tennessee, as well as to my colleague from 
Georgia, because they have both been involved in a very honorable way 
at the State level. Senator Alexander is a former Governor of 
Tennessee. Senator Isakson was an elected member of our State house, as 
well as our State senate.
  I say to the Senators, you gentlemen have experience dealing with 
Medicaid, and you know what the taxation side of Medicaid does from a 
State level. I would like to ask for your thoughts on what this 2,074-
page bill is going to do to Medicaid in this country as we know it 
today.
  Mr. ALEXANDER. Mr. President, I thank the Senator from Georgia. I am 
going to throw the question right back to Senator Isakson in just a 
minute.
  I appreciate Senator Chambliss taking time to point out what 
Republicans are for because it seems as if no matter how many times a 
day we say it, our Democratic friends do not hear it.
  Let me put it this way: Let's say Senator Isakson, who has been a 
small businessman, buys a new small business. He takes it over, and he 
sees that generally it is working pretty well but it has some problems 
with it. I wonder if the first thing he would do is come in and say, I 
tell you what, let's just turn it all upside down and change it all, or 
would he say, let's identify the problem, and let's take a few steps in 
the direction of fixing that problem.
  What Republicans are saying is, we have a big health care system that 
in general works pretty well. Mr. President, 250 million of us have 
health insurance plans; 47 million do not. Senator Chambliss has just 
pointed out who those people are. Thirteen million or 14 million are 
already eligible for plans and for one reason or another do not sign 
up. A few million are illegally here. Some others are young and think 
they are invulnerable and do not sign up. But we are saying the problem 
is the cost, people cannot afford to buy their own insurance, the 
government cannot afford its health care costs, and people are going 
broke over this. So we want to reduce the cost.
  Senator Chambliss identified this step-by-step approach. He mentioned 
reducing junk lawsuits against doctors. We have proposals for that. 
Combating waste, fraud, and abuse--we have introduced legislation for 
that. Senator Isakson talked about allowing small businesses to pool 
their resources. Additional ways to reduce cost is allowing people to 
purchase insurance across State lines, so you can shop for more 
insurance and reduce your cost through competition, and amending the 
health savings account laws so you can withdraw your money in a tax-
free way to pay for your insurance premium, and encouraging wellness 
and prevention. We could take those six steps, reduce costs, and then 
take six more.
  I wonder, Senator Isakson, with your experience in business, if you 
think it makes any sense for us to just come in here and say: OK, we 
are really smart here in the U.S. Congress. This is a big country, with 
300 million people. We are just going to turn the whole health care 
system upside down, write a 2,074-page bill, change the premiums, raise 
the taxes--do all these things--or would you go step by step in the 
right direction and try to re-earn the confidence of the American 
people who have lost a lot of confidence in Washington, DC?
  Mr. ISAKSON. I think it is an excellent question, because every year 
in my company we had an annual planning retreat at the end of the year 
for the next year, and ironically--and I didn't know we were going to 
get into this discussion--but our No. 1 topic that I would send out to 
all of my management team is: What is the No. 1 thing we need to 
correct or do in our company? We would spend the entire retreat talking 
about that one thing. If that one thing was the uninsured, then what we 
would have talked about is what do you do to insure that 14 to 15 
percent who don't have coverage.
  Senator Chambliss hit the nail on the head: Small businesses with 
health plans that allow independent contractors and contractors to be 
covered; that is one. Have an immediate identification and registration 
system for people who are eligible for Medicare, Medicaid, or SCHIP so 
that when they come to a provider or a doctor they end up getting 
covered. Then, third, come up with a program that meets that last 
third, which Senator Chambliss referred to as hard core, those who by 
choice or by chance are not covered.
  The last thing I would have done is said, We are going to throw out 
the 85 percent of this that works in order to fix the 15 percent that 
doesn't, and that, in effect, is what this bill does.
  Mr. ALEXANDER. I say to Senator Chambliss, one of the most difficult 
issues I think for many Americans who are watching what we are doing is 
the plan to cut Medicare. The new bill goes a step further. The way I 
read it--and I indicated the sections in the bill a moment ago--we are 
not only cutting Medicare, we are going to tax Medicare. Then we are 
not even going to spend the money on Medicare. In other words, we are 
going to cut grandma's Medicare, tax grandma's Medicare, then spend 
grandma's money on somebody else, and grandma's Medicare is going broke 
in 3 or 4 years, according to the Medicare trustees.
  Mr. CHAMBLISS. In addition to that, we are going to continue to tax 
young

[[Page 28657]]

people who are in the workplace for additional Medicare taxes that are 
intended to be used by them in what is called the CLASS Act, which is 
another part of this monstrous bill, and chances are those people are 
never going to see those benefits. There is one tax after another in 
this bill that applies to Medicare.
  One other aspect of Medicare that is of such critical importance here 
is that they have an $850 billion pricetag, according to the Democrats. 
According to the numbers and the figures of Senator Gregg, the ranking 
member of the Budget Committee, who came down here this morning and 
talked about it, that $850 billion is for the first 10 years. The taxes 
begin next year. The benefits don't begin until 2014. When you look at 
2014 to 2025, the first 10 years of full implementation, the cost of 
this bill is actually $2.5 trillion, not $849 billion.
  Why is it $2.5 trillion? Well, it is because the scope of government 
has broadened to such an extent that the expense of providing the 
services is going to be greater. We are going to have more people 
coming onto Medicare. We know now, as Senator Alexander said, according 
to the bipartisan Medicare Commission, we will be paying out more in 
Medicare benefits than we receive in Medicare taxes in the year 2017. 
There are only two ways to fix that: either raise taxes or decrease 
benefits. The majority that is in power in Congress today has a habit 
of not seeing a tax they don't love, so my guess is that is the 
direction in which they are going to want to go: Raise taxes on 
Medicare beneficiaries and those in the workplace again to ultimately 
pay for Medicare benefits down the road.
  The other part of this I wish to address with respect to Medicare is 
the Senator from Florida got up as we were coming on the floor and 
talked about this so-called deficit reduction. What do they mean when 
they say we are going to have a $32 billion deficit reduction over 10 
years? Well, here is how it works. The deficit reduction is brought 
about primarily by the addition of a program in this bill to Medicare, 
what is called the CLASS Act. The CLASS Act is a long-term policy of 
insurance to take care of long-term health care needs. Young people are 
going to be required--young people in the 20, 30, 40-year age bracket 
will pay into the so-called Medicare trust fund that will be used to 
pay benefits for long-term care for those individuals when they start 
reaching the age where they need long-term care. So CBO has said that 
because these folks are 20, 30, and 40 years old and they are going to 
be buying these policies, they are not going to be getting any benefits 
for another 20, 30, or 40 years. So we are going to take the position 
that all of those premiums, which go into the general fund, by 
coincidence, will go to reduce the deficit. But guess what is going to 
happen, even according to CBO, when all of these young people who have 
been paying into the CLASS Act start getting benefits. All of a sudden 
we are going to start seeing deficits in the outyears, and our children 
and our grandchildren are going to have an additional debt put on them 
because of the way this particular provision is scored--and it is being 
touted as a deficit-reducing provision right now--that truly is going 
to be a provision that adds to the deficit and the debt our children 
and grandchildren are going to have to pay.
  Mr. ALEXANDER. It must be a little confusing to the American people. 
I mean, one day Senator Reid comes out and, a big hurrah, we are going 
to reduce the deficit and we are only going to spend $800 billion, and 
then the next day Republicans come out and say, No, when the program 
gets going, it is $2.5 trillion over 10 years. I wonder if I could say 
to the Senator from Georgia, while we have heard you talk about these 
projections, the senior Republican on the Joint Economic Committee has 
come to the floor, the Senator from Kansas.
  How do you explain this to people in Kansas, Senator Brownback, who 
must be very confused by this back and forth?
  Mr. BROWNBACK. I don't think they are particularly confused. I think 
they smell a rat in this and they know if you are going to add this big 
of a program, somebody is going to tax me somewhere here.
  The interesting way this is actually scored in the bill is the 
government uses the old heavy hand of inflation. As we have heard, many 
economists have spoken in the past about how inflation is the most 
cruel tax of all, particularly for the people on a fixed income, 
because then the base dollars they have do not go as far as they used 
to. What is scored in this bill--and we have seen this time and time 
again--is what you have as an inflation factor that is not indexed. It 
is not indexed.
  I wish to show these charts here to prove it. At the end of how this 
is scored, we will end up having people who have subsidized insurance 
when they start out, but that in the outyears in the scoring will be 
taxed for having subsidized insurance. So we will be both taxing them 
at the same time as we are subsidizing their insurance. And we are 
also--and I will show a chart here in a minute--taxing their insurance 
plan that we are subsidizing at the same time, and that is built into 
the base score. So then that is how you get to a CBO score that, presto 
chango, the budget is balanced; we are even producing a surplus. It is 
this cruelty of inflation.
  People can remember back to the Jimmy Carter days with 10 percent 
inflation. They know what that did to them. Look at this. This is all 
in the CBO scoring. This is from the Joint Economic Committee staff who 
have been working through these calculations to see, How do you come up 
with adding a multitrillion-dollar entitlement program and come to a 
budget deficit-neutral facet to it? What we see here is surtax levels--
and this is kind of a busy chart--but this red line is 100 percent of 
poverty in 2009 and 100 percent of poverty built out over 100 years, 
which is also part of the scoring system, and then the median income of 
married households. What you see is families receiving subsidies 
beginning to pay the surtax in the scoring of this. That is all due to 
the cruelty of inflation.
  Mr. ALEXANDER. I wonder if I could ask the Senator from Kansas, 
haven't we heard this story somewhere before? As I remember, back in 
the late 1960s there was a so-called millionaires' tax. We were going 
after 155 very rich people in America who weren't paying any taxes and 
now we call it the alternative minimum tax, and if we don't fix it 
every year more and more people will end up paying this tax. I think 
last year there were 28 million Americans who would have had to pay the 
tax.
  Mr. BROWNBACK. That is absolutely correct, and it is the same 
technique. This is the alternative minimum tax on steroids in the 
insurance industry and in the insurance field. It is the same thing. We 
fix it every year. That is why this is such a fraud. Do you really 
think we are going to tax people for their health insurance at the same 
time we are subsidizing their purchase of health insurance? That isn't 
going to happen, so those dollars aren't going to arrive. So where are 
those dollars going to come from? It will be from deficit and debt, or 
you are going to have this cruelty of inflation taking place.
  The bill funds health care reform with increased Medicare taxes. We 
are going to see that taking place in this as well.
  Here is the chart I like that I will show. It demonstrates how we are 
going to have these Chevrolet plans--you have heard of these health 
insurance plans. Let me put this chart up. We are going to tax the 
Cadillac plans, all right? Well, it turns out under this bill, the 
Chevy becomes a Cadillac. So you are going to tax the Cadillac when it 
is still a Chevy. That is because of inflation.
  Most people know their health insurance premiums have been going up 
pretty consistently over time. Well, it turns out that the Chevy will 
metamorphose into a Cadillac and it gets taxed and that is in the CBO 
scoring of this bill, and that is how you come out with balancing the 
cost of the bill.
  None of this is going to happen. You will have some sort of AMT-type 
fix

[[Page 28658]]

that will take place on an annual basis, and at the end of the day you 
get a big debt and deficit you are going to have with it or horribly 
cruel high levels of inflation or maybe both.
  Mr. CHAMBLISS. I would ask the Senator from Kansas if he would yield 
for a question. The question is: The Senator from Kansas and I were 
elected to Congress in the same year. This is our 15th year, I believe, 
of serving. You have been over here longer than any of us have, and you 
were involved in State government as well.
  Have you ever seen a Federal program that was projected to be at X 
number of dollars of expenditure which came in on time and on budget?
  Mr. BROWNBACK. No, I haven't seen that take place.
  Mr. CHAMBLISS. Do you think that when Senator Reid comes down here 
and says this bill is going to cost $849 billion over 10 years, that is 
a correct figure for a massive reform of health care?
  Mr. BROWNBACK. No, and I don't know that there would be 5 percent of 
the public in my State who would believe that, because their experience 
tells them differently. Their experience tells them: Look, I know you 
guys make these great promises and everything, but I also know the 
further out you make this promise, the less reliable your data, and I 
have seen that whenever the government gets into things, it always 
costs a lot more and it seems as though our debt and deficit always 
keeps growing and it is way too big.
  What is troubling is that this is built into the base of how we get 
to the numbers of getting this as a budget-neutral matter. This isn't 
going to happen. On top of all of that, you say we are going to save 
$400 billion in Medicare. We have now voted four times for the so-
called doctor fix, which was a slight reduction in Medicare spending 
for providers, and I voted for it three times, to fix it, on an annual 
basis. Do you possibly think--possibly think--that the Congress is 
going to cut Medicare $400 billion, that people are going to come back 
here and say, You can't do that, you are going to be ruining Medicare 
and that Congress will fix it? I said this to Treasury Secretary 
Geithner yesterday: Our experience has never been to do something like 
that. So where does the money go? It goes right on the deficit and the 
debt and you are going to add to that $12 trillion estimate. We are 
hemorrhaging Federal money and, at the same time, the global community 
is saying, you have to get your fiscal house in order.
  We just had our President over in China, hat in hand, with our 
bankers saying, OK, we think human rights is pretty important, but we 
need that loan. What we are going to see take place, because this is a 
fiscally irresponsible package, I think we are going to see the 
international community saying words are one thing but action is what 
talks, and we are going to start pulling capital out of the U.S. 
marketplace. It is going to drive up interest rates, it is going to 
drive up inflation.
  So maybe this scenario happens, but it is cruelly done through 
inflation, and it is not fair to the American public.
  Mr. ALEXANDER. I wonder if I might ask Senator Isakson from Georgia, 
we talked a little bit about his experience as a small businessman. 
Senator Brownback has talked about taxes and how they are going to go 
up. According to the Republican Budget Committee analysis, the new 
taxes in this bill that we have on our desks would be about $850 
billion over a 10-year period of time. Senator Isakson has been a small 
businessperson. Some of those taxes would be on you. Who is going to 
pay the taxes?
  Mr. ISAKSON. My customer. The thing is, business is the collector of 
taxes for the government. Government imposes a fee, a fine, a cost to 
business, and it rolls into the base of what that business has to pay 
to produce its product and it is upon that which they make a profit. So 
this business of taxing business, they are getting business to collect 
a tax from the ultimate consumer. That is all it is.
  I want to throw something else in. I appreciate Senator Brownback 
very much. I was in Georgia a few weeks ago, Albany, near where Senator 
Chambliss raised his family, at a Rotary Club. I was asked by a fellow: 
You keep talking about a trillion. How much is that? I babbled and 
fumbled. Have you ever tried to explain that number and quantify that? 
It is a huge number. We are talking about $2.5 trillion in the first 
full 10 years. I got so frustrated that I got on the calculator to 
figure out an analogy as to how much it is. I decided, I wonder how 
many years would go by for a trillion seconds to pass. I got on the 
calculator and worked it out. It is 31,709 years for a trillion seconds 
to go by. That gives you some proportion of the volume of dollars we 
are talking about in taxes and costs and, as the Senator said so 
rightly, debt. That is a lot of money, and the American taxpayer 
ultimately is on the bill for every dime of it.
  Mr. CHAMBLISS. I ask my colleague from Georgia, we talked about this, 
and he has had extensive experience at the State level with respect to 
Medicaid. Take our State--and I think we are representative of all 50 
States. We have a Medicaid Program now that provides for coverage or 
eligibility at 100 percent of the poverty level. This bill takes that 
to 133 percent of the poverty level. Talk for a minute about the impact 
of going from 100 to 133 percent to cover some of those uninsured I 
referred to earlier. What is the impact on our State?
  Mr. ISAKSON. Right now, Georgia's current year budget for the cost of 
Medicaid is $2.15 billion, or about 12 percent of the State 
appropriations. This bill, as currently configured, raises that 
eligibility by 33 percent. But the Feds hold harmless the States for 
the first 3 years of that increase, and then it is a 90/10 split for 
the next 7 years, and then it is silent. To give everybody the benefit 
of the doubt, say States only have to pay 10 percent more. That is one-
quarter of $1 billion more in Georgia--from $2.15 billion to $2.4 
billion in the State budget.
  We all know what is going to happen--what happened with the original 
Medicaid program. The State will eventually have to pay the full 35 
percent match, which would mean that over time, at the end of the 10 
years, using today's numbers without inflation, Medicaid costs in 
Georgia for about 12 percent of the population would go from $2.15 
billion to $3.4 billion a year for Medicaid.
  Mr. CHAMBLISS. Whether it is paid by the Federal Government after 
that 3 years or by the State of Georgia, whose pocket will it come out 
of?
  Mr. ISAKSON. The taxpayers of the United States of America.
  Mr. ALEXANDER. As we were discussing earlier, it could be paid out of 
the pockets of the 18 million or 20 million students who go to, for 
instance, the University of Kansas and Kansas State. We began this 
discussion by pointing out that California raised tuition yesterday 32 
percent for its students. They are pointing fingers at each other, but 
they should be pointing at us for not reining in Medicaid because over 
time that is the biggest reason.
  Mr. BROWNBACK. In my State of Kansas, a huge budget debate is going 
on about where we are going to come up with the shortfall this year in 
the State budget. People can save in some places, but you have to do 
this on Medicaid. It ends up, in all probability, that a 
disproportionate share will come out of the schools for the 
schoolchildren. Is that what we at the Federal level want to see take 
place? No. That is one of the reasons I am voting against this bill. 
You are dictating a State budget. Initially the Feds are putting in the 
full amount, but I have seen this before too. You start with the 
Federal Government wiggling the carrot, saying: Take a bite. You can do 
it. Then once you get hooked, you say: OK, we are going to reel it in 
now, and you will pay more of it. It will be the Federal Government 
dictating the State budget, putting it into Medicaid and taking it away 
from schools. That is what will take place. That is what is happening 
in my State now.
  It is not fair to do that. It is not right for us to do that. Most of 
the people across Kansas think this whole issue is fiscal insanity--
literally fiscal

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insanity--what we are looking at doing with that level of debt, $12 
trillion a year. With my State having the level of debt it has, making 
this requirement--a multi-trillion-dollar entitlement expansion when 
the Federal Government is hemorrhaging money, as well as State 
governments--is fiscal insanity. The world community is saying: Get 
your fiscal house in order. This makes no sense.
  Mr. CHAMBLISS. I don't think we can overstate what the Senator has 
said. Not only is the Federal Government looking at the largest deficit 
we have ever seen in the history of our country--just this past year, 
$1.3 trillion--but every State is having the same problem. That deficit 
is trickling down.
  In Georgia, for example, we have one county that has run into these 
education reductions that Senator Alexander is talking about, which 
universities are facing. That one school system reduced the days the 
children are going to school from 5 to 4 days to save the cost of buses 
running and other bills, for heating and whatnot, for that extra day. 
That is not what we need to be doing as Americans. We need to figure 
out a way to struggle through this.
  Instead of struggling through it, we are now in the toughest times we 
have ever seen, as Senator Brownback said, we are adding these huge 
taxes that will stifle the small business community on top of the debt 
that we have seen created in this country just in the past 12 months.
  Mr. ALEXANDER. I have a question I will ask any of the Senators who 
want to comment. Someone asked me yesterday: Where is all this 
opposition to these health care bills coming from? We have seen the 
Gallup poll and the Pew poll. These are not Republican Polls. They are 
well-respected polls in this country that are showing that independent 
voters, by 2 to 1, say they don't want this bill.
  I have been in and out of politics for many years. I have never had 
as many people stop me on the street or in the airport or wherever, and 
say, ``Please don't do this.'' Somebody asked me yesterday: Why is 
there that much opposition?
  My answer was--and this is what I would appreciate comments on--this 
is not just about health care. This is, as President Obama said one 
time, a proxy for a national debate about the role of government in 
Washington and in everyday American life. This is about the stimulus 
package, about the Washington takeover of car companies. This is about 
the growing debt; this is about the takeover of student loans; this is 
about every Washington takeover, and every increase in debt. That is 
what this debate is about. I think that is why we are seeing such 
intensive opposition. I wonder if you have any reflection?
  Mr. BROWNBACK. I certainly think it is. What I observe, too, is 
people coming up to me in large numbers and very passionately saying 
they are both mad and scared. They are mad about this taking place, and 
they are scared it is going to actually happen to them. They feel like, 
how can this happen to them in this country? They look at that huge 
debt and at our President over in China talking as if he is going to 
see the banker, and they don't like it. This isn't their country the 
way they want it to be. They want our country to be fiscally sound 
instead of going to beg hat-in-hand to the ``banker'' in a foreign 
country. Then you are going to add another big entitlement on top of 
that? They are saying: Don't ask me, the taxpayer, for more money 
because I don't have it. They are mad and scared about this. It is very 
disconcerting for people in the country.
  Mr. ISAKSON. I agree with Senator Brownback. I guess I could sum it 
up in four phrases. There will be less access, seniors fear, because of 
cuts in Medicare. They will have less access. There will be higher 
costs because of the bending of the way in which they calculate 
premiums and the additional taxes. Everybody knows that will be a 
higher cost. There is a great fear of rationing, which is a component 
part of almost every plan to get from where we are to where they want 
to take us.
  Lastly, I hear a lot from young people who are considering a medical 
career either in research or in applied medicine. They fear that 
medicine will not be the practice in this country in the future that it 
has been in the past. If that is true, if they leave and go to other 
fields, we will have less innovation and research and development and, 
in the end, less quality health care for the American people.
  Mr. CHAMBLISS. These are not people who are on the extreme right or 
extreme left who are bombarding us with phone calls, e-mails, and 
letters as all of us get on airplanes, as I did Monday. I had people 
come up as I walked through the airport, and as I was on the airplane, 
and when I got off the airplane, saying: Please stop this bill. Don't 
pass this foolish bill that you all are talking about up there now. It 
is amazing, the type of folks who will come up and say that.
  I have two quick anecdotes I would like to read. One is a letter I 
got from a doctor. It reads:

       Dear Senator:
       I am a vascular surgeon in Rome, GA, with a patient 
     population that is 70 percent Medicare. I am deeply concerned 
     about the proposed Medicare cuts. After 8 years of college 
     and medical school, and 7 years of training, I have 
     accumulated a large debt in loans and interest. Plus there is 
     the huge administrative burden of a large Medicare population 
     in my practice. I don't know how I and other physicians are 
     going to be able to afford to continue to see Medicare 
     patients if these cuts go through. As it stands now, I am 
     paid only 23 cents on every dollar charged. I would 
     appreciate help in staving off these cuts.

  The other one is an e-mail I got in the last few days about a good 
friend of Senator Isakson and mine, Bob Lovein, a funeral director in 
Nashville, GA, which is close to my hometown. It says this:

       A lady walked into the funeral home and gave him a letter 
     from the VA. The letter stated that they (the VA) owed her 
     $307 on her husband's death benefits. Bob pulls her husband's 
     file and he had buried him 10 years ago . . . and we trust 
     the government to run health care?

  That is how ridiculous it is in the minds of people in this country 
who are calling and writing our offices--certainly the offices of every 
one of the Members of this body--because they don't understand why we 
are mortgaging and sacrificing our children's future, or why, as 
Senator Brownback says, when the President goes to China to see their 
banker--China owns almost $1 trillion worth of our debt--the Chinese 
Premier asked the President about the health care bill because he is 
concerned about the way we are spending money here.
  I can never remember any foreign leader ever asking the President of 
our country about anything to do with the financial condition, 
particularly a program like this, which would affect us.
  Mr. ALEXANDER. I am afraid our time is almost up.
  Mr. BROWNBACK. Yes, our President got lectured by the Chinese 
regulator about our financial system. This is unbelievable. This 
exacerbates it, if we pass this bill.
  Mr. ALEXANDER. I thank Senators Brownback, Chambliss, and Isakson. I 
think all four of us want the American people to know above all that we 
have repeatedly said that instead of 2,000-page bills that raise taxes, 
raise premiums, cut Medicare, and transfer costs to States, we would 
rather identify the goal of reducing costs and go step by step toward 
that goal. We have introduced specific legislation to take those steps, 
which could be bipartisan, such as allowing small businesses to pool 
their resources to purchase insurance, that Senator Isakson talked 
about, and reducing junk lawsuits, as Senator Chambliss talked about, 
and allowing competition across State lines. We have our step-by-step 
plan.
  We believe the American people have lost confidence in Washington and 
that they would prefer that we go step by step in the right direction 
to reduce costs and re-earn their trust rather than pass a 2,074-page 
bill that will bankrupt the country.
  I yield the floor.
  Mr. BROWNBACK. Mr. President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The bill clerk proceeded to call the roll.

[[Page 28660]]


  Mr. HARKIN. 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. HARKIN. Mr. President, the debate has now begun on the bill we 
call our health care reform bill. It has taken us a long time to get 
here. After a lot of hearings, a lot of markup, a lot of public 
discussion, a lot of town meetings around the country, now we are at 
the final pivotal moment, a historic moment in the long march to pass 
meaningful health care reform.
  I say long march because it started with Theodore Roosevelt and 
continued on through the New Deal, continued on to Harry Truman's 
administration, and on to this time. Every time we have been turned 
back by the status quo forces, those who want to stick with what we 
have, those who are afraid of making changes. This time they are not 
going to stop us. This time it is unstoppable. We have come this far, 
and we are not going to turn back.
  Just listening to a little bit of the discussion on the Republican 
side today and listening to what the Republicans have had to say about 
health care reform in the last few months and anticipating what we will 
hear from Republicans in the next few weeks, it will be a message of 
fear that somehow by changing the status quo, the American people are 
going to be worse off than they are now, that somehow we are going to 
take away something they have, that somehow if we just stick with what 
we have, everything will be fine. But you will hear a lot of words and 
messages from the Republican side meant to frighten people, to put a 
pall of fear over what we are trying to do.
  The frightening thing for the American people is if we do nothing, if 
we stick with the status quo. Too many people in this country have no 
health insurance whatsoever. Thousands every day in this country, every 
single day thousands of people lose health care insurance coverage. So 
many people who have preexisting conditions cannot get coverage at all. 
People who are beginning to retire but they are not quite 65 and cannot 
get on Medicare are left in a state of limbo, where they cannot get 
health care coverage.
  So many people in this country are being discriminated against in 
health insurance because--well, because they are a woman or perhaps 
because they are older, perhaps they are a person with a disability. 
For a variety of reasons, they are being discriminated against in 
health insurance coverage.
  We have to make these changes. We cannot continue to spend over the 
$2 trillion a year and still be so lacking in the essential health care 
services for the people of this country. We spend twice as much in this 
country on health care as Europe. Yet we have twice as many people sick 
with chronic illnesses. That does not seem to make sense.
  We have some of the highest of high-tech medical devices and 
procedures and interventions anywhere in the world and, of course, 
people who have a lot of money in other countries--we always see kings 
and princes and wealthy people from other countries come here. They 
come here for the very high-tech, high-cost interventions. We are very 
good at that. We are the best. We are unequaled in that. But where we 
fall short is helping the very broad mass of American people to have 
the peace of mind knowing that if something happens to them, if they do 
get ill, they are not going to lose everything.
  The single biggest cause of bankruptcy--I know in my State of Iowa 
and I think most of the country, the single biggest cause of bankruptcy 
is because of medical expenses because people bump up against lifetime 
caps or annual caps, they cannot make it, and they declare bankruptcy. 
In no other country in the world is this allowed to happen. It is 
incumbent upon us to get this bill through.
  At the beginning, I wish to salute our majority leader Harry Reid for 
what he has done. We had our bill that came out of the committee that I 
am now privileged to chair after the untimely death of our esteemed 
colleague and friend, Senator Ted Kennedy. Our HELP Committee bill came 
through under the great leadership of Senator Chris Dodd. We passed it 
on July 15. Then the Finance Committee, under the able leadership of my 
friend and classmate Senator Max Baucus of Montana, did their work. 
Then the two bills had to be put together and that was done by the 
majority leader and he did a masterful job of putting the two bills 
together and getting it down to the Congressional Budget Office and 
getting a score on what it would cost, what it would cover. When we saw 
the bill come back--the bill we now have in front of us, the so-called 
merged bill--it truly is a work of genius by the majority leader.
  I said the other day that he has the patience of Job, the wisdom of 
Solomon, and the stamina of Sampson to get this job done.
  I also salute all the Senators--Democrats and Republicans--whose 
ideas are incorporated in this bill. It is a robust bill. It went 
through a long, bipartisan process. In our committee, we had 
proceedings that spanned 13 days, 54 hours. Republicans were full-
fledged participants. They offered 210 amendments. We accepted 161, 
many of them making substantive changes in the bill.
  A similar open and inclusive process was followed in the Finance 
Committee. I daresay, when we got our bill through, after all that, 
after all the amendments offered, accepted or adopted, not one 
Republican would vote for our bill--not one. It is truly unfortunate 
now that we have put these bills together, we have gone through this 
long process that has taken most of this year, that Republicans have 
now chosen the path of delay and filibuster and obstruction.
  Why are we even here today? We are here because the Republicans are 
trying to prevent us from even bringing the bill to the floor for 
debate. How many people in America know that? The reason we are here is 
because the Republicans do not even want to bring the bill to the floor 
for debate and amendment. That is their right under the rules of the 
Senate. It is their right. They can filibuster. They can delay. They 
can obstruct. They can say no. But just as surely as that is their 
right, it is our responsibility, as Democrats, to move this bill 
forward.
  I remind my colleagues on the other side of the aisle that last year 
voters overwhelmingly voted for Barack Obama to make changes, and one 
of the changes he campaigned so hard on was changes in the health care 
system and, just as surely, voters elected Democrats to majorities--big 
majorities--in the House and the Senate to do the same thing. So it is 
our responsibility to lead, and that is what we are doing now by 
bringing this bill to the floor. We are taking another giant step 
toward fulfilling the mandate--the mandate--the people of this country 
gave to President Obama and the Democratic Party last November to 
undertake a comprehensive reform of America's health care system.
  As not only the long debate has made clear to the American people, 
but innately the American people know and they understand the current 
system is hugely dysfunctional, it is wasteful, and it is abusive. 
People are aware of the abuses that have become standard practice in 
the health insurance industry: denied coverage because of preexisting 
conditions; health insurance being dropped because they get sick; their 
insurance premiums jacked up 100 percent, 200 percent in a year simply 
because they had an illness.
  People know they can be charged higher rates simply because they are 
a woman. We know, we have the data. Woman, man, same age, same 
occupation, same status--a woman is charged more than a man for the 
same policy or they are charged more if they are older. We know about 
annual caps and lifetime caps I just mentioned that cause people to go 
into bankruptcy.
  The bottom line is this: Every American family knows that in many 
cases, they are one illness away from financial catastrophe. If you 
want to talk about fear, that is what people are afraid of, not so much 
of getting sick--that is part of life--but the fact that illness will 
drive them to financial ruin, that they will not have enough money to 
take care of their kids, to send them to college, or to take care of

[[Page 28661]]

themselves in their old age to supplement their Social Security because 
the money will be used for an illness.
  As I said earlier, 62 percent of U.S. bankruptcies are linked to 
medical bills. What is the kicker in this is that 80 percent of those 
were people who actually had health insurance, but they ran up against 
their lifetime cap. Abuses, abuses by the health insurance industry 
because they can do it and they can get by with it.
  Think about it this way: Health insurance companies employ armies of 
claims adjustors who routinely deny requests for medical tests and 
procedures. Why do they do that? Because they get bonuses by saying no 
to the policyholder. Think about that. An insurance company says to 
their claims adjustors: We will pay you more the more people you deny. 
What a system. It is outrageous. It is intolerable, and we cannot 
afford to let it go on any longer.
  One of the many things we do in this bill is to crack down on these 
health insurance companies' abuses in a very strong and robust way. 
Again, I deeply regret that our Republican colleagues refuse to join us 
in this reform effort. They have chosen to defend the status quo, 
protect the insurance companies and their profits over the health of 
the American people.
  Indeed, my friends on the Republican side and the health insurance 
companies are now joined at the hip--same talking points, same 
distortions, same untruths about this bill, same bogus, cooked-up 
studies, the same determination to obstruct and kill any health care 
reform effort.
  As I said earlier, this time they will not succeed. The more the 
American people learn about this bill and what is in this bill, the 
more they like it and the more they are demanding that we get the job 
done.
  President Obama pledged that we would do health reform and not add to 
the deficit. We have done that with this bill. The Congressional Budget 
Office says this bill will actually reduce the deficit by $130 billion 
next year and by $650 billion in the next decade--$650 billion--and it 
will reduce the deficit continually every decade thereafter. All the 
budget concerns have been put to rest. Now we can focus on what is in 
the bill.
  The Congressional Budget Office says our bill will cover 94 percent 
of the American people; 94 percent will now be able to have the peace 
of mind to know they have health insurance coverage.
  Our bill says if you have a health care plan that you like and that 
you want to keep, nothing will disturb that--nothing. You can keep 
whatever plan you want if you like it.
  A lot of people say this plan doesn't go into effect until 2014. It 
does take some time to get these exchanges and things set up, but there 
are some immediate things that will happen next year, and the American 
people ought to know what that means. For example, our bill right now 
would ban lifetime and excessive annual limits on coverage next year--
not 2014 or 2015, next year. Think about that in your own policy. Your 
policy, I guarantee, has some kind of lifetime cap or annual caps. Next 
year, they will not be able to do that any longer.
  Our bill bans rescissions. What that means is that right now so many 
people don't know that their health insurance policy can drop them. 
There is a clause in it that says that when you are up for renewal, 
they can drop you for any reason. The reason they use is, if you get 
sick. Think about that.
  I can't tell you how many people I have talked to in my State of Iowa 
who have come up to me, especially during the town meetings we have had 
this summer, and have said: I like my health insurance policy. I have a 
good policy, and I would like to keep it.
  My rejoinder is: That is fine, but I want to ask you a couple of 
questions. What is your lifetime or annual cap?
  Most often, people say: I don't know.
  I say: Do you have a lifetime or annual cap in your policy?
  They aren't certain.
  I say: Do you have a rescission clause in your policy?
  I can tell you 100 percent of the people I have talked to said: What 
does that mean?
  I said: What it means is, if you get sick, if you have to have a 
kidney transplant or if you have cancer or heart disease, can your 
insurance company drop you when your policy comes due, with no 
explanation whatsoever?
  They don't know.
  I said: You have to look at your policy and find out, because most 
policies have those rescission clauses.
  I daresay, when a lot of people say they have a good health insurance 
policy, they answer yes, they do have a good health insurance policy, 
as long as they are healthy. As long as you are healthy. Once you get 
sick, out the window it goes because you have a cap, either a lifetime 
or an annual, or you have a rescission clause.
  The other thing I hear from a lot of families: You know, my kids were 
covered when they were in school. They are now out of school, they have 
not quite gotten a job yet, and I can't keep them on my policy and it 
costs a lot of money to put them on a different policy.
  Our bill says that now these young people can stay on their family 
policy until they are age 26. This is a huge benefit to working 
families.
  I have said many times that the two biggest winners under our health 
care reform bill are small businesses and the self-employed. Small 
businesses--we are in a deep recession. If we want to get out of that 
recession, we better start focusing on small businesses because it is 
small businesses that create over 65 percent of the jobs in this 
country. Yet small businesses are thwarted in their effort to expand 
and grow. One of the biggest reasons is because of the cost of health 
care for their employees. So many small businesses now have dropped 
health care coverage for their employees because they simply cannot 
afford it or the premiums have gone up, the deductibles are huge, and 
basically what it has gotten to be is basically catastrophic coverage 
for their employees. Small businesses need help in order to grow and 
expand and get us out of this recession. This bill will provide 
immediately, next year, up to a 35-percent tax credit for health 
insurance policies for their workers. That is a big deal. It is not 
just for small businesses, it is for my farmers and for those who are 
self-employed--for so many self-employed in this country, next year, a 
tax credit of up to 35 percent.
  Next year, we are going to have a new policy option for people who 
have preexisting conditions. So if you had an illness in the past, if 
you have been living with cancer and you have it under control, you 
have a chronic illness, next year we are going to provide a new policy 
option to put people like that into a high-risk pool and provide that 
they can get insurance coverage at prices they can afford. When the 
exchanges come on in 3 years, all of that will go by the wayside. They 
will not be able to discriminate because of preexisting conditions. But 
next year, right away, people who have preexisting conditions can get 
policies at prices they can afford.
  How many times do I hear people tell me: Here I am, I have been 
working hard, I have been a construction worker, or something like 
that, that is hard work. I am 55. I have had some accidents. I have a 
bum leg and my back is bad. I can't work until I am 65. But what am I 
going to do about my health insurance?
  We have in here, starting next year, if you are an early retiree, we 
have a program to protect your coverage and at the same time reduce 
your premiums, both for you and your employer, until the time you get 
to be age 65. This is a big deal for so many people in this country.
  Last, in whatever time I have left--parliamentary inquiry: How much 
time does the Senator from Iowa have left?
  The PRESIDING OFFICER (Ms. Klobuchar). The Senator has 37 minutes 13 
seconds.
  Mr. HARKIN. Madam President, I understand my friend from North Dakota 
wishes to speak. I will wrap this up by saying there is one other part 
of this bill that is so important that doesn't get much play but I 
consider to be one of the most significant parts of this

[[Page 28662]]

bill, and that is an emphasis on prevention and wellness, keeping 
people healthy in the first place.
  There is a lot of talk about bending the cost curve and how we are 
going to bend that curve and get costs down. I submit that not only the 
best way but perhaps the only way we are going to do this is by keeping 
people healthy in the first place, putting more emphasis on prevention.
  I have often said that we don't have a health care system in America, 
we have a sick care system. If you get sick, you get care. Almost all 
of our expenditures go for interventions and patching and fixing and 
mending once somebody gets sick. Very little goes for prevention. About 
96, 97 cents of every dollar goes for taking care of you after you get 
sick. Only about 3 or 4 cents goes to prevention. It is time to do more 
for that, time to do more for prevention and wellness, keeping people 
healthy in the first place.
  In this bill, we have a provision that says that if you want to go in 
for your annual checkup and your annual screening, no copay, no 
deductions, and for certain other screenings, such as colonoscopies, 
breast cancer screenings, and things like that, no co-pays, no 
deductibles.
  In the ensuing days and weeks when we debate that, I will be talking 
a lot more about the prevention and wellness part of this bill. It is 
big. It is the first time we have ever done anything like this, to 
begin to move the paradigm in this country away from sick care to 
health care. Our goal in this bill with this provision is to change 
America into a wellness society, where it is easier to be healthy and 
harder to be unhealthy--just the opposite of what it is today. It is 
easy to be unhealthy in America today. It is hard to be healthy. We are 
going to change that around, and we are going to start with this bill.
  One of the most important parts of this bill is the massive change we 
are going to make in prevention and wellness.
  I note the presence on the floor of my distinguished colleague from 
North Dakota. I yield the floor.
  The PRESIDING OFFICER (Mr. Kaufman). The Senator from North Dakota is 
recognized.
  Mr. CONRAD. Mr. President, I thank the Senator from Iowa, Mr. Harkin, 
and I commend him for the outstanding work he did on the HELP 
Committee, especially on the prevention provision. I don't think there 
is anyone in the Senate who has been more dedicated to moving us from a 
sickness system to a wellness system than the Senator from Iowa. He did 
outstanding work on the prevention provisions in the Health Committee 
bill, many of which now are in the bill before us. I applaud him for 
his leadership because in many ways those are the most important 
provisions. If we can encourage people to lead healthy lifestyles and 
have an emphasis on wellness, we can change the quality of millions of 
people's lives.
  I personally think the provisions Senator Harkin authored that are 
part of this legislation are in many ways the most important pieces of 
this bill. What is interesting is they have received very little 
attention in the public debate. In fact, many of the most important 
provisions in this bill have very little attention in the public 
debate. Hopefully, over the next weeks that will change and people will 
learn what is really in this bill versus the rumors of what is in this 
bill. They are very different things.
  I again thank the Senator from Iowa for his leadership. It made a 
real difference to the quality of this bill.
  Why are we here? We are here because we face a completely 
unsustainable situation in health care in this country. Medicare is 
going broke, premiums are rising 3 times as fast as wages, 46 million 
people have no health insurance, spending is twice as much per person 
in our country as in almost any other country in the world, and the 
outcomes of our system for our people are not as good as they should 
be. So it is very clear: The status quo is unacceptable. Doing nothing 
is not an option. Failure is not an option. It is critically important 
that we reform the health care system in this country. If we do not, 
our families' budgets will be threatened, our businesses will be 
threatened, and the Government itself is threatened. That is the 
reality.
  I want to praise Leader Reid for putting together a responsible 
package and a really very good first step. I also want to praise 
Senator Baucus for his leadership in the Finance Committee. He did an 
outstanding job. I have never seen, in my 23 years, any committee 
chairman have as diligent and focused an effort as Senator Baucus gave 
this in the Senate Finance Committee over a 2-year period. Our group of 
6 alone met 61 times, and there were dozens and dozens of other 
hearings, meetings, forums, roundtables. Senator Baucus organized a 
health care summit last year, and that was a model of how Congress 
ought to approach an issue. So I give high praise to Senator Baucus.
  Senator Dodd, who was called in at the eleventh hour to replace 
Senator Kennedy because of Senator Kennedy's illness, deserves enormous 
credit, enormous praise for picking up the ball at a critical juncture 
and carrying it across the line in the HELP Committee as well.
  Senator Reid had the very difficult task of bringing together the 
Finance Committee bill and the HELP Committee bill, combining them into 
a vehicle for consideration here.
  This bill is not perfect. No work of humans ever is. Certainly more 
needs to be done to control cost. That is what I believe. But this is a 
very good beginning. This bill makes an important contribution to 
improving health care. Those who labored for months and months to 
produce it deserve our thanks and praise.
  I am somewhat taken aback by speeches I have heard from colleagues 
over the last several days acting as though this vote tomorrow is the 
end of the story. Anybody who understands Senate procedure even a 
little bit knows this is the beginning of the story. This is the 
beginning of the debate. This is the beginning of a process to amend 
and improve the bill. This is the beginning of the discussion on the 
floor of the Senate about legislation to reform the health care system. 
I don't know of a single credible reason to vote against going to 
consideration of legislation to reform the health care system in this 
country. This isn't about the final result. This is about beginning the 
discussion and the debate. Who would want to prevent a discussion and 
debate? Who would want to prevent Senators from being able to offer 
amendments to improve the legislation?
  If people are dissatisfied with the product at the end of the 
process, that is when they can vote no. They can vote no against 
cloture. They can vote no against the package. There are lots of 
opportunities to oppose it if you are unhappy with the final result. 
But being unwilling to even discuss the subject strikes me as a 
preposterous position.
  This plan meets key health care reform benchmarks. It is fully paid 
for. In fact, according to the Congressional Budget Office--not 
controlled by Republicans or Democrats; it is strictly nonpartisan--
this measure reduces the deficit by $130 billion over the first 10 
years. That is their judgment. In the second 10 years, they say this 
legislation will reduce the deficit by $650 billion. When people come 
out here and say this increases the deficit, this increases the debt, I 
don't know what legislation they are talking about. It is not the 
legislation before us. They are, of course, free to make up whatever 
numbers they want, but the official evaluation of this legislation by 
the nonpartisan CBO, the Congressional Budget Office, is that this bill 
reduces the deficit in both the short and long terms.
  It also expands coverage, according to the CBO, to 94 percent of 
Americans. It contains critical insurance market reforms and, perhaps 
even more important, delivery reforms. We will get into those in a 
minute.
  Let's talk about the need for action. This chart shows what is 
happening to premiums for health insurance coverage. Premiums are 
projected to continue to rise on American families. In 1999, premiums 
averaged $6,050. In 2009,

[[Page 28663]]

they increased by 117 percent. What the experts are telling us is, from 
2009 to 2019, they will go up another 71 percent to average premiums in 
2019 of $22,440 to an American family for health care premiums. How 
many families will be able to afford premiums of $22,440?
  At the same time we see employer-based health care coverage--and the 
vast majority of our people receive coverage at their place of 
employment--is in decline, from 68 percent to 62 percent in 2008. In 
2000, 68 percent of companies were offering health care coverage. That 
is down to 62 percent in 2008.
  At the same time we know 46 million fellow citizens do not have 
health insurance. That is projected to increase, by 2019, to 54 million 
who will not have health insurance. It is interesting because every 
other industrialized country in the world has universal coverage. They 
have figured out a way to provide health insurance to every family in 
their countries. France, Germany, Great Britain, Japan, every other 
major industrialized country has figured out a way to provide health 
insurance for every one of their citizens. It is time for America to do 
the same. That is a moral issue. That is not just a financial issue; it 
is a moral issue. What kind of country are we going to be?
  This is a letter I received from a constituent in September. I wanted 
to share it with my colleagues.

       Dear Senator Conrad, I am 51 years old and have never given 
     much thought to writing a Senator until now. Three days ago, 
     we received some of the worst news a person can get. My 
     husband has been diagnosed with bladder cancer. He does not 
     have health insurance. We are self-employed. Our income is 
     low but we do own some property which makes us ineligible for 
     most assistance programs. A few years ago we both dropped our 
     Blue Cross Blue Shield because the premiums were too high. I 
     re-applied and got my insurance back but my husband was 
     denied due to his weight. (He quit smoking 4 years ago and 
     put on weight gradually since then.)
       We are stunned by the diagnosis and are terrified by the 
     uncertainties of his prognosis. We already owe $2,000 just 
     for emergency room costs and he has surgery scheduled for 
     September 22 with at least an overnight stay in the hospital. 
     The medical bills will be astronomical. If the cancer is not 
     localized, he will be referred to oncology and will begin 
     chemotherapy/radiation treatment and possibly even more 
     surgery. We will have to sell almost everything we own to pay 
     [the] bills.
       Please, sir, consider our story when thinking about health 
     care reform. Any change will happen too slowly to help us but 
     others will benefit. Don't give up. We are counting on you to 
     make a difference.

  To that woman, I make this pledge: I am not going to give up. I think 
enough of my colleagues will not be giving up so that we can at least 
begin the debate on whether there should be health care reform in this 
country. I repeat, I can't think of a single credible reason why 
somebody would vote against beginning the debate, to have a chance to 
amend. If you don't like the product as it has come to the floor, that 
is what legislating is about, the opportunity to amend, the opportunity 
to improve, the opportunity to convince colleagues that we need to move 
in a different direction. I don't know what could be more clear than 
that we have to move in a different direction on health care.
  We are now spending 17 percent of our gross domestic product on 
health care. That is $1 in every $6 in this economy. The experts tell 
us by 2050, we will be spending 38 percent of our gross domestic 
product on health care, if we stay on the current trend line. That 
would be more than $1 in every $3 in this economy on health care. That 
would be a disaster for the American economy, a disaster for the 
budgets of families and businesses. That simply cannot be the result 
for our Nation.
  On Medicare and Medicaid spending, in 1980, if you put the two 
together, Medicare and Medicaid consumed 2 percent of our gross 
domestic product; $1 in every $50 in this economy was going to Medicare 
and Medicaid. In 2010, we are up to almost 6 percent of GDP for 
Medicare and Medicaid, three times as much as a share of our economy. 
But look where we are headed. By 2050, again on the current trend line, 
we would be spending 12.7 percent of gross domestic product just on 
Medicare and Medicaid, six times as much as back in 1980. If we look at 
the indebtedness of the country, there is no bigger contributor than 
Medicare. It is the 800-pound gorilla: $37.8 trillion of unfunded 
liability in Medicare. The comparable number for Social Security is 
$5.3 trillion. We can see the unfunded liability in Medicare is seven 
times the unfunded liability in Social Security.
  For those who say, let's not even go to a debate, let's not even go 
to a discussion on reforming health care, what is their proposal? Are 
they afraid to offer one? Do they not have one? Is their answer do 
nothing? Is their answer really to do nothing in the face of a crisis 
of this magnitude? Their answer is: Let's not even debate it; let's not 
have even have a chance to amend it?
  That is not a credible position. It is not a responsible position. It 
is not a serious position. That is a position of obstruction, pure and 
simple.
  If we look at our system, we have had a review by Dartmouth Medical 
School. They concluded:

       Although many Americans believe more medical care is better 
     care, evidence indicates otherwise. Evidence suggests that 
     states with higher Medicare spending levels actually provide 
     lower quality care.

  They went on to say:

       We may be wasting perhaps 30% of U.S. health care spending 
     on medical care that does not appear to improve our health.

  As a country, we are spending almost $2.5 trillion a year on health 
care. If 30 percent of that money is being wasted, is not contributing 
to better health, 30 percent of $2.5 trillion is $750 billion a year. 
The answer by some of our colleagues is, let's not even debate it. 
Let's not even discuss it. Let's not even attempt to address it.
  That is a remarkable position to take.
  If we look at our country versus others around the world, we see we 
are spending far more as a share of our income than they are. If we 
look country by country: Japan is spending 8 percent of GDP; the United 
Kingdom, 8.4; Belgium, 10 percent; Germany, about 10; Switzerland, 
almost 11; France, 11; and we are at 16 percent. That is as of 2007. We 
have gone up to 17 percent of GDP in 2009 on health care. We are 
spending as a share of the economy almost twice as much as any other 
major industrialized country in the world. Yet we still have 46 million 
people without any health insurance.
  Under the British model, they have universal coverage. Under the so-
called Bismarck model, countries of Germany, France, Japan, 
Switzerland, and Belgium have universal coverage. Yet if we remember 
their costs, we see even though they are providing universal coverage 
in these other countries, their costs are much lower than ours.
  If we look further at the quality of health care outcomes, quite an 
interesting story emerges. Those countries have universal care, lower 
costs. And if we look at quality outcomes, they do better than we do. 
On preventable deaths, the Commonwealth Fund, which is very 
distinguished and nonpartisan, looked at preventable deaths around the 
world. They found the United States came in nineteenth. But other 
countries that have much lower costs and have universal coverage, for 
example France and Japan, are ranked 1 and 2. With much lower costs and 
universal coverage, they are getting better results. And some do not 
even want to debate going to health care? They are going to have a tall 
order to explain why they do not even want to discuss it.
  On infant mortality, the United States is ranked 22nd, again, 
according to the Commonwealth Fund. Again, these are countries that 
have universal coverage, with much lower costs than we do. Ranked No. 1 
was Japan. France was No. 5. Germany was No. 9. From my earlier chart, 
you will remember each of those countries has universal coverage and 
much lower costs than we do, and yet they are getting, on these 
metrics, better outcomes than we are.
  It does not stop there. Here is life expectancy, as shown on this 
chart. The United States is ranked 24th. This is according to the OECD, 
the international scorekeeper. Again, Japan, Switzerland, France--
universal coverage, much lower costs--still ranked

[[Page 28664]]

much higher than we do on that metric.
  Japan, with universal coverage, much lower cost than we have--in 
fact, half as much as ours--yet they were No. 1. Switzerland, No. 2--
they have universal coverage, with much lower cost than we have, and 
yet they rank No. 2. France, with universal coverage, much lower cost, 
is ranked sixth in the world.
  It would seem to me we ought to look to evidence, and evidence shows 
us there is a better way, and that is what this legislation seeks to 
find. It seeks to find a better way to expand coverage, to improve 
quality, and to contain exploding costs.
  The key elements of this Senate health care reform plan are these: 
One, it reduces both short- and long-term deficits. I noticed in one of 
the newspapers circulated on the Hill today a full-page ad asking: How 
can Senator Conrad, who is a deficit hawk, be for this bill? Well, 
because I have read the CBO analysis, the Congressional Budget Office 
analysis, that says clearly and unequivocally this bill lowers the 
deficit. It lowers it by $130 billion over the first 10 years. It 
lowers it by $650 billion over the second 10 years, according to the 
Congressional Budget Office.
  So when somebody asks, How can a deficit hawk like Senator Conrad be 
for this bill? It is because this bill lowers the deficit. That is not 
my analysis. That is the official analysis of the Congressional Budget 
Office which is nonpartisan.
  This bill also expands coverage to 94 percent of the American people. 
It promotes choice and competition. It reforms the insurance market. It 
improves the quality of care. All of these issues are at the heart of 
what reform must be.
  The Senate health plan reduces short- and long-term deficits. It 
extends Medicare solvency. Medicare is going to go broke in 8 years. 
This bill extends the life of Medicare by 4 to 5 years. It extends the 
solvency of Medicare by 4 to 5 years. It includes reforms to improve 
delivery of care and reduces costs.
  It curbs overpayments to Medicare Advantage plans. Some Medicare 
Advantage plans are now costing 150 percent of traditional fee-for-
service Medicare. Medicare Advantage was started on the basis it would 
save money. In fact, it was initially capped at 97 percent of 
traditional fee-for-service Medicare. It was supposed to save money. 
Now there are Medicare Advantage plans that cost 150 percent of 
traditional fee-for-service Medicare. It is not saving money, it is 
costing much more money. And it will break Medicare if we do not reform 
it. That is clear.
  This bill also creates an Independent Medicare Advisory Board to make 
recommendations on how we can have further savings to extend further 
the solvency of Medicare. It also includes an excise tax on insurers 
offering Cadillac plans. Virtually every analyst who came before the 
Finance Committee said one of the most important things we could do was 
to start with a levy on Cadillac health insurance plans to reduce 
overutilization and to begin to control the exploding costs.
  When I say this bill reduces the deficit, that is not my assertion or 
the work of the Senate Budget Committee. That is the judgment of the 
official scorekeeper here, the nonpartisan Congressional Budget Office. 
Here is a page from their report, and it shows very clearly, from 2010 
to 2019, this legislation reduces the deficit by $130 billion.
  I have heard colleagues come to the floor and give all kinds of 
speeches about how this increases the deficit. They have every right to 
come here and make up any numbers they want to make up. They can make 
any claim they want. But let's be clear, the official analysis of this 
bill by the agency we have all empowered to give us objective analysis 
has concluded that this bill reduces the deficit by $130 billion over 
the first 10 years, and $650 billion over the second 10 years.
  The Congressional Budget Office on the Senate health plan and 
reducing long-term deficits:

       . . . CBO expects that the bill, if enacted, would reduce 
     federal budget deficits over the ensuing decade [beyond 2019] 
     relative to those projected under current law--with a total 
     effect during that decade that is in a broad range around 
     one-quarter percent of gross domestic product.

  Gross domestic product over that second 10-year period is forecast to 
be $260 trillion. One-quarter of 1 percent of $260 trillion is $650 
billion.

       . . . CBO anticipates that the legislation would probably 
     continue to reduce budget deficits relative to those under 
     current law in subsequent decades. . . .

  In other words, it would continue to reduce deficits beyond the first 
20 years.
  The excise tax, which virtually every analyst has said needs to be 
part of a package if you are going to be serious about controlling the 
explosion of costs, will target plans that have a value of more than 
$23,000 a year. The average premium in 2013 is projected to be $15,740. 
So these Cadillac plans are plans that would have a value of more than 
$23,000 a year. There are very few people in the country who have plans 
of that value today, and there will be very few who will have plans of 
that value in 2013.
  The Senate health care plan also expands coverage. According to the 
Congressional Budget Office, it covers 94 percent of the American 
people by building on our existing employer-based system. It creates 
State-based exchanges for individuals and small businesses.
  It provides tax credits to help individuals and small businesses buy 
insurance. In fact, there is more than $400 billion of tax credits 
here. Somebody said: Well, this is a big tax increase. It is a big tax 
increase. Well, they must have left out the $400 billion of tax 
credits. They must not have gotten to that page in the bill.
  It expands Medicaid eligibility with assistance to States so they are 
able to afford it.
  The Senate health plan also promotes choice and competition. It 
creates a public option to compete with private plans, but not one 
based on Medicare levels of reimbursement. I think many of my 
colleagues know I strongly resisted a public option tied to Medicare 
levels of reimbursement because that would work a real hardship in my 
State. But in this plan, there is no tie of a public option to Medicare 
levels of reimbursement. And States can opt out. It also provides seed 
money for nonprofit cooperatives--member-run, member-controlled 
cooperatives--to compete with private plans.
  This chart shows the Medicare reimbursement per enrollee for 2006. 
You can see, New York was getting nearly $10,000; North Dakota, though, 
$6,000. That is the kind of disparity that exists in Medicare 
reimbursement. It is even more dramatic if you look at institution to 
institution. In fact, for many years, I was shown a hospital in Devils 
Lake, ND--Mercy Hospital--that would get one-half as much as Lady of 
Mercy Hospital in New York City to treat the exact same illnesses--one-
half as much. That is all based on formulas based on historic costs. 
That is why many of us believe it would be unfair to tie a public 
option to Medicare levels of reimbursements. That disparity across the 
country would work an extreme hardship on low reimbursement States such 
as mine.
  The cooperative plan allows for not-for-profit co-ops to provide an 
affordable, accountable, transparent alternative to private insurance. 
The mission is to provide the best value for consumer members. It could 
operate at a State, regional, or national level. They are self-governed 
by members with an elected board--not controlled by the Federal 
Government--subject to the same State and Federal rules and regulations 
as private plans. There would be $6 billion in startup funding for 
capitalization by the Federal Government. And that would be the end of 
the Federal Government role.
  The Senate plan also reforms the insurance market. It prohibits 
insurers from denying coverage for preexisting conditions. It prohibits 
insurers from rescinding coverage when people become sick after they 
have paid premiums for years. It bans insurers from lifetime caps and 
unreasonable annual limits on health care benefits. And it

[[Page 28665]]

prevents insurers from charging more based on health status.
  This plan also improves the quality of care. It covers preventive 
services. It provides incentives for healthy lifestyles. It promotes 
adoption of best practices in comparative effectiveness research, and 
includes delivery system reforms to encourage quality over quantity of 
care.
  When we look at the major reforms that are in this bill on the 
delivery system and compare them to the House bill, we see that the 
Senate has accountable care organizations; the House a pilot. Both have 
primary care payment bonuses. Both have readmissions reforms. Only the 
Senate has hospital value-based purchasing. Both have comparative 
effectiveness research. Both have CMS innovation centers. Only the 
Senate has an Independent Medicare Advisory Board. And only the Senate 
has a full platform for bundling. The House just has a pilot.
  Debunking the myths: There is no government takeover of health care 
here. The public option, according to CBO, would get 2 percent of the 
American people--2 percent. That is hardly a government takeover. And 
there is no tying of the public option to Medicare levels of 
reimbursements. There is no cut in the guaranteed benefits for seniors. 
There is no coverage for illegal immigrants. There are no ``death 
panels.'' And there is no expansion of Federal funding for abortion 
services.
  To conclude, if we look at the Senate Democratic plan and the only 
Republican plan, and compare them, the Senate Democratic plan contains 
delivery system reforms. There are none in the Republican proposal. The 
Senate Democratic proposal reduces the number of uninsured by 31 
million people. The Republican plan makes no progress on that front. 
The Senate Democratic plan reforms the insurance industry, banning 
preexisting conditions and rescissions of coverage and health status 
ratings and lifetime benefit limits. The Republican plan has no similar 
provisions.
  The Senate Democratic plan improves rural Medicare reimbursement. The 
Republican plan does not.
  The PRESIDING OFFICER. The Democrats' hour has expired.
  Mr. CONRAD. Mr. President, I ask unanimous consent for 30 seconds.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. CONRAD. The Senate Democratic plan extends Medicare solvency by 4 
to 5 years. The House Republican plan has no extension of Medicare 
solvency. And, finally, the Senate Democratic plan reduces the deficit, 
according to CBO, by $130 billion--twice as much as the Republican plan 
from the House.
  I thank the Chair. I thank my colleagues.
  The PRESIDING OFFICER. The Republican deputy leader.
  Mr. KYL. Thank you. Mr. President, we are going to focus for the next 
hour on perhaps one of the most pernicious aspects of Leader Reid's 
bill: the fact that it cuts Medicare by almost $\1/2\ trillion--almost 
$500 billion in Medicare cuts.
  There are a lot of seniors in my State of Arizona and in the States 
represented by my other Republican colleagues. Those seniors are scared 
of these cuts. It is not because of anything Republicans have said to 
try to scare them; they have simply become aware of what is in these 
bills. By ``these bills,'' I am talking about both the Senate bill 
offered by the majority leader and the House bill, which are the two 
bills that would presumably try to be reconciled in conference. Our 
seniors have been told that under both bills, their benefits are going 
to be cut by about $500 billion, and that is enough to scare them.
  In fact, all of America is concerned about this. A recent USA TODAY 
Gallup Poll shows that an overwhelming number of Americans--61 
percent--oppose cutting Medicare to pay for health care reform. Yet, 
despite that overwhelming opposition, Democratic leaders in Congress 
have moved ahead with this bill to slash, as I said, nearly $\1/2\ 
trillion from Medicare to pay for the new health insurance programs. 
They are simply not listening to what Americans have to say about this.
  If Democratic leaders have their way, hundreds of billions of dollars 
will be slashed from hospitals that treat seniors, from the Medicare 
Advantage Program, which we will talk about in a minute, from nursing 
home care, home health care, and hospice care. Medicare already faces a 
severe challenge, including a whopping $38 trillion in unfunded 
liabilities and insolvency by the year 2017. That is almost 
incomprehensible--in just a few short years, $38 trillion in unfunded 
liabilities and insolvency. Obviously, seniors want us to fix that 
problem rather than raiding Medicare to pay for a new health care 
program, and they want to preserve Medicare Advantage.
  I receive letters from worried seniors every day about this 
Democratic plan to cut Medicare Advantage, which is a very popular 
program in Arizona. Medicare Advantage is the opportunity we have given 
seniors to enroll in a private insurance company to help them receive 
Medicare benefits. What these private insurance companies do is make a 
more attractive program by adding some additional benefits to the basic 
set of benefits that are promised under Medicare. What our seniors are 
telling us is, these are very important benefits to them, things such 
as vision care and hearing. Now that I am getting a little bit older, I 
can tell you that both my vision and hearing is starting to go, and I 
would like to have that kind of benefit. Dental benefits, preventive 
screenings, free flu shots, home care for chronic illnesses, 
prescription drug management tools, wellness programs, personal care, 
and durable medical equipment, all very important for seniors. By the 
way, physical fitness programs, one of which has a great name--it is 
called the SilverSneakers Program, and the seniors are very supportive 
of this because it keeps them physically fit which is, of course, what 
we should be doing.
  I get letters and phone calls from my constituents, and they are 
sharing their anxieties about losing these benefits, losing 
prescription drug coverage; about the overall decline in the quality of 
care that they understand will occur when their doctors' payments are 
cut, when all these other cuts under Medicare that my colleagues are 
going to discuss in a moment finally hit. They know it is going to 
impact their care. They don't like this interference from government 
bureaucrats, in effect, getting between them and their physicians when 
it comes to their health care.
  Let me read portions of three letters from constituents and then I 
will yield to my colleagues.
  A constituent from Surprise, AZ, writes:

       Dear Senator Kyl:
       Please fight the cuts to Medicare Advantage. I am on Social 
     Security disability and on a fixed income. The Medicare 
     Advantage insurance I have has literally been a lifesaver for 
     me. I cannot afford to lose the coverage that includes 
     prescription drugs. I need your help on this.

  Two Medicare beneficiaries, a husband and wife from Mesa, AZ, write:

       We believe that our health is our responsibility and that 
     we have a right to make all the decisions regarding our 
     health. We do not need permission from our government to take 
     actions that will protect and preserve our health. We do not 
     need a third party who has never met us and who is not acting 
     in our best interests in making decisions about our medical 
     care and we do not want to lose our Medicare HMOs.

  That is the Medicare Advantage about which I spoke.
  Then, a constituent from Sun City West, AZ, who incidentally is a 
World War II veteran, wrote a very powerful letter about how Medicare 
Advantage improved his life and his wife's life. He said:

       As a B-17 pilot I flew 50 combat missions out of England 
     and I earned five air medals after flying B-24s on coastal 
     submarine patrol. When we moved to Arizona to be near our 
     children I visited a local VA hospital to find out that I had 
     a $50 copay for each visit and I never saw a physician, just 
     an assistant. In desperation, I purchased a Medicare 
     supplement for my wife and myself. The cost was almost $600 
     per year and I only receive $833 a month on Social Security. 
     Fortunately, here in Arizona, my wife and I were both able to 
     sign up for MediSun, an Advantage plan, with no monthly 
     payment and simple $10 or $20 copays. That made it possible 
     for us to purchase a home. With the health care reform being 
     considered, we understand that Advantage plans will be 
     reduced or eliminated. What happened to ``if I like my 
     insurance, I can keep it''?


[[Page 28666]]


  Well, it is a good question from my constituent. Of course, he is 
exactly right. When the promise was made: If you like your insurance 
you get to keep it, unfortunately, that is not the way this legislation 
works. As a result, a lot of the benefits they are currently receiving, 
for example, from Medicare Advantage, would be cut or eliminated.
  My constituents are right to be wary of cuts to their Medicare 
Advantage. They depend on it. They realize you can't cut $\1/2\ 
trillion from Medicare without adversely affecting your health care.
  Mr. WICKER. Mr. President, I wonder, before the Senator closes, if he 
would yield.
  Mr. KYL. I am happy to yield to my friend.
  Mr. WICKER. Mr. President, I think it is important for us to 
understand that there are some differences between the bills--the HELP 
bill, the Finance Committee bill, and the bill that has come out of the 
House of Representatives--but in each and every case the proposals put 
forward by the Democrats do have this $\1/2\ trillion cut in Medicare. 
Indeed, as the Senator pointed out, these involve cuts to hospitals, to 
Medicare Advantage, Medicare cuts to nursing homes, to home health, and 
to hospice. There is no question about that. I appreciate the Senator 
bringing some information to the public and to the Senate about the 
concerns of his constituents.
  In the previous hour, I heard a Senator from the other side of the 
aisle talk about scare tactics Republicans will be putting forward 
during the coming weeks of this debate. Of course, you have read 
letters from your constituents outlining why the people of Arizona are 
legitimately fearful for the coverage they have enjoyed. I would tell 
my colleagues that the opposition to these Medicare cuts has come in a 
bipartisan way. We heard a great deal about that from our friends at 
the other end of the building when the House of Representatives was 
talking about this.
  The president of the Blue Dog Democrats, Mike Ross, a senior Democrat 
from Arkansas who has worked to try to make this palatable to people in 
his constituency, had this to say about these Medicare cuts:

       With more than $400 billion in cuts to Medicare, it would 
     force many of our rural hospitals to close, providing less 
     access to care for our seniors.

  Less than 12 days ago, Representative Ross from Arkansas said this. 
His constituency in Mississippi is very much like mine, and I can 
assure my colleagues that a great number of our hospitals in 
Mississippi and throughout the country are rural and no doubt they are 
in Arizona too. So there is a very real concern. The gentleman from 
Arkansas flatly says it can force many of these hospitals to close.
  Representative Larry Kissell from North Carolina said this:

       From the day I announced my candidacy for this office, I 
     promised to protect Medicare. I gave my word I wouldn't cut 
     it and I intend to keep that promise.

  Representative Kissell from North Carolina concluded that in his 
judgment, the only way he could keep that promise was to vote no on 
this legislation.
  Representative Michael McMahon of New York said:

       Medicare Advantage, which serves approximately 40 percent 
     of my seniors on Medicare, would be cut dramatically.

  This is not a Republican scare tactic; this is a flat statement by an 
elected Democrat from the State of New York in the Northeastern part of 
our country, one of the larger States. But he said flatly that Medicare 
Advantage would be cut for 40 percent of his seniors and he voted no on 
that basis.
  Representative Ike Skelton, the chairman of the Armed Services 
Committee, said:

       The proposed reductions to Medicare reimbursement could 
     further squeeze the budgets of rural health care providers.

  Chairman Skelton goes on to say:

       I also oppose the creation of a new government-run public 
     option and continue to have serious concerns about its 
     potential unintended consequences for Missourians who have 
     private insurance plans they like and, of course, we know 
     that this Reid bill also has the government-run option.

  Finally, to quote Representative Rick Boucher, another senior 
Democrat from Virginia, he said:

       I also intend to oppose the bill because of my concern that 
     a government-operated health insurance plan could place at 
     risk the survival of our region's hospitals.

  I am concerned, and I am determined to protect the rural health care 
we have in the State of Mississippi and that we have in these districts 
that are represented by these comments.
  So I wanted to jump in now, before the Senator from Arizona concludes 
his portion of the initial remarks, and say that the concerns are not 
only coming from Republicans, they are coming from actuaries, they are 
coming from people who have analyzed this bill, and they are coming 
from Democrats who have read the bill, who understand its meaning and 
who understand that these cuts to Medicare are real and they are 
hurtful.
  I yield back to the Senator.
  Mr. KYL. Mr. President, the Senator from Mississippi is exactly 
right. It is not just Members of the House and Members of the Senate, 
Republicans and Democrats and senior citizens in the State of Arizona. 
Here are some other third-party sources. I will just cite three: The 
Centers for Medicare and Medicaid Services; that is, CMS. That is the 
outfit that runs Medicare. They confirm that cuts will indeed 
compromise the services seniors now receive.
  The Washington Post--how about that for a third-party source--
summarizes a report in a November 13 article entitled ``Bill Would 
Reduce Senior Care.'' That is a fairly specific headline. It says:

       A plan to slash more than $500 billion from future Medicare 
     spending, one of the biggest sources of funding for President 
     Obama's proposed overhaul for the Nation's health care 
     system, would sharply reduce benefits for some senior 
     citizens and could jeopardize access to care for millions of 
     others.

  Then Politico, which is a Capitol Hill newspaper, reported that, by 
2014, enrollment in Medicare Advantage would drop from 13.2 million to 
4.7 million because of less generous benefit packages. That is a 64-
percent decrease.
  Looking at my colleague's chart there, Medicare Advantage, which I 
spoke about and which my constituents wrote to me about, the concern 
there is that people now enrolled--13.2 million--are going to be 
reduced down to 4.7 million because the reductions in the benefits are 
simply no longer sufficient incentive for them to enroll in that 
program.
  Of course, that is what the pro-government-run health care folks want 
to happen. They are all for a public company competing with private 
insurance companies in the market for folks, but when it comes to 
Medicare, they don't want the private companies that provide Medicare 
Advantage care competing with the government program. Under this bill, 
they will get their way. It is going to go from 13.2 million down to 
4.7 million. That is a lot of senior citizens who will lose their 
Medicare Advantage coverage.
  I will conclude by confirming what the Senator from Mississippi said. 
It is not just Representatives in the House or Senators who have sworn 
to help protect our constituents, but it is third-party sources as well 
in the government and in the media that have confirmed that this bill 
will cut benefits. They will certainly do it for senior citizens.
  We will talk later about the Republican ideas. Republicans have 
suggested a step-by-step approach to target specific solutions to 
specific problems, including things such as medical liability reform; 
allowing Americans to purchase insurance across State lines, which 
would expand competition for patient business; association health plans 
to help reduce costs. Most of our ideas are cost-free; they won't cost 
a dime. They wouldn't cut Medicare or diminish the quality of care for 
anybody. They have been rejected by our Democratic colleagues.
  I hope my colleagues will agree that a place to start in this 
legislation is not to cut Medicare. Why would you want to cut Medicare 
if the whole idea here is to provide greater opportunity for affordable 
and quality health care for American citizens? It makes no sense to me.

[[Page 28667]]

  I yield the floor to my colleague from Idaho.
  Mr. CRAPO. Mr. President, I appreciate the opportunity to be here 
with my colleagues from Arizona, Mississippi, and Florida.
  When the people of the United States talk about health care reform, 
they are seeking some way to control the punishing and skyrocketing 
increases, year after year, in health care insurance costs and medical 
costs and better access and quality of health care. Yet when this 
2,074-page bill, which was crafted in secret for the last 2 or 3 weeks, 
was finally revealed, that is hardly what we got. In fact, the reality 
is that this bill will drive up the cost of health care insurance and 
medical care in this country. It will increase taxes by hundreds of 
billions of dollars. It will cut Medicare by hundreds of billions of 
dollars. It will grow the Federal Government by $2.4 trillion of new 
spending over a 10-year period. It will push the needy uninsured not 
into subsidized health care insurance but into a failing entitlement 
program, Medicaid. It will impose a damaging unfunded mandate on States 
that are already strapped financially. It will leave millions of 
Americans uninsured, while probably creating the most enormous and 
massive government extension of Federal control over our economy that 
we have seen in our country, starting with creation of a new federally 
owned and managed insurance company.
  As the Senator from Arizona indicated, today we are here to focus on 
the Medicare cut aspect of this legislation. The Senate bill contains 
something in the neighborhood of $500 billion of cuts in Medicare. The 
first one I want to focus on is the one the Senator from Arizona 
already identified; that is, the Medicare Advantage cuts.
  The Senate bill contains $118 billion in cuts to the Medicare 
Advantage Program. Let me talk about that program for a minute. 
Currently, there are nearly 11 million seniors, as has been indicated, 
enrolled in Medicare Advantage. That represents about one out of four 
of all Medicare beneficiaries in the United States. In my State of 
Idaho, there are more than 60,000 Medicare Advantage beneficiaries, 
which is about 27 percent of the population in Idaho.
  In addition, this is an extremely popular program. A 2007 study 
reported very high overall satisfaction with the Medicare Advantage 
Program. Eighty-four percent of the Medicare respondents said they were 
happy with their coverage and 75 percent would recommend Medicare 
Advantage to their friends or family members. Yet, despite this, there 
are massive cuts coming forward in the bill. Why would that be the 
case?
  I don't think most Americans who are not on Medicare recognize the 
difference between Medicare generally and Medicare Advantage. Medicare 
Advantage was a modification of the traditional Medicare Program that, 
frankly, was put into place--I ask my colleague from Arizona to 
comment. Wasn't it put into place when the Republicans were in control 
of the Congress to try to help get market forces more engaged and 
involved in the administration of Medicare benefits?
  Mr. KYL. Mr. President, the answer to that is yes. The idea was that 
seniors were complaining about the existing program. One thing was that 
a lot of folks in rural areas were not receiving good, efficient, and 
quick care because they had to drive long distances and couldn't find a 
doctor to serve them and hospitals couldn't take care of them.
  Republicans tried to figure out, how could we incent the insurance 
companies to put together pools of physicians and hospitals to go into 
rural areas and take care of citizens who live there. The Medicare 
Advantage Program was one of the ways in which that was done. It has 
proved to be very successful.
  Mr. CRAPO. If you look at the Federal entitlement program Medicare, 
the portion of Medicare that truly does have some private sector 
involvement, where private sector companies can come in and contract to 
provide the government's responsibilities under Medicare, it is the 
most popular of all Medicare programs, the one that was growing and 
letting the private sector deliver the benefits.
  One of the aspects of the Medicare Advantage Program is that senior 
citizens on Medicare Advantage actually get additional benefits beyond 
those traditional Medicare benefits that those in the normal or 
standard Medicare Program get because the private sector options have 
been able to identify ways to enhance and create opportunities for 
greater and stronger benefits.
  Yet those who don't want to have anything but a single-payer system, 
those who want to make sure the government-provided health care is 
provided only by the government, do not like the Medicare Advantage 
Program. So it is not surprising that we see this level of cuts in this 
program.
  During the Finance Committee markup, CBO estimated that the value of 
extra benefits that Medicare Advantage plans provide will drop from 
$135 a month to $42 a month of extra benefits. The CBO Director, Mr. 
Elmendorf, confirmed this during the markup. I asked him:

       So approximately half of the additional benefit would be 
     lost to those current Medicare Advantage policyholders.

  His answer was:

       For those who would be enrolled otherwise under current 
     law, yes.

  In other words, compared to current law, if these cuts are put into 
place, about half of the benefits would be lost to these Medicare 
Advantage beneficiaries.
  We now have more detail on that. I am sorry we don't have a bigger 
chart. We will have one in the future. If you can see the United States 
here, the States in the deep red are those that have cuts in excess of 
50 percent to their Medicare Advantage beneficiaries; those in the 
lighter red are between 25 and 50 percent. In the white, there are only 
five States; they are the ones that don't have a negative impact. So 45 
of the 50 States will see significant reductions in the Medicare 
Advantage benefits that are provided to their constituencies. You just 
have to look at the map to see it is a large percentage of those 45 
States that are getting cuts in excess of 50 percent of their benefits.
  Mr. LeMIEUX. Will the Senator yield for a question?
  Mr. CRAPO. Yes.
  Mr. LeMIEUX. The Senator is saying that seniors who have Medicare 
Advantage now will have big reductions in the benefits they receive. My 
understanding is that includes flu shots, eyeglasses, and hearing 
aids--as the Senator from Arizona said, programs to keep seniors 
healthy. My folks in Florida very much appreciate the Medicare 
Advantage Program. We have more than 900,000 Floridians who are on 
Medicare Advantage.
  I want to make sure I understand this correctly--that under the 
proposal put forward by Senator Reid, we are going to make substantial 
cuts to Medicare Advantage and the benefits Medicare Advantage 
provides.
  Mr. CRAPO. The Senator is right. The way I look at it is that it is 
the extras. Some say Medicare benefits aren't being cut by these 
proposals, but that is a real stretch. When you look at Medicare 
Advantage, it is an outright misrepresentation. The benefits are vision 
benefits, dental benefits, and the kinds of preventive medicine, such 
as the mammograms, the PSA tests, and other types of things we have 
found that help you to dramatically increase your health, if you pursue 
these kinds of preventive medicine options. They are the ones that will 
be deprived through these benefits.
  Mr. WICKER. Will the Senator yield?
  Mr. CRAPO. Yes.
  Mr. WICKER. I notice that in Florida that reduction, according to the 
CBO map, would be 81 percent. That is an unthinkable, drastic change in 
Medicare Advantage. In my area of the country, over in Arkansas, for 
example, it has a 40-percent reduction. My State, Mississippi, has a 
41-percent reduction. Our neighboring State of Louisiana--these are 
some examples--has an 81-percent reduction, the same as the proposed 
reduction this legislation would cause for the State of Florida. I

[[Page 28668]]

think it is important for our constituents to understand the magnitude 
of these Medicare Advantage reductions.
  Mr. CRAPO. That is absolutely true. Taking a couple of other States, 
California is 68 percent; Arkansas, 40 percent; New York, 69 percent; 
New Mexico, 65 percent. The list goes on. The point here is this: The 
CBO Director made it clear that these will be benefits Medicare 
Advantage holders will be losing.
  I want to move on to some of the other reductions in Medicare. The 
argument being made by the proponents of this bill is that we can cut 
$500 billion out of Medicaid and not impact anybody's benefits or the 
quality of the medical care they are receiving. That is not true. Where 
are the other cuts, non-Medicare Advantage cuts, coming from? They come 
from home health agencies, hospice, skilled nursing facilities, 
hospitals that provide care to seniors, and other Medicare providers in 
what is called the market basket.
  You might say we can just continue to cut the compensation or the 
allocation of return for procedures and health care provided in these 
medical providers' services and not have any impact. The reality is far 
from that. What will happen is this. I will give a couple of specific 
examples. In general, what happens is, when a home health agency or a 
skilled nursing facility or a hospital receives these massive 
reductions of over $100 billion worth of cuts in these areas, they have 
to adjust somehow. Let me give you some examples. The adjustment is 
this: In some cases, providers simply stop taking Medicare patients 
because they can no longer make a profit. In that case, the Medicare 
population loses access because they have fewer providers from which to 
choose. In other cases, they reduce services or reduce employees. 
Again, both the quality and the quantity of health care services to 
seniors is reduced.
  Let me give some examples. A few weeks ago, I spoke to Gary Thietten 
of Idaho Home Health and Hospice about the impact of Medicare cuts to 
home health and hospice providers, which is his business. He described 
to me just how bad the fiscal situation has already become for home 
health, hospice, and other Medicare providers in Idaho.
  Idaho has already lost nearly 30 percent of its home care providers. 
Let me repeat that. Already, it has lost nearly 30 percent of its home 
health care providers. They are going out of business because we are 
squeezing them down so tight. And that included Idaho's largest 
provider. The providers that are still in business are working under 
the same Medicare reimbursement levels they received in 2001--8 years 
ago. If the kinds of cuts contemplated by this legislation go into 
effect, on top of the current reimbursement issues, the situation will 
get worse.
  Gary said that he compared this situation for home health and hospice 
providers to the farmers in Idaho. He said that most farmers don't grow 
just one crop. Similarly, home health agencies do more than just 
provide home health; they provide hospice and private-duty care along 
with medical supplies and equipment. All of this will get reduced.
  Let me give another example. Robert Vande Merwe of the Idaho Health 
Care Association talked to me about the impact of these cuts on skilled 
nursing facilities.
  Skilled nursing facilities, such as the hospice facilities, already 
face a budget challenge under recent CMS rules restricting their 
compensation for the services they provide. The cuts they have already 
received, not counting what will come at them in this bill a 
hundredfold more, have already caused a reduction in reimbursement in 
Idaho by over $4 million per year to skilled nursing facilities.
  He pointed out to me that in the nursing home world, more than 70 
percent of the expenses they have are labor, primarily nurses and 
nursing assistants. He said when payment cuts like these occur, they 
cannot go to their buildings and take bricks out of it. What they have 
to do is reduce their employment. That cuts employees. That cuts 
benefits and services to those who are there.
  Let me make this clear. First of all, these cuts are going to reduce 
jobs and, secondly, they are going to directly tie to the quality and 
number of staff there to provide care for those in the Medicare system.
  Mr. KYL. Mr. President, I ask if my colleague will yield for a quick 
question.
  Mr. CRAPO. Yes.
  Mr. KYL. We talked a lot about the rationing of health care that is 
the inevitable result of these cuts in this bill; that when you reduce 
the amount of money you compensate hospitals, doctors, nurses, and 
others, they cannot provide as many services. Some leave the business 
altogether. As the Senator from Idaho pointed out, some businesses go 
out of business. So there are fewer entities providing the care. That 
means it takes longer for patients to obtain the care where it is 
available, and frequently they do not get as good of care because folks 
cannot take that much time to take care of them in that sense.
  Will my colleague please talk about his concerns about the overall 
problem of rationing that comes from the reductions in the benefits to 
providers? By the way, the Senator's chart says ``other Medicare cuts 
to providers.'' We use that term ``providers'' as a short-cut term. 
Will my colleague explain what it means to a 70-year-old woman in Idaho 
who is a provider and how important is that, what happens when you 
don't pay that provider so that provider is no longer available to take 
care of her?
  Mr. CRAPO. Mr. President, I appreciate that question, who are the 
providers. If this Medicare beneficiary is in a skilled nursing 
facility, the provider is the facility itself, which I said we already 
lost 30 percent of our facilities. It is the nurses and the nurse 
assistants who are there to assist them and care for them.
  The bottom line is, you simply cannot cut hundreds of billions of 
dollars out of these services and expect to provide the same level of 
access and quality and available health care.
  The same would be true if the care were being provided in a home 
setting, which a lot of the home care services are compensated by 
Medicare or in a hospital which is there to provide care in some of the 
most serious types of circumstances. Whatever it is, whether it is home 
hospice care, skilled nursing facility, a hospital or what have you, 
what we see is a reduction in the number of facilities and personnel 
available, and that is nothing other than rationing.
  It is a different kind of rationing than will occur under some other 
parts of this bill where the government will actually get in the 
business of saying what kind of health care you can get and at what 
time in your life you can get it. But it is a kind of rationing that 
simply forces the availability of health care down so far that the 
system itself rations it out.
  Mr. LeMIEUX. Will the Senator yield?
  Mr. CRAPO. Yes.
  Mr. LeMIEUX. I wanted to follow up on my colleague's point. With all 
these cuts to Medicare, $464 billion in this proposal, $192 billion in 
reductions to most services, $118 billion in cuts to Medicare 
Advantage, $21 billion cuts to hospitals serving low-income patients, 
$23 billion from other sources, it seems inevitable that seniors are 
going to have a lower quality of health care. We were told by the 
President that if you liked your health care, you were going to be able 
to keep it. But it seems to me that we need to change that a little bit 
because under this proposal, you might be able to keep it unless you 
are a senior and that seniors are going to have a diminished quality of 
health care under this proposal; is that correct?
  Mr. CRAPO. The Senator is absolutely correct. I will comment on that 
and then conclude and turn the floor over to my colleagues from 
Mississippi and Florida for their comments. That is exactly right. In 
fact, one of the most clear and obvious places in which this 
legislation violates the President's pledge--that if you like what you 
have you can keep it--is in Medicare Advantage because one out of four 
Medicare beneficiaries in America will not be able to keep what they 
have and will see their benefits cut.

[[Page 28669]]

  There are also other parts of this bill that impact people outside of 
Medicare in terms of the kind and quality and extent of health care 
insurance coverage they have and expect that will be impacted. It would 
impact beyond this. This is about as clear a case there is of violating 
that promise.
  Mr. WICKER. Mr. President, before the Senator leaves that subject 
matter, I wonder if I could interject. My friend from Idaho also has 
listed specific cuts under this legislation: hospitals, Medicare 
Advantage, cuts to nursing homes, cuts to home health, and hospice. But 
also I think Senators and Americans need to understand that the Reid 
bill also establishes a permanent board of unelected members appointed 
by the administration which, in this case, initially at least would be 
the Obama administration, and they would dictate further savings under 
Medicare.
  This gets to the question of my friend from Arizona about rationing. 
It would dictate annual Medicare cuts geared toward reducing Medicare 
spending. These people are not going to be like us--accountable. They 
will not have to go back to their district every 2 years or their 
States every 6 years. But they will have the unbelievable power under 
this legislation to dictate additional cuts that we know not. The Wall 
Street Journal called this a rationing commission. This ties right in 
with the concerns that Americans have had over the last 2 or 3 days 
about these recommendations with regard to mammograms.
  I realize I am intruding on the Senator's time, but I have a letter 
from a physician in Mississippi who is fearful that this sort of 
rationing board is going to impose the requirement that mammograms not 
be given until after age 50. He says:

       My wife and I have two daughters who had breast cancer in 
     their 40s. One daughter was age 42 and it was picked up on a 
     routine yearly mammogram. The other daughter was age 49 and 
     she found an abnormality by self breast exam and it was 
     confirmed by a mammogram. . . .

  Now we have a group of unelected people coming forth and saying you 
are not supposed to get a mammogram, you are not entitled to a 
mammogram, and we learned that some insurance companies have already 
decided to follow that dictate. This gentleman, a physician, says my 
two daughters would be dead from breast cancer if that were imposed.
  I am afraid that in addition to these very definite cuts, this 
permanent board of unelected members would impose the very type of 
requirement that we are fearful might come forward on mammograms.
  Mr. CRAPO. The Senator is correct. I will conclude with this. I think 
we have all seen folks are almost falling over themselves backing away 
from the news on the mammograms that came out. But it is a very clear 
example in a way a study can come out from a government source or 
otherwise to say we don't need to have this kind of health care in the 
United States, it is a cost saving. What do you think is the potential 
for this commission to say: We are charged with saving costs in these 
programs, and we are going to do that.
  I suspect that the mammogram issue is one they would not do it on 
today because of the reaction to it. Somewhere this commission is going 
to save tens of billions of dollars, in addition to these kinds of 
cuts, by reducing services. Color it as you want, you cannot make this 
kind of reduction of health care services, personnel, and 
infrastructure without reducing the access to and the quality of care 
that Americans receive.
  I will conclude by saying these issues face every State in America. 
We are going to see in this arena a dramatic reduction of the quality 
and content and quantity of health care that our Medicare beneficiaries 
today see because of these proposals, and they are being done not in 
order to make the Medicare system more solvent but to finance yet 
another major Federal entitlement program that will cost hundreds of 
billions of dollars. As a matter of fact, if you look at the true 
numbers, the cost will be over $2 trillion in a full 10-year period of 
time.
  There is a lot more we could say, but I know my colleagues from 
Mississippi and Florida have some remarks they wish to make. I yield to 
them at this time.
  Mr. LeMIEUX. Mr. President, I thank the Senator from Idaho for his 
great remarks today. I want to follow up on what he started to discuss 
and continue also with the comments from my colleague from Arizona 
about Medicare Advantage because it seems to me, being a Senator from 
Florida where we have the second highest senior population in the 
country, the highest per capita senior population, we have 3 million 
people on Medicare, more than 900,000 on Medicare Advantage, that 
Florida is going to receive the worst impact perhaps of any State in 
the country because of this proposal.
  I am here today to talk about this not just as an American but as a 
Floridian because I want my fellow Floridians to know, especially 
seniors, what is in this bill and what it means to them. That is our 
job. It is our responsibility to read through this document, this 
2,074-page bill that we received a day and a half ago and to talk about 
what it means for the average American and, in my case, the average 
Floridian.
  We find out today this Medicare Advantage Program that 900,000-plus 
Floridians enjoy is going to have a substantial cut to the benefits. 
This is not just extras or fringe benefits. These are things people 
need to stay healthy--eye doctors, hearing aids, programs to make sure 
folks stay in shape, all sorts of things that contribute to the health 
and wellness of seniors. Our seniors enjoy this program. The popularity 
of this program is sky high.
  But we are finding out today--and I am looking at this map--that 
Florida is getting the worst impact of any State in America. Only 
Louisiana is going to get it as badly as Florida. We get the 
hurricanes, and now we are going to get the Medicare Advantage cuts--an 
81-percent reduction in the benefits to our seniors.
  What is that going to mean? It means they are not going to have the 
health care they enjoy now, which is what the President promised.
  Right now this bill says the benefits offered will drop from $135 a 
month to $42 a month. Florida seniors will lose 81 percent of this 
additional coverage. I have some constituents who have written to me 
because they have been hearing about these problems. I want to read one 
or two of these letters from Floridians who are concerned about losing 
Medicare Advantage. This one is from Dennis Shelton in Plant City, FL, 
which is in central Florida. He writes to me:

       Senator LeMieux, I am writing this letter to express my 
     deep concern about the proposed cuts in Medicare Advantage 
     funding. I am currently enrolled in an advantage program that 
     is crucial for me to get medical attention. The plan provides 
     doctors, medicines, urgent care and my diabetic supplies. The 
     plan does this significantly better than traditional Medicare 
     at a reduced cost.
       By regular visits . . . I have been able to maintain 
     reasonable health. If the cuts reduce services then my health 
     will suffer along with other seniors that are in the 
     Advantage program.
       This is distressing and I sincerely hope that you will 
     strongly advise fellow congressmen how important Medicare 
     Advantage programs are to seniors all across the United 
     States.

  I am new to this body. I have only had the honor of serving here for 
a couple of months, so I am still learning the ways of Washington. But 
my understanding of this health care process and this health care bill 
is we were going to maintain quality, we were going to try to cut costs 
for people who have experienced the high cost of insurance, and we were 
going to try to provide more access.
  But what I am finding out from this proposal is that we are going to 
cut quality for seniors, and we are not going to reduce the costs of 
health care for the 170 million people who actually have insurance.
  It occurs to me that the goals that were set are not being achieved 
by this plan. Worse still, we are taking a program that seniors rely on 
and that seniors paid into their whole life through their wages and we 
are going to cut $\1/2\ trillion out of it, a program that in 7 or 8 
years is going to run a deficit and be in tremendous trouble.

[[Page 28670]]

  The question I have--and maybe my colleague from Mississippi can help 
me with this since I am new to the Chamber--is why are we going down 
this path? This doesn't seem good for seniors. It doesn't seem good for 
people in any walk of life in America, especially in light of what my 
colleague from Mississippi pointed out with the mammogram issue that 
came out and the self breast exam issue that came out this week. Why 
are we going down this path?
  Mr. WICKER. I appreciate the Senator asking that question. The answer 
is there is no reason for us to go down that path.
  Early in our hour, the Republican whip pointed out that there are 
many proposals the Republicans have that do not require the huge 
expenditure, the huge expansion of Federal power and actually are 
relatively simple and relatively inexpensive. For example, we have a 
proposal:
  To reduce junk lawsuits against doctors, by Senator Ensign, the 
Medical Care Access Protection Act. It is only 28 pages, compared to 
these huge pieces of legislation in front of us. That would not cost 
anything. It certainly would not require any reduction in Medicare.
  To combat waste, fraud, and abuse, by my friend from Florida, and I 
congratulate him for that. It is only 21 pages, something Republicans 
have been begging for and arguing for for years and have been stymied 
on.
  To allow small businesses to pool resources to purchase health 
insurance for employees. Small business people in restaurants and 
realty companies, small motels, ought to be able to pool together and 
have the same purchasing power the huge corporations have. But that 
would only take 8 pages, it would not involve a cost to the Federal 
Government, and certainly not involve these draconian cuts of $\1/2\ 
trillion to Medicare and Medicare Advantage.
  Further, we could purchase health insurance across State lines. We 
certainly agree there is not enough competition in health care 
purchasing. I would love to see a commercial someday with someone 
coming in saying, ``I have great news, I just saved a ton of money on 
my health insurance by switching to XYZ Company.'' We see that in car 
insurance and life insurance. There is vibrant competition. But if we 
opened competition across State lines to the 50 States and if I could 
buy insurance from Idaho, I might find a company that gives me better 
service, that provides better care or reduced premiums. Or if I could 
look at a Florida insurance company, the Senator from Florida might 
look at a Mississippi company. We would use good old American 
competition that has worked in our market society for years but has not 
been allowed to work in the area of health insurance.
  Then, of course, health savings accounts--a one-page bill by my 
friend from Arizona and our colleague Senator DeMint. And then wellness 
and prevention, again only a simple 14 pages.
  None of these would require cuts to Medicare. None of these would 
involve the $2.5 trillion that this spends per decade, once it is fully 
implemented. So the answer to the question of why we are doing it is, 
it is not necessary. I guess the reason people might be doing it is 
that they believe that big government works well. I have a different 
view on that.
  I see, as the Senator pointed out, all of these Federal programs that 
are not exactly working as efficiently as they were projected to be. My 
dad is on Medicare. We are going to protect Medicare. Republican and 
Democrat, we are going to do that. But as the Senator pointed out, it 
goes broke in the year 2017. We certainly do not need to be taking from 
Medicare to pay for a new entitlement.
  Medicaid, as has been pointed out--many doctors will not take 
Medicaid payments anymore because it is broke and it doesn't reimburse 
at a market rate. So we see in my home State of Mississippi, 60 percent 
of the doctors will not take Medicaid. Yet there are some people in 
this building, there are some people in this country within the sound 
of my voice, who believe that somehow a huge $2.5 trillion takeover of 
one-sixth of our economy can work and will not be like the Census and 
Fannie and Freddy, like the post office and the highway trust fund, and 
will not be broke.
  It comes down to a difference in philosophy. But certainly we ought 
to all agree that savings we find in Medicare ought to be used to shore 
up Medicare, to make sure it is there for people such as my dad and 
people who are going to rely on that program for years to come.
  Mr. LeMIEUX. I thank the Senator for that explanation. That is very 
helpful to me. What is disconcerting about the path it seems we are on 
is we are going to have this government-run health care system and if 
already now people cannot go see their doctor if they are on Medicaid 
because doctors won't take Medicaid, and if it is growing more and more 
the case that you cannot see a doctor if you are on Medicare--I have 
some information here about 29 percent of beneficiaries surveyed saying 
they are having a problem finding a doctor who will take Medicare.
  There is a senior from Sanford, FL, Earl Bean, who was interviewed 
this week and he said:

       I called about 15 doctors and was told repeatedly that they 
     were not accepting Medicare patients. . . .

  They wouldn't even take his name when he called. So what I am worried 
about is we are going to enter into a system where 5 years from now, 10 
years from now when everybody in the country is basically on a 
government-run health care program--Medicare, Medicaid, or this new 
program which unfortunately we all think will push the private insurers 
out of the business eventually and we all have government health care--
is we will be going places, there will be 100 people waiting in the 
room if we can get a doctor at all, they will be rationing the care, 
they won't be providing mammograms such as this recommendation that 
came out this week by the Government task force, for women in their 
forties to be discouraged from self-breast exams, and we will all have 
very poor health care unless you are wealthy.
  What is already happening now is that those folks who are wealthy--
there are doctors now who are not taking Medicaid, they are not taking 
Medicare, and they are not even taking insurance. So what concerns me--
maybe the Senator from Mississippi can comment on that--if we enter on 
this path, we are going to a world where the majority, the vast 
majority of Americans are going to have poor quality government-run 
health care and only the very rich will have access to good doctors and 
all the best quality of health care. That does not seem to me like an 
America we want to live in.
  Mr. WICKER. I think this constituent of mine, from Brandon, MS, said 
it very well in a recent e-mail I received. Obviously she is dependent 
upon home health care.

       I support the goal of health care for all. However, that 
     goal should not come at the expense of frail, elderly and 
     disabled homebound Medicare beneficiaries receiving care in 
     their homes and communities. . .

  She points out what this legislation would do to home health care.
  Truly, this bill before us and the one from the House and the one 
from the two committees takes money from America's seniors to the tune 
of $\1/2\ trillion, and instead of shoring up the system that needs to 
be enhanced and protected, it puts that money in the new government 
entitlement program we have exhibited here. I certainly believe we can 
do better.
  Mr. KYL. Mr. President, I want to interrupt my colleague from 
Mississippi for a moment and ask him--or I think the Senator from Idaho 
has some experience with this as well--we have been talking about $\1/
2\ trillion in cuts to Medicare. But we have not even talked about the 
biggest one yet. We have talked about cuts to Medicare Advantage, we 
have talked about the cuts that will be ordered by this new Medicare 
Commission. But I guess I would ask my colleague from Idaho, isn't it 
true that the biggest dollar cuts to Medicare are going to come because 
we are going to pay the doctors and the hospitals and the nurses a lot 
less money?
  Of course, every one of my constituents who has talked to me about it 
said

[[Page 28671]]

wait a minute, if you are going to pay them a lot less money--I am 
having a hard time finding a doctor who will take Medicare patients. 
Isn't that going to result in delay of care for me and denial of care, 
in effect rationing of care? There will not be enough doctors and 
nurses to take care of me because they are not being paid enough to 
even keep their doors open.
  Mr. CRAPO. The Senator is right. As a matter of fact, if I understand 
the legislation correctly, it assumes the current projected cuts for 
physicians are going to happen. That is how it says it is not going to 
increase the deficit. You and I both know this Congress will not let 
that happen.
  But even today, 29 percent of Medicare beneficiaries looking for a 
primary care doctor had a problem finding one because, both with regard 
to Medicaid and Medicare, because of the problems we have been 
discussing here, there are fewer and fewer providers who will take 
patients in those programs.
  Mr. LeMIEUX. Mr. President, I was wondering if I could ask my 
colleague, the leader from Arizona, a question because we are about at 
the end of our time. My understanding is we are going to have a vote 
tomorrow at 8 o'clock. Again I am new here. I was hoping the Senator 
could explain this for me. My understanding is we are going to vote 
whether to proceed on this bill. It is not going to be this bill, it is 
going to be some kind of shell bill or something, which hopefully can 
be cleared up for me. But I am told by folks who work with me that the 
Congressional Research Service has said when there is a vote to proceed 
on a bill, that 97 percent of the time that bill passes. So it seems to 
me if we are voting tomorrow to proceed, that is really a vote on this 
bill.
  Do I understand that correctly?
  Mr. KYL. Mr. President, I would say to my colleague from Florida that 
is exactly right. I was interested in that Congressional Research 
Service report, a totally nonpartisan report, which essentially makes 
the point if you vote to proceed to the bill, 97 percent of the time 
you are voting to approve the bill because they end up passing. Those 
of our colleagues who say they have problems with this bill, serious 
problems with the bill, are enablers if they vote to proceed to the 
debate of this bill. They are enabling those who want to pass a bad 
bill to do so because that is exactly what will happen.
  In order for them to try to fix the bill it would take 60 votes to 
get an amendment agreed to and that is a very tall order around here.
  The second part of the question, yes, this may be a little confusing, 
but what the majority leader has asked is that we vote on a cloture 
motion to proceed to a House bill that has to do with bonuses for AIG 
people. You say, What does that have to do with this? The answer is it 
has nothing to do with this. The leader ordinarily would have taken the 
House bill, which is the bottom half of this stack here, would have 
taken the House-passed health care bill and asked to proceed to that 
bill. If we then agree to proceed to that health care bill, he would 
then substitute his own version, which is the second half of the stack 
here, and then you would have a Senate version that we would begin to 
amend or act on or at least debate.
  I don't think the majority leader wants those on his side of the 
aisle to have to vote on the House-passed health care bill. It doesn't 
appear to be very popular out in America. In fact, by about 2 to 1 the 
American people say they don't want to have anything to do with that 
bill. So, instead, we are going to a shell bill that has nothing to do 
with health care and then the leader will simply shift to his 
substitute health care bill. As my colleague from Florida knows, once 
you vote to begin the debate on this bill, you have put in motion the 
process by which it could, and in 97 percent of the cases does, end up 
getting passed into law.
  For those colleagues who say I am not sure I like this bill but you 
know I will move the process along by at least going to it, the time to 
stop it and to say let's fix it before is the time right now, not after 
you get on the bill. It is too late.
  Mr. WICKER. Will my colleague yield? This Reid substitute that will 
be substituted for the shell bill contains taxpayer funding of 
abortions and it contains a government-run company to compete with the 
private sector. So Senators who vote to proceed on that bill, in my 
opinion, are playing with fire and very much risking that type of 
legislation might come out of the closed room that will be the House-
Senate conference.
  Mr. KYL. The point is this: Unless they have a way to get 60 votes to 
get those provisions out they are in effect endorsing them by voting to 
proceed to the bill because they can't get them out. My colleague is 
exactly right.
  The PRESIDING OFFICER (Ms. Klobuchar). The time of the Republicans 
has expired.
  The Senator from Florida.
  Mr. NELSON of Florida. Mr. President, I rise to support the majority 
leader and his motion for cloture to cut off debate to allow us to vote 
on the motion to proceed which will allow us, then, to get the bill to 
the floor so that we can debate and start amending this bill. I wish to 
use the next several minutes to lay out a comprehensive reason of why 
this Senator supports moving to take up this legislation.
  I look forward to the amending process, and there will be vigorous 
attempts to amend it. I had offered a number of amendments in the 
Finance Committee. Most of those amendments were, in fact, adopted, but 
there was one in particular that was not adopted on a vote of 13 to 3. 
It would save the American taxpayers $109 billion by having the price 
of drugs that are sold to Medicare recipients under the Medicare Part D 
who also are eligible for Medicaid but get their drugs under Medicare, 
it would cause those drugs to be sold at the same discounts that they 
get the drugs under Medicaid. There have been discounts for a couple 
decades because of the bulk purchases of millions and millions. It is 
close to 50 million people who get drugs under Medicaid. There are 
about 43 million people who get their drugs under Medicare.
  Let me correct that. There are 43 million people on Medicare. There 
is some number less than that who are now getting their drugs under 
Medicare Part D. But, in fact, they don't get the same discounts that 
those very same people in Medicaid would get, even though they are 
eligible for those discounts. Those people are called dual eligibles 
because they are eligible because they are poor to get it under 
Medicaid, but they are also over 65. Therefore, dual eligibles should 
be able to get cheaper drugs. No, we can't do that. Because in the 
Medicare prescription drug benefit passed 6 years ago, those kinds of 
discounts were not allowed.
  That is a huge additional cost to the taxpayers. The overall amount 
of Medicare drugs being sold, if you got those discounts, would be 
something in excess of saving the American taxpayer $200 to $250 
billion. For those who are dual eligible--they qualify for Medicaid but 
get their drugs under Medicare--the savings would be $109 billion.
  This Senator is going to offer that amendment. It is a high threshold 
of 60 votes that we have to get but, indeed, we will see and on down 
the line.
  Why am I insisting on continuing to offer this? Well, it is 
interesting that just recently an AARP study has come out, along with 
another study called IMS. They have noted that the cost of drugs, brand 
name drugs, their wholesale prices have increased, in the year 2008, 
9.3 percent. Contrast that to the rate of inflation, which was about 
zero percent. So you see that the cost of drugs is continuing to go up. 
It is time to give our people some relief.
  We could do a lot with that extra $109 billion. First, we could lower 
the deficit by $109 billion. So whereas this bill brought forth by the 
majority leader saves the Treasury money over the 10-year period and 
reduces the deficit by $130 billion, we could add another $100 billion 
to that. We could be lowering the deficit $230 billion. But we could 
take part of that money that we would save the taxpayers and use that 
to fill the doughnut hole.
  That is the strange creature in statute that gives senior citizens 
under

[[Page 28672]]

Medicare some reasonable compensation for their drugs, up to a certain 
level. That level is, generally, between about $2,500 and $4,500 of 
total drug purchases within a year. But once they get into that zone, 
that doughnut hole, in fact, they get no assistance from Medicare. That 
is called the doughnut hole. We could help senior citizens fill that 
doughnut hole so they are not bearing the full cost of those drugs when 
they get hit with huge drug expenses in a particular year.
  We will see what the will of the Senate is as we come out here and 
start to vote.
  The reason it is important, tomorrow night at 8, for us to get 60 
votes to shut off debate is so we can go to the motion to proceed to 
get this bill to the floor. The reason is we need a debate. We can't 
afford not to have a debate. In what is known as the world's most 
deliberative body, that is what we do--debate and amend and try to 
perfect. Is anyone denying that health care, the cost of health care, 
the availability of health care, the availability of health insurance, 
the availability of health insurance at a reasonable price, is anybody 
disagreeing that is not a problem? Our people are hurting.
  One of the main purposes of bringing this legislation out here and 
trying to find a reasonable solution is to make health insurance and 
health care available and affordable.
  For example, what about if you have a preexisting condition. You 
can't get health insurance. We are going to change that in this 
legislation.
  What about if you are sick and your insurance company suddenly comes 
and says: We are going to take away your insurance, we are going to 
cancel your health insurance. Is that a good outcome? There is nobody 
in America who thinks that is a good outcome. That is what we are 
trying to change. By the way, that is what the bill proposed by the 
majority leader will, in fact, do.
  What about all those 46 million people who don't have health 
insurance? First of all, a lot of those folks do get health care, but 
where do they get it? They get it at the most expensive place at the 
most expensive time. They go to the emergency room, after what could 
have been very possibly prevented becomes an emergency. So it is at the 
most expensive place at the most expensive time. By the way, guess who 
pays. Do you think all those costs suddenly evaporate in the ether? No. 
They are costs in a hospital that are ultimately borne by all the 
people who support the health insurance system; that is, those who have 
health insurance policies and pay premiums. It is no small amount that 
we pay. As a matter of fact, nationwide, the additional cost to a 
family health insurance policy to take care of uninsured people is 
between $900 and $1,000 per year extra. It is a hidden tax on all the 
rest of the people who are paying their health insurance premiums.
  In my State of Florida, it is even higher. It is estimated to be 
$1,400 per family policy per year, a hidden tax. That is a hidden tax 
that will disappear, if we can bring in those 46 million people 
nationally who are uninsured, 4 million of whom are in Florida, if we 
can bring them into the system. Will we bring them into the system? The 
bill the majority leader has put on the table will cover 98 percent of 
all Americans with health insurance. That is the entire spectrum of 
Americans who receive health care. Is that worthwhile doing? I 
certainly think it is.
  I said at the outset this bill also tries to approach this in a 
responsible financial way. The actual cost of the bill is about $848 
billion over 10 years. But that $848 billion is more than paid for 
because, at the end of that 10 years, there is an additional $130 
billion that is left over. That is surplus that will go directly to 
lower the deficit. The projection by the Congressional Budget Office 
for the second 10-year period is at least a $650 billion reduction of 
the budget deficit in that 10-year period and possibly as high as $1 
trillion in lowering the deficit.
  What does that tell us? What it tells us is that one of the reasons 
we need a bill coming out on the floor is that not only do our 
individual Americans have difficulty paying for the cost of health 
care, the U.S. Government is having difficulty paying for the cost 
explosion of Medicare.
  Unless we start getting those costs under control, then, in fact, we 
are going to be in an unsustainable proposition with Medicare. A system 
of revising health delivery capabilities so people are not being 
canceled, no preexisting conditions, people can get health insurance at 
affordable rates but at the same time starts lowering the overall cost 
to not only individuals but to the U.S. Government, it seems to me that 
is desirable.
  So you will hear and we have just heard comments about how Medicare 
is going to be cut. Well, there are clearly inefficiencies in Medicare 
that need to be wrung out. Let me give you an example. Right now, we 
have what is known as Medicare fee for service. It basically pays the 
doctor's bill that is submitted for the person who is eligible for 
Medicare. But what happens is, the Medicare patient goes to this 
specialist, that specialist, that specialist, and all of them are not 
talking to each other. This one orders this particular set of tests, 
and that one, because he does not know what the other one is doing, is 
ordering the same test, but Medicare is getting all of the same bills. 
This bill, in reforming health care delivery, is going to try to get at 
that. It is going to set up accountable care organizations. It is going 
to set up electronic records so there is no more of this shifting 
around and, oh, I didn't get the report. It is going to be there 
available immediately. These are obvious technology increases we have 
to do. That is Medicare fee for service.
  How about a program called Medicare Advantage? Let me tell you what 
Medicare Advantage is. Medicare Advantage is a fancy word for a 
Medicare HMO. Do you know what an HMO is? An HMO is an insurance 
company. It was originally designed in the late 1990s that you could 
deliver health care cheaper to senior citizens in Medicare through an 
HMO. So when it was first set up, Medicare HMOs were given 95 percent 
of fee for service because they were going to save costs. They were 
going to save costs to the individual, they were going to save costs to 
the government--95 percent.
  But, lo and behold, in 2003, in the Medicare prescription drug 
benefit, it not only set up what I described a while ago as this 
unusual doughnut hole and drugs that cannot be discounted to the 
Federal Government when it is buying drugs in bulk for millions of 
Medicare recipients, it also set up that we are going to give a cushy 
arrangement to insurance companies where insurance companies that want 
to sign up Medicare recipients are going to get 14 percent more per 
patient--114 percent instead of 100 percent of Medicare fee for 
service. Is it any wonder costs are exploding in Medicare if suddenly a 
program gets 14 percent more per patient than what the standard 
baseline ought to be, which is Medicare fee for service? It does not 
take a rocket scientist to figure that out.
  Because insurance companies--Medicare HMOs; the fancy name is 
``Medicare Advantage''--because they get more, 14 percent more, then 
they can offer additional things to the senior citizens, and this has 
proved to be quite popular. Basically, 30 percent of all Medicare 
recipients in my State of Florida have signed up for Medicare 
Advantage. Indeed, the biggest thing they have that is desirable--you 
hear about eyeglasses and hearing assistance and so forth, but the 
biggest thing that is the most popular is that because the insurance 
company is getting paid so much more per person, it can then use part 
of that money to pay the copays on Medicare, such as Medicare hospital 
insurance, Part A and part B, as well as Part D, the drugs. So it is 
very popular.
  So what I said in the Finance Committee is--obviously, we ought to 
reform the system. And I can tell you, this Senator did not vote for it 
6 years ago, which set up this system, which was a cushy system for 
insurance companies as well as the drug companies. But the fact is, we 
have not.
  So this Senator said, in the Finance Committee: All right, what I 
want to

[[Page 28673]]

do is I want to grandfather the people who have it in Florida so that, 
on a going-forward basis, when this takes effect--in this bill, it 
takes effect in 2013--when it takes effect, it is only those new people 
signing up who will operate under the new system that will make it more 
streamlined but that those who have the existing benefits from Medicare 
Advantage will not be cut. I offered that amendment along with other 
Senators in the Senate Finance Committee, and that amendment was 
adopted.
  So the statements that have been made on this floor about Florida 
Medicare Advantage recipients being cut in Florida is not accurate on 
this bill. I fought for that. Everybody knew I fought for that. And of 
the 949,000 Medicare Advantage recipients in Florida, at least 800,000 
are operative under the formula we put in and the remaining 149,000 
virtually would not be affected anyway. I cannot speak for the other 
States, but I can sure speak for Florida. That is in this bill. Those 
other Senators who offered the amendment with me in the Finance 
Committee had things that tended to their States, as well, that were 
part of that amendment. But that is what the situation is with regard 
to this legislation.
  Let me say that if we can get this legislation out of the Senate and 
get it to a conference committee with the House, the House has a whole 
different approach. The House works on streamlining Medicare Advantage 
from the basis of not something known as competitive bid, which is in 
the Senate bill, but what is known as fee for service, as the target 
benchmark. That does not have the Draconian cuts, in my opinion, to 
many of our Medicare Advantage recipients.
  But I want the record clear here that with regard to Florida, Florida 
Medicare Advantage people have been grandfathered in of those who are 
in existence and those who still will be in existence having signed up 
for Medicare Advantage until the date at which the new system would 
start.
  I see we have changed Presiding Officers, and it is such a pleasure 
to have the esteemed Senator from Minnesota in the chair. Madam 
President, there is room for improvement. We spent 2 full weeks in the 
Senate Finance Committee on amending this legislation. We had spent 3 
months prior to that discussing it. You can imagine, in a nation as 
diverse and complicated as ours and a health care industry where 
everybody and his brother and sister have their fingers in the pie, how 
complicated this is. But that is the reason for the amendatory process: 
to improve, to perfect.
  I want to wind up my remarks by giving a picture of the totality. We 
have had so much of the debate, ever since summer, dominate on the 
concept of a public plan. Many organizations have now come out and said 
that a public plan, at max, is going to affect 4 million or 6 million 
people. If it affects 6 million people who sign up for a public plan--
if there is one in existence. And, of course, the majority leader has 
in here not one that is mandatory. He has it as an option where a State 
can withdraw from having a public plan. But if the max of 6 million 
people signed up on a public plan, that is 2 percent of the entire 
country. Yet you would think that was the only thing when you listen to 
the arguments--and sometimes we watched fights in these townhall 
meetings back in the summer--you would think that was the only thing 
this whole health care reform was about. In the max, it is going to 
affect 2 percent.
  Why is that? Why is it that it only affects 2 percent? Well, look at 
the whole population to whom we want to give health care delivery.
  Take my State of Florida. Approximately--and I am rounding these 
numbers--approximately 50 percent of our people in Florida get their 
health insurance from their employer and they are in a group policy. 
Another 16 percent in my State get their health care from Medicare 
because they are eligible at their age. Another 10 percent in my State 
get their health care from Medicaid because they are either qualified 
under the income level or they are disabled. Now add that up. That is 
76 percent right there of all the people of Florida. That includes 
children. OK. What about the remaining 24 percent? About 4 or 5 percent 
of our people also have health insurance but they pay through the nose 
because they are buying it as individuals as opposed to a group policy. 
If you are buying it individually, where all the health risk is on one 
life, the cost of those premiums is very high. The remaining 19 percent 
are the uninsured. That is as to the population of my State of Florida. 
That will vary with different States. Obviously, in Florida we have 
more people aged 65 and older and therefore eligible for Medicare than 
most States.
  But you can see now that what we are going to do is, over here for 
this remaining 24 percent, we are going to set up a health insurance 
exchange. In the case of Florida, it is going to have potentially 4 
million people in it. It is going to be the uninsured who are now going 
to have access to health insurance with no preconditions, and they 
cannot cancel their policies, and it is affordable. It is also going to 
be available to those people who, in fact, have policies they cannot 
afford, usually the individual policies. There will be some small 
business employers--for example, those with 50 employees or fewer--who 
will not be offering health insurance, and their employees will, for 
the first time, be able to go to the health insurance exchange and be 
able to get health insurance.
  All right. The competition in that health insurance exchange is going 
to have a public plan, if a State approves. That is why it comes down 
to such a small percentage. That is why an issue has dominated the 
debate but is not the main issue. The main issue of this legislation is 
to provide health insurance and health care to our people that is 
available and affordable.
  I will close with this: We have all heard these stories because 
people have been coming to us in our townhall meetings, on the phone, 
in the airport, back during the parades, at the meetings, and they have 
been telling us these very tragic stories: the woman who is in the 
middle of chemotherapy and suddenly gets a cancellation notice from her 
health insurance company; the person who desperately needs health 
insurance and can't get it and who has had it for some period of time; 
the person who is hanging on for dear life to that job because that job 
they have is not only their means of financial remuneration but is also 
their ticket to having health insurance.
  These are the tragic stories we want to change. We want to make 
people's lives better. We have to start somewhere. That point of 
starting is going to be at 8 o'clock tomorrow night, Saturday night, 
because the Senators are going to parade on this floor and indicate yea 
or nay on whether we are going to shut off the filibuster in order to 
get to the motion to proceed which will then allow us to get to the 
bill after Thanksgiving.
  It is absolutely essential for the sake of our people that we bring 
this legislation to the floor and that ultimately we get a product we 
can pass and get it on to a conference with the House and have an 
agreement that the President can then sign into law.
  Madam President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Delaware is recognized.
  Mr. KAUFMAN. Madam President, I rise this afternoon to talk about the 
topic that is on the mind of each and every Senator today: health care 
reform. First off, I wish to congratulate our majority leader, Senator 
Reid. He has accomplished something that has not been done in years. He 
has the Senate on the precipice of debating a major health reform bill 
on the Senate floor.
  I agree with the Senator from Florida. Tomorrow night at 8 o'clock we 
should come to the floor and we should move this bill. It is essential 
that we pass health care reform this year. The present system lets down 
all Americans and we need a new, reformed health care system. We should 
move this bill and then we can debate, we can amend, as the Senator 
from Florida said, and we can deal with this bill then. But it is 
essential that we move this bill.
  Senator Reid has melded the good work of the Finance Committee and

[[Page 28674]]

the Health, Education, Labor, and Pensions Committee into one bill that 
we stand ready to bring to the Senate floor. If people don't 
acknowledge that accomplishment, they are forgetting history. For all 
the efforts to reform our health care system back in 1994, the Senate 
never came close to bringing a bill to the floor to debate. Because of 
the searing experience the Congress went through back then, it took 
another 15 years to pass before Congress attempted another major reform 
of our present dysfunctional health care system.
  I believe if we don't get it done this year, it might take another 15 
years or more before we will bring it up again, and Lord only knows 
what will happen to the health care system in this country in the 
interim. But thanks to Senator Reid and Chairmen Baucus, Dodd, and 
Harkin, as well as the tremendous efforts of their members, the 
committee staffs, all the long hours, weekends in the office and time 
spent away from their families, we stand here this afternoon literally 
a day away from the first procedural vote on the Patient Protection and 
Affordable Care Act. Make no mistake. We cannot afford to wait another 
day to fix our health care system.
  We need to pass health care reform because the trajectory of our 
national health care expenditures is out of control. In 1979 we spent 
approximately $220 billion as a nation on health care-- $220 billion. 
By 1992 we spent close to $850 billion. And in 2009 we will spend $2.5 
trillion on health care--from $220 billion in 1979 to $2.5 trillion in 
2009. The trajectory clearly is absolutely unsustainable.
  We need to pass health care reform because premium costs for middle-
class Americans are rising at an astronomical rate. Take my home State 
of Delaware, for example. In 2000, the average premium for family 
health coverage was just over $7,500. In 2008, that number had jumped 
to $14,900, almost doubling in just 8 years. If we do nothing and allow 
the current health care system to continue, the same premium for family 
coverage is expected to reach $29,000 in 2016, another doubling of the 
price. Think about it. Every 8 years, our premiums doubling in size. 
That is simply unaffordable.
  We need to pass health care reform because failure to do so will 
drive more and more Americans into bankruptcy. Today, bankruptcies 
involving medical bills account for more than 60 percent of U.S. 
personal bankruptcies, a rate 1\1/2\ times that of just 6 years ago. 
Keep in mind, keep in mind, 75 percent of families entering bankruptcy 
because of health care costs actually have health insurance. To repeat: 
More than two-thirds of all bankruptcies due to medical expenses are of 
Americans who have health care insurance. That number is simply 
appalling.
  We need to pass health care reform because small business owners and 
their employees are desperate for relief from the cost of health 
insurance. Right now small business owners and their employees pay much 
higher premiums than their counterparts in large corporations. In fact, 
during the past 5 years, one in five small businesses reported premium 
increases of 20 percent annually. Add that up and that is 100 percent 
over 5 years. Imagine paying a 100-percent increase.
  Largely because of the increase in premium rates, fewer and fewer 
small businesses offer coverage to their employees. For example, in 
2000, 68 percent of small businesses were able to offer health 
insurance coverage to their employees. By 2007, just 59 percent of 
small businesses offered health benefits. That is a reduction from 68 
percent to 59 percent in just 7 years.
  Small businesses are the engine of our economy and will be the 
catalyst to get us out of this recession. It is time to make it easier 
for small business owners to provide health insurance for their 
employees so they can retain the workers they have and hire more to 
help lift us out of this economic distress.
  We need to pass health care reform because failure to do so could 
bankrupt the country. Just look at Medicare and Medicaid. One of the 
biggest driving forces--in fact, the biggest driving force--behind our 
Federal deficit is the skyrocketing cost of Medicare as well as 
Medicaid. In 1966, Medicare and Medicaid accounted for only 1 percent 
of all government expenditures. They now account for 20 percent. If we 
do nothing to start bending the cost curve down for health care costs 
for Medicare and Medicaid, we will eventually spend more on these two 
programs than all other Federal programs combined.
  I am pleased the Patient Protection and Affordable Care Act begins to 
tackle these problems and begins to reform our health care system. It 
is passed time.
  This bill is fiscally responsible. Anyone who is concerned about our 
budget deficits should embrace this bill. According to the 
Congressional Budget Office, the bill will reduce deficits by an 
estimated $130 billion over the first 10 years from 2010 to 2019, and 
by more than one-quarter percent of GDP in the decade after. This 
amounts to about $55 billion in 2020 and several hundred billion 
dollars over the next 9 years. This is not chump change. This is real, 
effective deficit reduction that will help our economy over the next 10 
to 20 years.
  In addition to reducing the deficit, the bill strengthens the 
Medicare Program. Contrary to claims of the bill's critics that we hear 
on the Senate floor, the Patient Protection and Affordable Care Act 
adds coverage for Medicare beneficiaries. It doesn't cut a single 
service. Let me repeat: It doesn't cut a single service.
  For instance, the bill provides seniors with three annual wellness 
visits under Medicare where they can develop personalized prevention 
plans with their doctors to address their health conditions and other 
risk factors for disease, making the conditions easier and less costly 
to treat. The bill also eliminates out-of-pocket costs for recommended 
preventive care and screenings such as mammograms. In terms of 
restrictions on drug coverage, the bill helps seniors manage the cost 
of the doughnut hole in Medicare Part D coverage by giving a 50-percent 
discount on brand-name drugs and biologics to low- and middle-income 
seniors.
  Most importantly, the act helps ensure the sustainability of the 
Medicare Program for years to come. In the past year, Medicare spending 
has increased by roughly 8 percent a year. According to the CBO, under 
this bill, the annual growth rate for Medicare dropped substantially to 
6 percent for the next several decades. Adjusted for inflation, CBO 
estimates that Medicare spending per beneficiary under this bill will 
increase the annual average rate of growth of roughly 2 percent during 
the next two decades, much less than the roughly 4 percent annual 
growth rate of the past 20 years.
  Right now, the Medicare Hospital Insurance Trust Fund is projected to 
become insolvent in 2017. But with the measures to strengthen the 
Medicare Program contained in this bill, the date of insolvency of the 
trust fund is put back by at least 4 to 5 years. Simply put, this bill 
is good for seniors and Medicare and good for the Federal budget.
  As I mentioned earlier, small business owners struggle to provide 
their employees with affordable health insurance. This bill will help 
small business in this quest. The bill will provide a sliding scale tax 
credit based on the number of employees and annual average wages of 
these employees to help these small employers pay for health insurance 
for their employees. This tax credit is estimated to reach more than 
3.6 million small businesses nationwide. In addition, small businesses 
will be able to purchase insurance through the new State-based 
exchanges. These exchanges would allow small businesses to expand their 
risk pool and thereby lower premiums. The bill is a win for small 
business.
  The bill helps protect middle-class Americans against the worst 
abuses of the insurance industry. No longer will Americans be denied 
coverage because of preexisting conditions. Let me repeat that: No 
longer, if we pass this bill, will Americans be denied coverage because 
of preexisting conditions. No longer will insurers be able to rescind 
people's coverage once they get sick

[[Page 28675]]

and they actually need the insurance they have been paying premiums on. 
No longer will insurers be able to charge people more based on their 
health status or gender.
  The bill helps protect the finances of middle-class Americans and 
helps reduce the number of medical-related bankruptcies by placing a 
cap on what insurance companies can require families to pay out of 
pocket. It also restricts the use of annual limits and prohibits the 
lifetime limits on insurance benefits, which is especially important 
for Americans with high-cost conditions to treat. It creates a health 
insurance exchange that provides a public insurance option to compete 
with private insurers to provide consumers with more choice.
  This will make a great difference in States where one or two 
insurance providers dominate the marketplace and where there is no true 
competition.
  These are good, strong provisions that will help provide health 
security and stability to all Americans.
  The bill is strong in two other areas as well: promoting prevention 
and wellness and cracking down on waste, fraud, and abuse. On the 
prevention front, the bill recognizes that we have to move away from a 
system that encourages people to wait until they are sick to seek 
treatment. Instead, it encourages prevention and early treatment of 
diseases which can help lower the cost of treating patients.
  The bill recognizes the need to shift this emphasis by eliminating 
any copayments or deductibles for recommended preventive care and 
screenings, such as cancer screenings, colonoscopies, and mammograms. 
The bill would allow employers to offer premium discounts and other 
awards for up to 30 percent of the total premium for individuals who 
quit smoking, lose weight, lower their cholesterol or blood pressure, 
or take other steps to improve their health status.
  We have already seen how successful this type of program can work at 
companies such as Safeway. All of these measures will help increase the 
use of preventive measures and reduce the need of costly new treatments 
as a result of waiting too long to treat a condition or disease.
  Finally, I wish to highlight the measures contained to reduce the 
waste, fraud, and abuse that exist in our current system. Each year, 
health care fraud drains between $72 billion and $220 billion from 
doctors, patients, private insurers, and State and Federal Government. 
Left unchecked, fraud drives up the cost of care while reducing public 
trust in our health care system. I am pleased this bill will increase 
the funding for the Health Care Fraud and Abuse Control Fund to fight 
fraud in public programs. In fact, CBO estimates that every $1 invested 
to fight fraud results in approximately $1.75 in savings.
  In fact, CBO estimates that every $1 invested to fight fraud results 
in approximately $1.75 savings.
  The bill will also establish new penalties for submitting false data 
on applications, false claims for payment, or for obstructing audit 
investigations related to Medicare, Medicaid and the State Children's 
Health Insurance Program.
  By reducing the amount of waste, fraud and abuse tolerated in the 
health care system, we will be able to bring health care costs down for 
everyone.
  Mr. President, this is a good bill.
  I have only touched on parts of the bill, as time does not allow me 
to discuss every provision--including the fact that the bill will 
extend insurance coverage for an additional 31 million Americans.
  But it is a good bill. It is fully paid for. It reduces short and 
long term deficits. It strengthens the Medicare program. It provides 
security and stability for the middle class. It provides Americans with 
greater insurance choices. It promotes prevention and wellness. It 
cracks down on waste, fraud and abuse. I applaud the hard work that 
went into the drafting of this bill.
  As I have said many times, it is time to gather our collective will 
and do the right thing during this historic opportunity by passing 
health care reform.
  We can't afford to wait another 15 years. We need to act now. We can 
do no less.
  The American people deserve no less.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. Kohl). The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Ms. KLOBUCHAR. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Ms. KLOBUCHAR. Mr. President, I am going to focus for the next 10 
minutes on the issue of costs. I know many people are focused on 
important issues like the fact that this bill will finally eliminate 
the limitations on preexisting conditions, so if your kid gets sick, 
you don't have to lose your health care; and the fact that people will 
be able to keep their kids on their health care until they are 26. 
These are very important parts of the bill. It is very important to 
people of my State.
  The other facet that is very important to people in my State is 
something I heard about all over the last few months: the issue of more 
affordable health care. This is why: At $2.4 trillion per year, health 
care spending represents close to 17 percent of the American economy. 
It will exceed 20 percent by 2018 if the current trend continues.
  Hospitals and clinics are providing an estimated $56 billion in 
uncompensated care. In fact, today, Peter Orszag, the Budget Director 
for the President, wrote an opinion piece for the Washington Post that 
highlights the fiscal importance of passing health care reform. One of 
the things he said is, looking forward, if we do nothing to slow the 
skyrocketing costs of health care, the Federal Government will 
eventually be spending more on Medicare and Medicaid than all other 
government programs combined. He notes that it is time to move toward 
the high-quality, lower cost health care system of the future.
  As you know, Mr. President, coming from Wisconsin, we know how to 
deliver high-quality, highly efficient care. They do it in Wisconsin 
and in Minnesota. They also do it in Washington State. A number of 
States have figured out how to do this. Those are the models we need to 
see all across the country. We need to make health care affordable for 
everybody, and we need to reduce the waste and fraud that plagues the 
current system in this country.
  In 2008, employer health insurance premiums increased by 5 percent, 
two times the rate of inflation, and the annual premium for an employer 
health plan covering a family of four averaged nearly $12,000.
  In fact, I tell people around me that they have to know 3 numbers: 6, 
12, and 24. Ten years ago, the average family was paying $6,000 for 
their health care premiums. Now it is $12,000. That is average. A lot 
of small companies in Minnesota--the owners of companies are paying 
more than that. But right now the average nationally is $12,000. If we 
do nothing to bend the cost curve, the average family will be paying, 
on an annual basis, $24,000 for their health care 10 years from now.
  Meanwhile, a new study found that small businesses pay up to 18 
percent more to provide health insurance for their employees. We are 
talking about a backpack company up in Two Harbors, MN. A guy started 
that small company, and it is now up to 15 employees. He has a family 
of four and is paying $24,000--in Two Harbors, MN--for his family to 
make sure they have health insurance. He said if he knew it would have 
cost that much, he might not have started that company. Now they are 
providing beautiful, great backpacks for our troops who are serving 
us--high-quality backpacks. Those backpacks wouldn't have existed if he 
knew what was happening. Those jobs would not have existed. He could be 
working at a big company and paying less. But he was an entrepreneur, 
and we should reward that.
  The American people know inaction is not an option. If we don't act, 
costs will continue to skyrocket, and 14,000 Americans will continue to 
lose their health insurance every single day. We must keep what works 
and fix what is broken.

[[Page 28676]]

  Let me tell you about some good news. It is encouraging news that the 
Senate will start considering the bill that will reduce the Federal 
deficit by $127 billion in 10 years. If we go out 20 years, it is a 
$650 billion reduction in the deficit. That is good news. We achieve 
these long-term savings by making our health care system more 
efficient, rewarding quality, and improving patient outcomes, and 
reducing administrative spending and waste.
  Most health care is purchased on a fee-for-service basis. So more 
tests and more surgery mean more money--quantity not quality pays.
  According to researchers at Dartmouth Medical School, nearly $700 
billion per year is wasted on unnecessary or ineffective health care. 
That is 30 percent of total health care spending. One study showed if 
the hospitals in some of these inefficient areas would follow the high-
quality protocol the Mayo Clinic uses--and a lot of people would like 
to have that kind of health care--we would save $50 billion in taxpayer 
money every 5 years for chronically ill patients--$50 billion. That is 
just one example for one set of patients.
  That is what we do in Minnesota. We want that same kind of health 
care, the same kind of high-quality care, the incentives on the Federal 
level that aren't there now, and that is what we are seeing in this 
reform package.
  I am pleased the ``value index'' I proposed, which was cosponsored by 
Senator Cantwell of Washington and Senator Gregg of New Hampshire, was 
included in the Senate bill. This indexing will help reduce unnecessary 
procedures because those who produce more volume will need to also 
improve care or the increased volume will negatively impact their fees. 
Doctors will have a financial incentive to maximize the value and 
quality of their service instead of the quantity. This is supported by 
doctors in my State.
  Linking rewards to the outcomes for the entire payment area creates 
an incentive for doctors and hospitals to work together to improve 
quality and efficiency. In too many places patients struggle against a 
fragmented delivery system, running all over with x rays in the back of 
the car, seeing specialists, and not having someone in charge, or a 
quarterback running the team, having 20 wide receivers running this way 
and that way. That is why we need the integrated care that is rewarded 
in the bill--bundling of services. What you pay for is the result, the 
combination of services that gives you good results. That is what 
bundling is about.
  There is another good thing about the bill. In 1 year, hospital 
readmissions cost Medicare $17.4 billion. A study found that Medicare 
paid an average of $7,200 per readmission that was likely preventable. 
Who wants to go back in the hospital if you don't need to? One of the 
problems, if we don't have quality indexes in place--my State has one 
of the lowest hospital readmission rates in the country. If we don't 
have that index in place, we are rewarding bad practice. We want to 
reward high quality and put the patient in the driver's seat. That is 
what we do with the provisions in the bill.
  I am encouraged the Senate bill includes a provision that calls for 
reduced payments to hospitals if they have preventable readmissions.
  In this bill, we also work to better reward integrated health care 
systems. At places such as Mayo Clinic or Health Partners in Duluth, a 
patient's overall care is managed by a primary care doctor in 
coordination with specialists, nurses, and other care providers, as 
needed--one-stop shopping.
  In our rural communities, critical access hospitals utilize this 
model and provide quality health care for residents in their 
communities with a team of providers.
  To better reward and encourage collaboration, we encourage the 
creation of accountable care organizations. This is what I hear from 
the people in my State and across the country: We want more 
accountability in this health care system.
  Do you know what else accountability means? It means better 
enforcement of Medicare fraud. When the dollars are so tight and people 
are having so much trouble affording health care, why do we want to 
waste $60 billion a year on fraud? Think what that money could be spent 
for to make it easier to go to the hospital or doctor instead of $60 
billion wasted on fraud.
  This bill and some of the amendments we are going to propose in the 
next month will bring us much closer to reducing that fraud, bringing 
that fraud down, and will hold the perpetrators accountable, including 
criminal penalties--that is important--making sure we have direct 
deposit, a bill that Senator Snowe and I have, so nobody can make out 
false checks and try to get the money that way; giving our law 
enforcement officers more tools to go after Medicare fraud. We can save 
$60 billion a year.
  In today's Washington Post, Peter Orszag writes:

       As we enter the homestretch, the greatest risk we run is 
     not completing health reform and letting this chance to lay a 
     new foundation for our economy and our country pass us by.

  I argue one of the most important things we can do--and I know 
everybody is focusing on who pays and what the provision means--is to 
change the delivery system in this country, reward that kind of high-
quality, highly efficient care, so that our big companies are able to 
compete with companies in other countries that have more highly 
efficient delivery systems so our small companies are able to exist and 
multiply and keep their employees on health care, so that individuals 
in this country aren't cut off just because their child gets sick. That 
is what this reform is about. Thank you. I look forward to the vote 
tomorrow.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Arizona.
  Mr. KYL. Mr. President, the whole point of health care reform is to 
bring down costs and to make health care more affordable for American 
families. So why have Democratic leaders produced a health care bill 
loaded with provisions that will increase premiums?
  Independent studies from the nonpartisan Congressional Budget Office 
and the Joint Committee on Taxation and even a study by the chief 
actuary at the Department of Health and Human Services confirmed this: 
that the Democrats' plan will drive up premiums and overall health care 
spending faster than in the absence of these so-called reforms.
  How is this so? Let me mention five specific ways.
  First, new insurance mandates and new taxes on the insurance 
industry. New insurance requirements and new taxes on the insurance 
industry will force premiums to rise for many Americans, particularly 
the young and healthy. According to an independent analysis that 
studied the effect of the new insurance reforms and new taxes on the 
insurance industry, insurance premiums in my home State of Arizona 
could skyrocket by as much as $2,619 for individuals and $7,426 for 
families.
  Think of that, an increase of $7,426 for families in my State. That 
is outrageous.
  What can $7,426 buy an Arizona family? A lot of things. It could pay 
for a year's tuition at the University of Arizona. It could pay for a 
year and a half of groceries or nearly 2 years of utility bills or it 
could pay for 2 years' worth of gasoline. Families have a lot of 
expenses and a lot of ways to spend $7,426. They don't need the Federal 
Government intruding on them and dictating that money has to go 
somewhere else.
  Our friends on the other side of the aisle will say they could 
provide subsidies. In fact, the legislation will provide subsidies to 
help with this increased cost. But not every family will qualify, and 
the subsidies may not even cover the total cost of the increase.
  Moreover, what is the point of raising the cost of health insurance 
and then subsidizing a portion of the increase? You are still raising 
premiums. It is nonsensical to have a health care reform that makes 
families worse off and then gives them a government subsidy to help 
make up for part of the cost.
  Second, new mandated benefits will increase costs. Under the Reid 
bill, the government will require insurers to

[[Page 28677]]

cover a broad range of new medical benefits determined by Washington, 
regardless of whether those benefits are actually needed by each 
individual patient.
  These additional benefits might help some patients, of course, but 
the government cannot provide them to everyone for free. So the cost 
will be shared by everyone in the insurance pool, and that means 
increased premiums for many Americans.
  In fact, the Council for Affordable Health Insurance estimates the 
new mandated benefits would increase the cost of basic health coverage 
between 20 and 50 percent. That is the second way insurance premiums 
are increased.
  Here is the third way: limits on plan types. Under this Reid bill, 
insurers are limited to offering a total of only four specific kinds of 
insurance plans. So the low-cost, high-deductible plans that currently 
families and individuals enjoy will be virtually eliminated. They will 
have to buy more expensive plans, again paying more in premiums. 
Whatever happened to getting to keep what you have? Just as one size do 
not fit all, in this case, four sizes do not fit all either.
  Here is the fourth way premiums increase: New taxes are imposed on 
groups such as medical device makers. According to the Congressional 
Budget Office and the Joint Committee on Taxation, a new tax on medical 
devices will increase premiums and increase the price of everything 
from wheelchairs to diabetes testing supplies, to pacemakers, and it 
will be paid entirely by the patients.
  Its cost, according to the Joint Committee on Taxation? It is $19.3 
billion over 10 years. This tax will hit cutting-edge technology such 
as CT scanners, replacement joints, and the arterial stents that 
doctors use during angioplasty. This tax will clearly stifle 
innovation.
  As the Wall Street Journal editorialized:

       This new tax will eventually be passed through to patients, 
     increasing healthcare costs. It will also harm innovation, 
     taking a big bite out of the research and development that 
     leads to medical advancements.

  The fifth way in which this legislation will increase costs for the 
insured is it actually taxes the insurance plans themselves for the 
first time. You buy insurance, you get taxed. The Reid bill, for the 
first time, directly accomplishes this. As the independent Joint 
Committee on Taxation told us, this new tax will increase the cost of 
health insurance for everyone, since insurers will pass the costs along 
to their patients.
  This tax alone could raise some Americans' premiums by $487 per year. 
Because this tax is indexed to regular inflation rather than to health 
care inflation, just as with the alternative minimum tax, it could soon 
start hitting middle-income families.
  According to former Congressional Budget Office Director Douglas 
Holtz-Eakin, half of all families making less than $100,000 per year 
could end up paying this tax.
  Those are five specific ways in which this bill will increase your 
costs, increase the premiums you pay for health insurance once this 
bill is in effect. We believe there are better ideas. Republicans have 
proposed a variety of solutions to target specific problems and, in 
particular, the problem of cost.
  I, specifically, want to conclude by mentioning the Republican health 
care alternative in the House of Representatives. The majority voted it 
down, but the truth is, it would, in fact, lower premiums for 
individuals, families, and small businesses. Contrast the House-passed 
bill which increases premiums, the Reid bill which increases premiums, 
but the Republican House bill which would actually decrease premiums 
and you will see Republicans in the Senate proposing similar ideas.
  According to the Congressional Budget Office, under the Republican 
plan, premiums would be $5,000 lower than the cheapest plan under the 
Pelosi bill.
  Small businesses, too, would see their premiums decrease by as much 
as 10 percent, again according to the Congressional Budget Office.
  Those in the small group market would also see a 10-percent decrease 
under the House Republican bill, again according to the nonpartisan 
CBO.
  The House Republican bill included such reforms as allowing States to 
sell policies across State lines. You have heard a lot of Senators on 
the Republican side talk about that point. That would have enabled 
1,000 companies to compete nationally, and that helps to drive down the 
costs. Medical liability reform, a proven way to cut costs. My State of 
Arizona, Texas, and Missouri have all seen premiums go down because of 
medical malpractice reform. Health savings accounts, which put patients 
in charge of their own health care by allowing them to save their 
health care dollars to spend as they choose, this, too, would have been 
strengthened by the House bill, and you heard Republican Senators talk 
about that as a reform. There are many other ideas we have. We will be 
talking more about those ideas as we go forward.
  I wish to conclude my remarks about the Reid bill, loaded with 
provisions that increase insurance premiums, and to make the point that 
since, as I said at the beginning, the whole point of the exercise is 
to reduce health care premiums, the last thing we should be doing is 
adopting the provisions in the Reid bill, which will actually increase 
health care premiums.
  Let's keep in mind that health care reform is all about making things 
better for Americans, and this bill does not meet that test by a long 
shot.
  The PRESIDING OFFICER. The Senator from Maine.
  Ms. COLLINS. Mr. President, I rise to discuss the health care bill 
that the Senate will begin voting on tomorrow evening. Let me begin by 
making clear that I believe our health care system needs fundamental 
reform.
  One of my top priorities as a Senator has been to work to expand 
access to affordable health care. The fact is, however, that the 
greatest barrier to health care coverage today is the exploding cost. 
Monthly health insurance premiums in Maine have risen at an alarming 
rate. They now often exceed a family's mortgage payment. Whether I am 
talking to a self-employed fisherman, a displaced mill worker, the 
owner of a struggling small business, or the human resource manager of 
a large company, the soaring cost of health insurance is a vital 
concern.
  Much of the health care reform debate so far in this Congress has 
centered around the need to expand coverage to the uninsured, a goal I 
embrace. The fact is, however, it will be difficult to achieve our goal 
of universal coverage until we find a way to control health care costs 
that have driven up the cost of insurance coverage for families, 
employers, and governments alike.
  While I agree that our health care system is broken and in need of 
major reform, the bill we are about to consider falls far short when it 
comes to reining in health care costs. This is a critical issue because 
the high cost of health care is the biggest barrier for those who lack 
insurance. The high cost of health care is what is driving up the cost 
of insurance premiums, causing many middle-income families and small 
businesses to struggle to meet these rising costs.
  I am concerned that this bill takes us in the wrong direction and 
that it will actually drive up costs and reduce choices for many 
middle-income Americans and small businesses.
  Health care reform should give Americans more, not fewer, choices of 
affordable health insurance options. Under this bill, many Americans 
will be required to purchase health insurance that is more expensive, 
not less expensive, than the coverage they currently have.
  Under the majority leader's bill, all individual and small group 
policies sold in our country must fit into one of four categories: 
bronze, silver, gold, or platinum, and they must have an actuarial 
value of at least 60 percent. Post reform--if this bill becomes law--it 
will be illegal to issue new policies in the individual or small group 
markets that do not meet those standards.
  Moreover, unless they are grandfathered, most Americans who are not 
enrolled in at least a bronze plan will face a new $750 fine.
  Let's look at what this means. In my home State of Maine, 87.5 
percent of

[[Page 28678]]

those purchasing coverage in the individual market today have policies 
with an actuarial value of less than 60 percent. In other words, they 
have policies that do not qualify under the standards that would be 
established by this bill.
  The most popular individual market policy sold in Maine costs a 40-
year-old about $185 a month. Under Senator Reid's bill, that 40-year-
old would have to pay at least $420 a month, more than twice as much, 
for a policy that would meet the new minimum standard, or pay the $750 
penalty.
  I believe Americans should have the choice to purchase more 
affordable coverage if that is what works best for them. Health care 
reform should be about expanding affordable choices, not constricting 
them. It should not be about forcing millions of Americans to buy 
coverage that is richer than they want, need, or can afford. Yet under 
this bill, even an individual who does not qualify for any taxpayer 
assistance, for any subsidy, would have to buy a prescribed plan rather 
than, for example, a low-cost, high-deductible policy that, when 
combined with a health savings account, may best meet his needs.
  Moreover, the very tight rating bands in this bill will increase 
costs for young people.
  Why does that matter, when we are trying to expand coverage for those 
who are uninsured? For this reason: More than 40 percent of uninsured 
Americans are between the ages of 18 and 34. Extreme price increases 
for the young and healthy will simply force them out of the market 
because most young people, I fear, will just do the math. They will 
decide to pay the new $750-a-year fine, rather than paying $5,000 a 
year or more for health insurance. This is particularly true because 
under the bill, if they do get sick later, they can still buy insurance 
with no penalty, no increased cost. That is why the National 
Association of Insurance Commissioners--keep in mind, this is the 
association of State officials which regulates insurance; these are 
public officials--according to the NAIC, these provisions will lead to 
severe adverse selection that will drive up the cost of premiums for 
everyone else who is in the insurance pool.
  Proponents of this legislation contend that the subsidies included in 
the bill for low- and moderate-income Americans will compensate for any 
premium increases. Let's take a look at that. First of all, it is 
important to know that the subsidies do not go into effect until the 
year 2014 yet a lot of the taxes which I am going to discuss later, 
which are also going to drive up the cost of premiums, go into effect 
next year. So that is a problem as well.
  Moreover, these subsidies are going to be available, it is estimated, 
to fewer than 8 percent of Americans. Moreover, if you receive your 
health insurance from your employer, as the vast majority of Americans 
now do, you are not eligible for a subsidy under this plan. But your 
premiums are still going to go up because of the increased taxes and 
fees imposed by the bill.
  When Americans understandably are so upset about the high cost of 
health care, and when health insurance premiums are going up by double 
digits, making it so difficult for most Americans to afford health 
insurance, the last thing we should be doing is to make the situation 
worse. I can't help but think of the Hippocratic Oath, ``do no harm.'' 
Should not that be our first rule?
  Americans who are already shouldering the burden of too high health 
care costs would hardly consider a bill to be ``reform'' if it drives 
those costs up further. Yet I fear that is exactly what will happen if 
this bill becomes law as written.
  In light of this, I think it is a legitimate question to ask whether 
this bill may actually increase the number of uninsured Americans by 
driving up the cost of health insurance for years before the subsidies 
go into effect?
  Let me take a further look at some of the increased taxes that are in 
this bill. Americans will face at least a dozen new or increased taxes 
and fees amounting to $73 billion before the subsidies go into effect 
in 2014. What kind of new taxes are we talking about? This chart shows 
just some of the taxes that will hit Americans when the bill goes into 
effect--and there are many more. Here are a few.
  There is a tax on pharmaceutical manufacturers, a tax on health 
insurance providers, a tax on medical devices. Think of what we are 
talking about taxing here: We are talking about insulin pumps, 
artificial hips and knees, stents put into hearts--all sorts of medical 
devices. If a new fee is put on these devices, that is going to be 
passed on to consumers and reflected in insurance premiums.
  All in all, as I mentioned, these taxes will cost $73 billion before 
2014. These taxes will be paid right away by Americans in the form of 
higher health insurance premiums. That is not just my opinion, that is 
the view of the Congressional Budget Office, which evaluated the impact 
of several of these taxes. For example, here is what the CBO said about 
the $6.7 billion increased tax on insurers:

       We expect a very large portion of the proposed insurance 
     industry fee to be borne by purchasers of insurance in the 
     form of higher premiums.

  The problem is, the way these taxes are structured, they are going to 
be passed on to consumers, and it is not only the taxes on insurers 
that will be passed on. Here is what the CBO Director said about new 
fees on the pharmaceutical industry and also on medical devices. The 
CBO said:

       Those fees would increase costs for the affected firms, 
     which would be passed on to purchasers and would ultimately 
     raise insurance premiums by a corresponding amount.

  The Joint Committee on Taxation looked at the tax on the so-called 
Cadillac plans, the 40-percent excise tax. Here is what it said:

       As insurers pass along the cost to consumers by increasing 
     the price, the cost of employer-provided insurance will 
     increase.

  I do not believe that the American people have sent us to Washington 
to raise their taxes and call it health reform--especially now, in the 
midst of a recession, with unemployment above 10 percent.
  This leads me to another point. I am so concerned about the impact of 
this bill on our small businesses. They are the job creators in our 
economy, and the rising cost of health care has been particularly 
burdensome for them. A small business owner in Maine recently e-mailed 
me to say the following:

       I just received our renewal proposals for our small 
     business. The plans are all up anywhere from 12 to 32 percent 
     on the three plans that we offer. . . . You are right when 
     you say we need to address the cost of health insurance, not 
     create another vehicle to deliver the services. The current 
     legislation, as I understand it, totally misses the mark.

  How does this bill help small business? On balance, it doesn't. That, 
again, is not just my opinion; that is the opinion of our Nation's 
largest small business group, the NFIB. In a statement on the bill 
released yesterday, the NFIB said:

       This kind of reform is not what we need. New taxes . . . 
     new mandates . . . new entitlement programs . . . paid for on 
     the backs of small business.

  In fact, NFIB described the bill as ``a disaster.''
  I ask unanimous consent a copy of the NFIB statement be printed in 
the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

            [From NFIB--Small Business News, Nov. 19, 2009]

                    Senate Bill Fails Small Business

                        (By Stephanie Cathcart)

       Washington, DC.--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.

[[Page 28679]]

       ``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.''

  Ms. COLLINS. Mr. President, there are some provisions in the bill 
that are intended to try to help small business but again they miss the 
mark. I support and have long proposed the idea of tax credits for 
small businesses to help them afford to provide health insurance for 
their employees. But the credits for small businesses in this bill are 
poorly structured. Only businesses with no more than 10 workers, paid 
an average of $20,000, can get the full tax credit. So if a small 
business hires additional employees or pays more, its credit begins to 
decline and it is eventually phased out. Businesses with more than 25 
workers, or paying average wages of above $40,000 get no tax credit 
whatsoever.
  Take a look at this. I realize this chart is a bit busy, but stay 
with me. Under the Finance Committee bill, if you have 10 employees and 
you pay them on average $20,000, you get a 50-percent tax credit 
applied to the cost of the insurance. But if you give them a raise, the 
tax credit begins to decline. For example, if you have 10 employees and 
you pay them $25,000 on average, you only get a tax credit of 38 
percent.
  Let's say you are trying to improve their quality of living. They 
have done a great job for you, so you give all your employees a raise, 
bringing their average wage to $30,000. Now the tax credit is only half 
as much as when you paid them $20,000.
  If you pay them $40,000 on average--zero. You lose the tax credit 
altogether.
  What we have here is a tax credit that is structured in such a way 
that it discourages small businesses from adding employees and paying 
them better. That doesn't make any sense at all. That makes no sense at 
all.
  This legislation would have enormous consequences for our economy and 
for our society. We have to remember that this bill would affect every 
single American, every small and large employer, every health care 
provider. It affects 17 percent of our economy.
  There are many reforms, such as allowing small businesses to pool 
together to have better bargaining clout, that I support and that have 
strong bipartisan support, that could have been the basis for further 
debate and amendments. So it disappoints me greatly that we are about 
to proceed to a divisive, partisan bill. I continue to believe that the 
American people would be better served by a bipartisan bill that brings 
together the best ideas on both sides of the aisle, and I pledge to 
continue to work with Members on both sides of the aisle to develop 
alternatives that will bring about true health care reform.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. BARRASSO. Mr. President, I find it fascinating, listening to the 
comments from the Senator from Maine. Maine and Wyoming are similar in 
a number of ways. One is that the engine that drives our economy is 
small businesses. What we heard is that this bill right here, this 
large bill which is the bill the Senate is considering right now, over 
2,000 pages--underneath it is the bill that passed the House--I hear 
these are actually going to penalize the small businesses of Maine and 
the small businesses of Wyoming when those businesses try to hire 
another employee.
  We are looking at 10.2 percent unemployment right now. People in our 
States are well aware of those numbers. I don't know if that number is 
being neglected by others, but for small businesses trying to hire 
people, this health care bill makes it much tougher. It will certainly 
make it tougher for them to provide insurance, and it will make it 
tougher for those small businesses to give raises to people.
  It is, indeed, unfortunate that we are here in the Senate Chamber 
looking at a bill that is going to raise premiums for the American 
people who have insurance and who like the insurance they have. Their 
big concern isn't cost. We are looking at a bill that is going to cut 
Medicare for seniors who depend on Medicare, and the numbers are huge, 
almost $500 billion. And we are looking at a bill that is going to 
raise taxes on the American people.
  I heard the Senator from Maine, and she can jump in and correct me if 
I am wrong. What I heard her say is that it is not just a tax on the 
rich; it is a tax on people all across the board because the taxes are 
going to be passed on. I see the Senator nodding her head in the 
affirmative. When taxes are raised on medical devices or on medication, 
on one thing after another after another, those are costs that will get 
passed on to all the consumers of health care.
  Right before this party took the floor, we had the senior Senator 
from Minnesota talking about the Mayo Clinic and the wonderful care 
that is given there. It is wonderful care. But the Mayo Clinic has also 
said they don't want any part of this bill, nothing to do with it, to 
the point that they have sent doctors in my home State and States 
surrounding the Mayo Clinic who refer patients--and I practiced 
medicine in Wyoming for 25 years, have taken care of families there as 
a physician, and we sent patients to the Mayo Clinic--they just said: 
Stop sending patients on Medicare or Medicaid. We want nothing to do 
with it because the government is the biggest deadbeat payer. The Mayo 
Clinic said: Every time we get one of those patients, we have to charge 
the people who pay their own way, the people who have insurance. We 
have to charge them more. We don't want to take any more patients on 
Medicare and Medicaid. Hospitals and the communities in Maine, South 
Dakota, and Nevada, hospitals in those States have to take all those 
patients.
  So what happens to people who pay their own way because they buy 
insurance themselves or they get it through work is the hospitals have 
to charge them more to make up for the biggest deadbeat payer of all 
time--the Federal Government.
  I see the Senator from Nevada rising to his feet. I imagine the exact 
same thing is happening to hospitals in Nevada. Premiums are going up 
on the 85 percent of the people who have insurance they like. Yet we in 
the Senate tomorrow night are going to vote on a bill which, to me, the 
people of America don't like. Do you know who doesn't like it the most? 
Seniors. They are concerned. They know Medicare is going broke. And by 
the year 2017, there will be $500 billion of cuts in Medicare. Yet the 
money that is being cut from Medicare isn't being used to save 
Medicare; it is to start a whole new program that will cause Americans 
who have insurance to pay more. It will cause people who don't have any 
insurance to make it harder to get or if they go to an emergency room 
and have to pay a bill, that bill will be higher, all because of what I 
believe is an irresponsible piece of legislation that is going to be a 
huge weight on the American economy at a time when we have 10.2 percent 
unemployment.
  I see the Senator from Nevada. He has a similar copy of the bills 
next to him. He may want to chime in on what he sees in his home State 
and what he is hearing from people who live in Nevada, from small 
businesses as well as hospitals and providers.
  Mr. ENSIGN. Mr. President, these pieces of legislation were put on 
our

[[Page 28680]]

desks to show the American people what we are dealing with. We have 
only just started going through these bills. Already we have found 
major problems with the legislation.
  What we are going to talk about over the next few minutes is the 
premium increases for the American people. If you have insurance now, 
your premiums are going to go up because of this legislation we have 
before us. Probably in other ways we don't even know about yet, we will 
discover in the future, but we at least know some ways that are going 
to cause the premiums to go up.
  Let me first talk generally about the bill and what some of the 
problems are and just briefly on some alternative ideas Republicans 
have come up with in more of a step-by-step type approach.
  We know this bill cuts Medicare by $465 billion, including $118 
billion in Medicare Advantage cuts. That means millions of seniors who 
are on Medicare Advantage today will lose the plan they have. Medicare 
Advantage plans in my State are incredibly popular among senior 
citizens. I know they are across the country. We know taxes are going 
to go up by almost $500 billion. We know premiums are going to go up 
for millions of Americans.
  This bill was supposed to bend the cost curve. Because it is actually 
deficit neutral, maybe it helps the deficit a little bit because of the 
smoke and mirrors they play with it. They say that bends the cost 
curve, but when we look at the American people and the actual cost they 
will be paying for health care, their cost curve continues to go up and 
up and up into the future.
  This bill will also lead to rationing. We saw this week a Federal 
board that talked about mammograms, and it caused an outrage in women 
across America. That is the sort of thing that is going to happen 
because of this legislation. Federal bureaucrats are going to be in 
charge of your health care, not your doctor and you. We need to have 
legislation that focuses on that doctor-patient relationship that 
should be so sacred in our health care system today.
  Republicans have come up with the idea of medical liability reform to 
start driving down the cost of all of this defensive medicine that is 
practiced. We all know doctors order all kinds of unnecessary tests to 
prevent themselves from being sued in all these frivolous lawsuits.
  Both sides agree, let's eliminate the preexisting conditions. That is 
kind of a given. That is something on which we all agree. That is part 
of the step-by-step approach this side of the aisle would certainly be 
willing to do.
  I also believe we need to encourage healthier behavior in America 
because 75 percent of all health care costs are because of people's 
behavioral choices--smoking, people who are overweight. We know obesity 
contributes to every kind of cancer, to heart disease, diabetes. It is 
epidemic in this country. Look at our young people. If we don't turn 
around people's behavior, get them to exercise more, eat right, quit 
smoking, I don't care what health care reform you pass, we are not 
going to do anything about driving down the cost. And the high cost of 
health care is the No. 1 problem with our system.
  We believe we should have small business health plans where small 
businesses can join together to buy health insurance, take advantage of 
purchasing power that larger businesses have. We believe individuals 
should be able to buy across State lines the way you do with car 
insurance. If your State is too high on insurance, buy it in another 
State where it is cheaper, where maybe they don't have as many 
mandates. Doesn't that make sense?
  We also believe we should have transparency on cost and quality. When 
you walk into your doctor's office, you should be able to get a written 
estimate of what it is going to cost. You should be able to shop that 
estimate so that we have more consumers making more intelligent choices 
on health care. When was the last time you went into your doctor's 
office and got a written estimate or knew how much something was going 
to cost? I practiced veterinary medicine for many years. When you walk 
into my practice, you get a written estimate. We have you sign that 
written estimate because we have to give that. That is part of our 
general practice. We need to bring that into human medicine, whether it 
is hospitals or doctors' practices. We need to have transparency for 
cost and quality.
  How does this bill drive up premiums for Americans?
  First, there are nine new taxes put in by the Democratic majority: a 
40-percent insurance plan tax for what are called Cadillac plans; 
another tax on insurance companies; an employer tax; a drug tax; a lab 
tax; a medical device tax; a failure to buy insurance tax; a cosmetic 
surgery tax, brand new in this bill; and also an increased employee 
Medicare tax, a brandnew tax structure on Medicare taxes. Who pays for 
these kinds of taxes? It isn't just insurance. On the failure to buy 
insurance, 71 percent of that tax is going to be paid for by people who 
make less than $120,000 a year.
  Almost every one of the taxes I just put up of those nine new taxes--
the vast majority of them are paid by people who President Obama, when 
he was campaigning, said would not pay one dime more in new taxes. He 
repeated that promise time after time. He said: No new fees, no new 
taxes, capital gains. He went through the whole litany of types of 
taxes that would not be raised. Yet in this plan approximately 80 
percent of all of the new taxes are paid by people making less than 
$250,000 a year.
  Another way this massive piece of legislation raises premiums is this 
thing known as cost-shifting. The doctor from Wyoming practiced 
medicine. He was talking about the Mayo Clinic and why the Mayo Clinic, 
the Cleveland Clinic, and other places and other doctors don't want to 
take Medicaid and Medicare patients anymore. Why? Because the 
government pays 20 to 30 percent less than private health insurance in 
reimbursement to doctors; isn't that correct?
  Mr. BARRASSO. Plus, when you read this bill, one of their so-called 
solutions is they will put more people on the Medicaid rolls.
  Mr. ENSIGN. How many more people are going to go on the Medicaid 
rolls?
  Mr. BARRASSO. It is millions and millions of people, with the cost to 
the States. You say we will take it out of here. You won't see it in 
this bill because they are going to make the States pay over $20 
billion in money because it is a matching program, so they get it off 
the Washington books. But it is still the taxpayers and the States, and 
we all come from States. That is going to drive up the cost for 
individuals as well as increase taxes around the country.
  Mr. ENSIGN. Because you were in the practice of medicine, I ask the 
Senator from Wyoming, I have heard numbers as high as 15 million new 
people on Medicaid, plus we have a new public option, so there will be 
more people on another government plan. What will happen as far as cost 
shifting to those of us who have private insurance? For those tens of 
millions of Americans who have private health insurance, what will 
happen to their cost of insurance when more people are on government 
plans?
  Mr. BARRASSO. Those costs will have to go up. Premiums will go up for 
all people who have insurance, private insurance. The Senator from 
Nevada is correct. Some people think the number is 15 million more who 
will go onto the Medicaid rolls because there is a difference between 
the Senate bill and the House bill as to how many more folks they move 
onto the Medicaid rolls. But either way, we are talking tens and tens 
of billions of dollars that will come out of the taxpayers' pockets 
around the States. But that is still for a government-run program that 
doesn't reimburse, doesn't pay the hospitals, doesn't pay the doctors 
even what the cost of delivering the care is.
  Across the board, hospitals will tell you they cannot keep their 
doors open if everyone is paid at Medicaid or Medicare rates. The only 
way they can pay the nurses, keep the lights on, take the food in the 
trays around to the patients, do all the things a hospital has to do, 
or keep a doctor's office open, the only way they can do it is because

[[Page 28681]]

they charge more to people who have private insurance than they get 
paid for people on Medicare or Medicaid. And Medicaid is worse than 
Medicare in terms of the payment.
  So it is this cost shifting that occurs. Who pays that? The people 
who have regular insurance. It is the hard-working men and women of 
America through their jobs who pay for that. We just heard from the 
Senator from Maine. Anytime we try to help that individual--I see the 
Senator from South Dakota is in the Chamber as well, and he may want to 
jump in as well because South Dakota is a State like mine where we have 
lots of small businesses that are going to be hit specifically hard as 
they try to continue to provide insurance. This does not even allow 
small businesses to group together to get better deals.
  The Senator from Nevada talked about buying insurance across State 
lines to help people get the costs down. This bill prevents that. It 
also prevents small business groups from getting together, which would 
be a great help.
  I know the Senator from South Dakota is interested in getting into 
the discussion. I invite him to discuss this very aspect and the impact 
of all these increasing premiums on the folks in his State.
  Mr. THUNE. Mr. President, Wyoming is not a lot unlike the States of 
South Dakota or Nevada, as the Senator knows, although they have a few 
larger businesses in Nevada. But the people who get hit hardest under 
this bill are small businesses.
  We heard the Senator from Maine, Ms. Collins, point out the impacts 
on small businesses. The ironic thing about that is a lot of small 
businesses, where you would want to encourage them to offer health 
insurance to their employees, will be discouraged from doing so under 
this bill. In fact, what most of them are probably going to do is pay 
the $750 penalty and then push everybody off into the government plan.
  The assumption that is being made in here is that the government 
plan--it will grow over time, obviously. I think 5 million people will 
lose their private insurance, according to CBO. My guess is that number 
is going to be much higher because I think what is going to happen is 
small businesses that are impacted the most by these tax increases are 
going to find themselves less and less able to provide health insurance 
coverage to their employees.
  The other thing I want to point out, as to what my colleagues from 
Wyoming and Nevada have said, is that I would be somewhat, I guess, 
interested in what is being proposed by the other side if it did 
anything to impact cost. But it does not. The whole purpose of this 
exercise, at least in the minds of most Americans, is to drive the cost 
curve down. I heard my colleagues on the other side get up and talk 
about, well, their plan is going to decrease costs for people in this 
country.
  Well, here is the cost curve, as shown on this chart. The blue 
represents the cost curve; that is, what would happen if we do nothing. 
That is the expected increase in health care costs in this country if 
we do nothing.
  What is ironic is, the red represents what happens under this bill. 
So instead of bending the cost curve down, it actually increases the 
cost curve. So we are going to spend $160 billion more on health care 
in this country by enacting this bill, this monstrosity of a bill right 
here, which, as my colleagues have pointed out, is 2,074 pages. The 
Senators from Nevada and Wyoming both also have the House version, 
which is 2,200 pages. But look at this thing. You would think somewhere 
in here, in all this volume of paper, there would be a way to actually 
do something to actually bend the cost curve down. But all that 
represents more spending.
  In fact, if you look at the amount of spending in the bill when it is 
fully implemented, it is much more than what the CBO estimated it would 
cost. There was all the publicity when they unveiled this health care 
plan a couple days ago that it is going to be under $1 trillion. Well, 
in fact, we all know they have used a lot of accounting gimmicks, a lot 
of scoring tricks, a lot of ways to obscure the true cost. In fact, 
even in the first 10 years it understates the cost, which is over $1 
trillion. But the 10-year fully implemented cost of this bill is $2.5 
trillion--a $2.5 trillion expansion in the size of the Federal 
Government.
  If you look at how that plays out and how it is paid for over the 
fully implemented phase--we all talked about $\1/2\ trillion in 
Medicare cuts. For 10 years, fully implemented, it is over $1 trillion 
they have to cut Medicare to pay for this thing, and then to raise 
taxes by another $1 trillion. So you are talking about not only cutting 
Medicare to senior citizens, as the Senators have talked about, but 
also raising taxes substantially on small businesses. But at the end of 
the day, after all is said and done, what do you end up with? You end 
up with an increase in cost above and beyond what we would see if we 
did nothing. Tell me how you can call that reform.
  The other point I will make before I yield back to my colleagues is, 
if you are someone who already has insurance--and 182 million people in 
this country have insurance--you are not going to be able to 
participate in the exchange.
  You get no more options out of this. There are 19 million Americans 
who would, perhaps, benefit from being part of an exchange. But if you 
are one of the 182 million people in this country who currently have 
insurance, you cannot get into an exchange and you cannot get any 
subsidy. What you get are big fat tax increases and increases in your 
insurance premiums, for all the reasons that have been mentioned. 
Because when you tax the health insurance companies--as this bill 
does--when you tax the medical device manufacturers--as this bill 
does--when you tax the pharmaceutical companies--as this bill does--and 
create all new kinds of mandates on insurance companies, including 
changing these age band ratings, going to a 3-to-1 age band rating, you 
are going to raise premiums for a lot of people in this country, and 
you are going to raise them the most for people who are age 18 to 34. 
The people who are age 18 to 34 do not realize what is coming at them 
today, but it is about a 69-percent increase in their insurance 
premiums. They are the ones who get stuck the hardest.
  But if you are any of these 182 million people, your taxes are going 
to go up, your insurance premiums are going to go up, and you are not 
going to see any benefit from being able to participate in any sort of 
an exchange. These are the cold, hard facts.
  I have heard countless Democratic colleagues come down here and talk 
about bending the cost curve down and reducing premiums for people in 
this country. As shown on this chart, this is the Congressional Budget 
Office number. This is not anything the Republicans put together. This 
is the CBO cost estimate of what it would do to the cost curve. As I 
said before, the red represents the increase: a $160 billion increase 
in health care spending over 10 years--all of which is going to be 
borne by those 182 million Americans in this country who already have 
insurance.
  Mr. ENSIGN. If the Senator from South Dakota would yield, I wish to 
get your comments--maybe from both of my colleagues--on a couple of 
quotes from the Congressional Budget Office as well as the Joint 
Committee on Taxation dealing with these premium increases and who is 
actually going to bear the taxes. Because a lot of people think that: 
Well, let's tax the insurance companies. Let's tax the medical device 
companies. Let's tax somebody else. Well, this is what the 
Congressional Budget Office says. Let me read a couple quotes. One 
quote is:

       Although the surcharges would be imposed on the firms, 
     workers in those firms would ultimately bear the burden of 
     those fees, just as they would with pay-or-play requirements. 
     . . . Many of those workers are more likely to have earnings 
     at or near the minimum wage.

  So it is the low-income people who are going to end up paying when 
you actually put some of these taxes that we have talked about in.
  Here is another quote from the Congressional Budget Office. Let's 
remind folks, the Congressional Budget Office is nonpartisan. It is not 
Republican,

[[Page 28682]]

not Democratic. They are kind of the objective scorekeeper around here. 
They say, these taxes ``would increase costs for the affected firms, 
which would be passed on to purchasers and would ultimately raise 
insurance premiums by a corresponding amount.''
  The last economic quote is this. This is by the Joint Tax Committee:

       Generally, we expect the insurer to pass along the cost of 
     the excise tax to consumers by increasing the price of health 
     coverage.

  I say to the Senator, this is what you are talking about on that 
other chart you have up. I wish to hear your comments on that.
  Mr. THUNE. Well, the Senator is absolutely right. I think what the 
CBO has pointed out is--and I have the Joint Tax Committee there; the 
data they produced is very similar to what CBO said--84 percent of the 
tax burden is going to fall on people making less than $200,000 a year. 
And half of the families making under $100,000 a year are going to get 
hit with new taxes under this bill. So it is going to fall on those 
people in this country. And I think they like to think they are taxing 
medical device manufacturers and everybody else, but at the end of the 
day, a lot of this gets passed on. And the taxes in the bill, the 
premium increases in the bill, are all going to be borne by the people 
who are probably least able to absorb that and take that, and it is 
going to be the people in the lower income categories.
  So the Senator from Nevada is absolutely right. I again come back to 
the basic premise of this whole purpose of health care reform, which 
should be to get health care costs down, not raise them. The Senator 
from Wyoming has alluded to a number of things we believe would do 
that, that actually do put downward pressure on health care costs in 
this country. It is done in a step-by-step way. It is done in a way 
that does not call for throwing out everything that is good about the 
health care system in this country, creating this massive new expansion 
of the Federal Government here in Washington, DC, with $2.5 trillion in 
costs over a 10-year period when it is fully implemented.
  And probably--who knows--if a lot of these things do not happen, if 
the tax increases, for some reason, do not happen, if the Medicare cuts 
do not occur, it means borrowing from future generations. They talk 
about reducing the deficit by $130 billion only because they did not 
include the physician fee fix in this, only because they added $72 
billion in revenue from something called the CLASS Act, which we know 
is never going to become law--and even if it does, it is a huge money 
loser in the outyears.
  So you have all these things that they did, including delaying the 
implementation date by 5 years so it understates the true cost of this 
thing--all these things that have been done to try to make this turkey 
look like something other than what it is, which is a massive increase 
in spending, massive tax increases on the American people, and 
increased premiums for Americans, particularly those 182 million 
Americans who already have health insurance who are going to get hit 
the hardest by this.
  Mr. ENSIGN. Maybe we could have the Senator from Wyoming comment. One 
of the big things Republicans have been talking about--instead of 
driving premiums up, which this bill does--is driving premiums down. 
Maybe the Senator can discuss medical liability reform, which the 
Congressional Budget Office, which is a very conservative estimate, has 
said would save about $100 billion in medical costs in this country.
  As a practicing physician, maybe the Senator could talk about the 
unnecessary tests that are ordered, the huge increases in medical 
liability insurance costs that physicians face today.
  Mr. BARRASSO. Mr. President, if you do a poll of doctors, with the 
question: Have you ever ordered a test that was not going to help that 
person get better, that patient get better, but you were doing it 
because you did not want to miss something for fear of a malpractice 
suit, every hand will go up of every physician. The Massachusetts 
Medical Society did a poll and 87 percent of doctors said that. 
Massachusetts has their new health care plan.
  As an aside, the dean of the Harvard Medical School had an editorial 
in one of the major national publications this week, and he gave this 
whole thing--he said: I give this whole thing a failing grade. He said 
people who support this--the legislation that is being proposed--are 
engaged in collective denial. We need to do some things that will help 
with cost, with access, with quality. All this bill is going to do is 
drive up the cost, with no improvement at all in quality.
  So there are step-by-step things we can do: letting people buy 
insurance across State lines, getting the same tax breaks as others. 
The Senator talked about helping people stay healthy--exercising, 
getting down the cost of their care by getting their cholesterol down.
  But also you have to deal with lawsuit abuse. It is out there. You 
could do a thing as easy as loser pays. Obviously, there are great 
objections to trying to do that. There are people who would oppose that 
all the way. But it would help eliminate--eliminate--a lot of the 
unnecessary tests and certainly a lot of the costs of the system. 
Because two-thirds of the cost of that whole liability system goes to 
the system, it does not even go to the injured person. If somebody is 
injured, you want to take care of them. But this does not do it at all.
  One of the things the Senator from South Dakota mentioned, fairly 
quickly in passing, was age band ratings, which flies in the face of 
the things we have been talking about: individual responsibility, 
opportunities for people to stay healthy. The big problem is that we 
know 50 percent of all the money we spend on health care on this 
country is on 5 percent of the people--the people who eat too much, 
exercise too little, and smoke. But yet under this government-forced 
insurance, where people are going to be forced to buy insurance--and if 
young people do not buy it, they are going to be listed as either tax 
cheats or criminals because they are going to get fined or they are 
going to get taxed an amount for not buying the insurance--they are 
going to have to buy insurance.
  As the Senator from South Dakota talked about a 3-to-1 ratio--and the 
Senator from Maine mentioned the same thing--what that means is for the 
youngest, healthiest person buying insurance--that kid out of college 
who is staying healthy or might be working construction, who is in good 
shape, going to the gym--what they are doing on a 3-to-1 ratio is that 
person has to pay a lot of insurance compared to the person who does 
eat too much, exercises too little, and smokes. The ratio of their 
insurance premiums--this person can pay no less than one-third of what 
this person pays, when you might have 100 young people where their 
total health care bills for a year would be equal to that one person 
who exercises too little, eats too much, and smokes.
  So these young people are going to end up paying the cost. And it is 
their premiums--and I think we heard that from the Senator from South 
Dakota--their premiums are going to go up--did I hear 69 percent?
  Mr. THUNE. Mr. President, 69 percent. If you are 18 to 34, that is 
what you are looking at in the form of premium increases, not to 
mention the fact that future generations are going to deal with all of 
the debt we continue to pile on them, which I think bears heavily on 
this debate right now, when you are looking at trillion-dollar deficits 
as far as the eye can see. This is not a good deal if you are a young 
person in America.
  Mr. BARRASSO. It is the wrong prescription for America.
  I am going to continue to speak on the floor about the things that I 
think are problems with this bill. I think it is the wrong approach. I 
think it costs way too much. I think it raises taxes on all Americans. 
It cuts Medicare. What we have heard now, and what we know for sure, is 
it is going to raise premiums for people who have insurance, who like 
the insurance they have, who want to keep the insurance they have; and 
their costs are going to continue to go up if this becomes law, at a 
rate faster than, as we saw from the graph, if nothing was passed at 
all.

[[Page 28683]]

  The PRESIDING OFFICER (Mr. Bennet). The time has expired.
  The Senator from California.
  Mrs. BOXER. Mr. President, what is the order?
  The PRESIDING OFFICER. The Democrats control the next hour.
  Mrs. BOXER. Thank you very much, Mr. President.
  I have listened to several of my Republican colleagues and I wish to 
note that they have the bill in front of them and they are attacking 
this health care bill, but nowhere on their desks do we see their bill. 
They have no answers, no solutions.
  Mr. THUNE. Will the Senator from California yield?
  Mrs. BOXER. I can't yield.
  They have no solutions at all on an issue that affects every single 
American.
  What we have before us is the Reid bill which I think is an excellent 
piece of legislation that will make life better for every single 
American. I will spell that out in the course of my remarks.
  We all know change isn't easy. It is easy to come down here and 
demagog and pound your fists and complain. It is human nature to resist 
change. But every once in a while a situation cries out for change, and 
that is the case today with our health care system.
  The status quo is not benign. It is hurting our people. I wish to 
share the story of Nikki White as brought to us in the book ``The 
Healing of America'' by T.R. Reid. He talks about Nikki in the prologue 
where he poses it as a moral question: What we do about health care? 
This is what he writes:

       If Nikki White had been a resident of any other rich 
     country, she would be alive today. Around the time she 
     graduated from college, Nikki White contracted Lupus. That is 
     a serious disease, but one that modern medicine knows how to 
     manage. If this bright, feisty, dazzling young woman had 
     lived in say, Japan, the world's second richest Nation, or 
     Germany, the third richest, or Britain, France, Italy, Spain, 
     Canada, et cetera, the health care systems there would have 
     given her the standard treatment for Lupus and she could have 
     lived a normal life span. But Nikki White was a citizen of 
     the world's richest country--the United States of America. 
     Once she was sick, she couldn't get health insurance. Like 
     tens of millions of her fellow Americans, she had too much 
     money to qualify for health care under welfare, but too 
     little money to pay for the drugs and the doctors she needed 
     to stay alive. She spent the last months of her life 
     frantically writing letters and filling out forms pleading 
     for help. When she died, Nikki White was 32 years old.

  That is a story that should move every one of us, move every one of 
us to action.
  Look, we have spent years studying and analyzing what is working in 
our health care system and what is not working. What it comes down to 
is this: Too many of our fellow citizens are suffering because of the 
broken promises of a health insurance system that abandoned them when 
they needed it the most. Too many cannot afford health insurance. Too 
many are getting sick after praying to God that they wouldn't because 
they knew that sickness could leave them in economic ruin. Praying is 
not a health care insurance plan.
  Americans will spend over $2.5 trillion on health care next year; 
$2.5 trillion. In all, we spend twice as much per person on health care 
as other advanced nations. Yet, the United States of America, out great 
Nation, ranks near the bottom of the 30 leading industrialized nations 
in basic measures of health, such as infant mortality rate and life 
expectancy--the bottom of the list. That is where we are. So we spend 
twice as much and the results are not anywhere near where they should 
be. It is clear why. Too many people don't have affordable health 
insurance, and they wait too long before they get the help they need. 
Or, they are like Nikki and they never get the help they need.
  Health care premiums have more than doubled in the last 9 years--more 
than doubled in the last 9 years--and one respected nonpartisan study 
says if we fail to act, the average American family will have to spend 
45 percent of their income on health insurance premiums alone, and that 
is by 2016. By 2016, 45 percent of their income, the average family, by 
2016, if we do nothing. My friends on the other side stand there with 
the bill and downgrade what we are doing and never address that issue.
  It is time for change. When we know that two-thirds of all 
bankruptcies are due to a health care crisis, it is time for change. 
When we know that every day--every day--another 14,000 Americans lose 
their health care coverage, that tells me it is time for change.
  I know there are many people listening who think the uninsured are 
not their problem, that it doesn't affect their health care. They are 
flat wrong. Right now, every one of us with insurance is paying $1,100 
a year--each of our families--for those who are uninsured. Why? Because 
we have to pay for the emergency room services they get when they are 
rushed into the hospital because they have neglected a health care 
problem and it is very expensive, and we are paying for it. That tells 
me it is time for change.
  When family after family tells us they paid for insurance for years, 
but when they had a crisis their insurance company walked away from 
them--in T.R. Reid's book, we learn about a man who paid all his life 
for insurance and he got struck by an automobile and he was in the 
hospital with a terrible situation, and the insurance company knew it 
was going to cost them a lot. You know what they did? They rescinded 
his insurance. They told him that he weighed more than he should have, 
and they walked away from him. Story after story. Good, hard-working 
people unable to get health insurance, knowing that their future is 
dark. It is time for a change.
  Today, I want to say to America's families: Change is definitely on 
the way. It won't be easy. It is going to be tough. But all these 
things I have said are truths. Everybody here has to be moved by that. 
I believe we will finally bring change. I am hopeful. I am hopeful 
because of the work of so many of our colleagues and the work of 
Senator Harry Reid. He has put a bill before us that, as I said, will 
make life better for every single American. It is called the Patient 
Protection and Affordable Care Act. First and foremost, if you have 
health insurance you like, this bill gives you the security of knowing 
it will be there for you when you need it. And if you don't have health 
insurance, you will be able to get affordable coverage through a new 
exchange which includes the public option.
  Ultimately, under this bill, we are expanding health care to cover 
more than 94 percent of the American people, and all the while we are 
cutting the Federal deficit by an estimated $130 billion over 10 years, 
because there are real savings and real revenues in this bill to offset 
the new important programs.
  When this bill is signed into law, America's families will see 
immediate improvements to their health care. They won't have to wait.
  For example, right away, when President Obama signs this bill, your 
insurance company won't be able to kick you off your plan for some 
made-up reason because they no longer want to cover you. They will no 
longer be able to cap your coverage. I can't tell my colleagues how 
many people think they are safe because they had a $500,000 cap on 
their insurance. They never dreamed they would use it up. But one 
difficult and terrible illness can use it up, and then they are out of 
luck. No more rescissions, no more caps.
  Parents will be able to keep their children on their health care 
policy up to the age of 26. Small businesses will have immediate access 
to tax credits to make covering their employees more affordable. And 
seniors will have a more generous benefit through their prescription 
drug coverage. We all hear about that doughnut hole that affects 
seniors as soon as they need to buy more pharmaceuticals. This will 
give them another $500 before they reach that point. Those are just a 
few of the immediate benefits of the Patient Protection and Affordable 
Care Act.
  Here is a sample of other major provisions. This is a very important 
one. In this bill, no family of four making less than $88,200 a year 
will have to pay more than 9.8 percent of their income for health 
insurance premiums. Let me say that again. No family of four making 
less than $88,200 a year will have to

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pay more than 9.8 percent of their income for health care premiums. So 
if you make anything between say the poverty rate all the way up to 
$88,200, you never have to pay more than 9.8 percent of your income for 
health care premiums, and if you are on the lower end, it is even less. 
It goes down to about 2 percent. So it ranges from 2 percent to 9.8 
percent at $88,200. That means that more than 62 percent of all of our 
families will be able to be assured that they will not have to go broke 
to buy health insurance.
  Remember what I said. A respected study has already stated that if we 
do nothing, by 2016 people will be paying 45 percent of their income on 
premiums. In this bill, we ensure that our middle class down to our 
working poor do not have to worry about those kinds of premium 
increases.
  For the rest of our Nation's families who are more affluent, there is 
the security of knowing that the insurance company reforms in this bill 
are going to help you. The insurance company can't walk away from you. 
If you have a preexisting condition, they can't turn you down. If you 
have a child you want to keep on until age 26, you can. If you are a 
small business, you will get tax credits to help you pay for your 
employees. There are many other benefits, including some free 
prevention coverage that kicks in right away. So no more discrimination 
against those with a preexisting condition.
  By the way, no longer will insurance companies be able to 
discriminate based on gender. Right now, women in my home State of 
California are paying almost 40 percent more for the same insurance as 
men. There is gender discrimination. That will end when this bill 
becomes law.
  In this bill we increase competition, which is perhaps one of the 
most important things we can do to bring down costs to our families. We 
have the health care exchange which includes a public option that will 
compete on a level playing field with insurance companies to keep them 
honest. In other words, there will be a government option, but there 
won't be anything different about the government plan in terms of the 
way it negotiates with the insurance companies.
  There has been a lot of shouting from my colleagues about the public 
option. Why shouldn't the American people have access to a public 
option?
  I ask that question. I don't hear my Republican friends coming down 
to the floor and saying they are going to give up their public option. 
More than 90 percent of us have a public option right now--the Federal 
Employee Health Benefits Program. I don't see one of my colleagues who 
have been trashing the public option coming to the floor and saying I 
wish to get rid of mine. Oh, no. They like it. But they don't want it 
for the rest of the people. I don't understand it.
  There are lots of public options we have here. Medicare is a public 
option, run by the government. I don't hear my Republican friends 
coming here and saying we should end Medicare. They used to say that. 
They don't say it anymore. Now they say they depend on it. It is a 
public option; 45 million Americans are covered by it. Not one of them 
said get rid of Medicare.
  I don't hear any of my Republican friends coming to the floor saying 
we should get rid of another public option called Medicaid. That is for 
the poor. It works well. It is tough, and there are problems with it, 
but it works and it covers 60 million Americans. So you have 45 million 
Americans in a public option called Medicare, 60 million Americans in a 
public option called Medicaid.
  How about the veterans health care program? I don't hear them 
pounding the table and saying get rid of the public option for our 
veterans. I will tell you, maybe they want to, but they would not say 
it because the veterans would be at their door because that public 
option covers 7.9 million veterans. Not one of my Republican colleagues 
say they want to end it.
  I don't hear my Republican friends coming to the floor to say we 
should end our TRICARE program for our military. That is a public 
option for 9.5 million people. I don't hear them saying stop that 
public option.
  Again, their own health care, brought to them by FEHBP, Federal 
Employees Health Benefits Program, that is a public option that covers 
8 million people, including them, and they don't seem to want to end 
that. But when it comes to everybody else, they come down here and 
basically say: a government takeover of health care. False.
  The public option is just one option in the exchange. It has to run 
by the rules of all the other insurance companies. I say if it is good 
enough for a Republican Member of the Senate and a Democratic Member of 
the Senate, a public option ought to be an option for the people whom 
we represent.
  Small business needs help here. I don't know if everybody is aware of 
this, but small businesses pay as much as 18 percent more for the same 
health insurance as large businesses. In California, we have seen 
increased premiums to small businesses that have meant a choice between 
laying off employees or not providing health insurance at all. More and 
more of these businesses are dropping health care coverage. If you are 
in the position where you work for a small business, you don't have 
health care coverage, and you want to stay there, when this bill goes 
into effect, you can go into the exchange and then you will have some 
buying power or your small business can go into the exchange.
  This bill will protect our seniors, and it will strengthen Medicare. 
Medicare is a success story. Before Medicare became law, half our 
senior citizens went without health insurance. Now, 98 percent of our 
seniors are covered by Medicare. They believe in the program and they 
want it to continue. Those of us supporting this bill want to make 
Medicare stronger, and we do. This bill will ensure a stronger, more 
sustainable Medicare Program. It lowers prescription drug costs, as I 
mentioned before. It increases access to preventive services for our 
seniors, and it extends the solvency of the Medicare Program by 4 to 5 
years.
  My Republican colleagues are standing here saying that Democrats want 
to hurt Medicare--by the way, Medicare is a public option. They are 
saying the Democrats want to hurt Medicare, a public option. Honestly, 
who could believe that?
  In 1964, George H. W. Bush called Medicare ``socialized medicine.''
  Newt Gingrich, when he was Speaker of the House, said he wanted to 
see Medicare ``wither on the vine.''
  In 1995, while seeking the Republican nomination for President, 
Senator Bob Dole bragged that he voted against creating Medicare in 
1965. He bragged about it and said: ``I was there fighting the fight, 
voting against Medicare . . . because we knew it wouldn't work in 
1965.''
  The Republicans are saying the Democrats want to destroy Medicare in 
this bill. That is beyond ridiculous. The American people know who is 
on their side when it comes to protecting Medicare. We didn't just wake 
up this morning. We know who brought us Medicare.
  This bill expands Medicaid. That is for the poor to ensure that the 
poorest and sickest among us can get into the program. We are going to 
get those with incomes below 133 percent of the poverty level into the 
program. That means that more than 1.5 million Californians who are 
uninsured or are struggling with the cost of health care, that will 
allow them to be covered.
  I thank the majority leader for working with us to ensure that 
California receives increased Federal support as we expand Medicaid. 
For the first 3 years of this expansion, the Federal Government will 
fully cover the cost of expanding Medicaid.
  I talked a little bit about prevention. Today, only 4 cents of every 
$1 we spend on health care is on prevention. Yet more than half our 
people live with one or more chronic conditions.
  Five chronic diseases--heart disease, cancer, stroke, chronic 
obstructive pulmonary disease, and diabetes--are responsible for more 
than two-thirds of the deaths in America.
  This bill will eliminate copays and deductibles for preventive care 
so people don't get to that serious illness. Those preventive services 
go into effect immediately.

[[Page 28685]]

  That is an overview of the Patient Protection and Affordable Care 
Act. My friends on the other side have already come out against this 
bill. They say it is too long, too complex. One of them said it is 
``holy war.'' This bill will cause them to fight a ``holy war,'' for 
some reason. Where is their bill? They don't have one. After all the 
things we know are wrong with the system--and you don't have to agree 
with us on everything, but where is your bill?
  It seems like my Republican friends care more about playing politics 
than about protecting our families. That is what it feels like. They 
seem to care more about bringing down our President than bringing down 
the cost of health care.
  They seem to care more about all that than Tim and Josie Jentes, of 
Los Angeles, CA. Tim is retired from Raytheon. He gets his health care 
through his retirement plan. During 2007, the first year of his 
retirement, their monthly health care premium was $460. During 2008, it 
rose to $630. In 2009, it rose to $850. That is an 85-percent increase 
in 2 years for this retiree.
  Tim wrote to me and said:

       I understand that compared to many we are fortunate to have 
     good health care and insurance. But we look forward to you, 
     Senator Boxer, the Senate, and the House . . . addressing the 
     seemingly unbounded increase in health care cost.

  We do it in this bill. People such as Tim will be protected. But my 
friends across the aisle say: No, we are not going to help Tim.
  What about Madeleine Foote of Costa Mesa, California? She turned 25 
and lost the health care coverage she had under her parents. She tried 
to get coverage, but because she is taking medicine, she was denied. 
They said it was a preexisting condition. They said you can have health 
care, but you have to have a $3,000 deductible and premiums of $300 a 
month. She wrote:

       As a young person working in a restaurant, repaying student 
     loans and trying to make it on my own, this is a huge 
     financial burden. I cannot afford insurance that charges me 
     so much. . . . For now, I am forced to hope that nothing 
     extremely bad befalls me.

  She is another one who prays not to get sick. That is not a health 
care plan. My friends on the other side say: No, sorry, we are not 
going to help you, Madeleine.
  I have so many other stories. There is Douglas Ingoldsby, a small 
business owner in Santa Barbara, CA. He has 11 employees, and soon he 
will not be able to afford to get them insurance anymore. He asked that 
I support a public option, and I do. My Republican colleagues are 
saying: Douglas, no, we are not going to help you. It goes on. The 
stories go on.
  One of the stories is from a doctor, a retired pediatrician in 
Sacramento, Robert Meagher, who wrote and said that some parents begged 
him not to write on the form--after he saw a child with asthma, they 
asked: Please don't write down asthma. Say it was bronchitis. If you 
write down that my child has asthma, they will have a preexisting 
condition and when they go out on their own, they cannot get insurance.
  Can you imagine a doctor having to face a parent like that? My 
Republican friends don't want to think about that. They seem to be 
thinking about politics and the next election.
  We all know the bill before us isn't perfect. They should vote to 
start debate. They can try to make it better. There are many issues I 
am working on for California. There is the Disproportionate Share 
Hospital Program. I am working to get better prevention for women.
  At the end of the day, this is where we are. Health care coverage for 
all of America's families has been an elusive goal since Teddy 
Roosevelt first proposed it nearly a century ago. Our dear friend, 
Senator Ted Kennedy, whom we miss so much, fought for health care right 
here on this Senate floor from the moment he arrived in the Senate in 
1962 to the moment he died. Today, I am proud to say we are moving 
closer to fulfilling this promise of health care for all.
  Robert Kennedy once said:

       Few will have the greatness to bend history itself; but 
     each of us can work to change a small portion of events, and 
     in the total of all those acts will be written the history of 
     this generation.

  This is our time. This is our moment. This is the moment for us to 
come together as a nation and make sure our people never again have to 
face what Nikki White faced in her last days--filling out forms, 
praying to God she could get health care, not being able to get it, and 
dying at age 32. That is immoral. It is not necessary. We can fix it, 
and we should.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from North Dakota is recognized.
  Mr. DORGAN. Mr. President, I note that this has been a lengthy 
discussion already. My guess is that because this is merely a motion to 
proceed to a subject on the floor of the Senate--my guess is that were 
this motion to be approved, we will have weeks on the floor of the 
Senate talking specifically about amendments, about approaches that 
will strengthen and improve some portions of the legislation that will 
be before us. The subject is health care.
  Frankly, health care is personal to everybody--from senior citizens 
on Medicare to people who get their health care policy from their 
employment, to families who are struggling to pay for increasing costs 
of health care year after year. So the question before the Senate 
tomorrow evening is: Should we debate and vote on these matters? It is 
not should we approve a health care bill but should we proceed to the 
bill to have a discussion and have some amendments.
  Health care has changed dramatically in a very short period of time. 
My background is from a town of 300 people. In my little town, as was 
the case many decades ago, we had a town doctor in a town of 300 
people. It doesn't happen much anymore. We had a doctor, Doc Hill. He 
came when he was a young man, and he stayed until he died. He delivered 
probably 1,500 babies. They had a Doc Hill Day once, and all the babies 
he birthed came to march in the parade in my little hometown.
  As times changed, medicine changed, things changed. Doc Hill used to 
go on house calls to the farms, yes, to deliver babies and to deal with 
illness, house calls all around the region. Times changed and those 
practices changed as well.
  The big debates in the last half century or perhaps century about 
health care have, in most cases, advanced health care. I was not here, 
of course, nor were most of my colleagues--I guess a couple of them 
were perhaps here--during the debate on Medicare. I remember vividly as 
a very young boy the old folks in my hometown, some of whom had 
nothing, lived in little shacks, certainly had no health care, no 
health care coverage, because when you got old, back in those days, no 
insurance company wanted to cover you, even if you could pay for 
insurance. Nobody was chasing old folks to say: Now that you are 70, 80 
years old, can't we sell you a health insurance policy? They couldn't 
find health insurance.
  Half the senior citizens in this country couldn't get health 
insurance. So the Congress came together and said: What do we do about 
the people in their sunset years, those who helped build this country, 
went to war, built the roads, built communities? What do we do about 
that? So they passed Medicare.
  Medicare has been an unbelievable success. Yes, there are financial 
strains on Medicare, but that is born of success. People are living 
longer and over a period of a longer life, they often need more health 
care. But that is a success, not a failure. We have changed medicine in 
our country in many ways. Medicare is one example.
  Miracle medicines, medicines that did not exist some decades ago now 
can be used to keep people out of acute care hospital beds. Vaccines 
can now prevent people from getting sick. Polio was cured. Smallpox was 
cured. Think of the changes over all of these years. And, yes, it is 
the case that if you have a very serious illness, in most cases you 
want to be in this country.
  It is the case, however, that many in this country cannot afford to 
access the health care that exists. But people come here, not 
elsewhere, for good health care. We have terrific clinics

[[Page 28686]]

and opportunities for people to get good health care in this country. 
The problem is, the cost is relentlessly increasing every single year 
and pricing health care out of the reach of too many Americans. Too 
many families cannot figure out how to pay for health care. They cannot 
pay for the increased insurance premium that is going up double digits 
every year. They have to go to the grocery store and stop in the 
pharmacy to figure out what a prescription drug is going to cost. They 
buy their medication first and see what they have left for groceries.
  The fact is, prices of health care are marching relentlessly upward, 
so too many people do not have coverage. Families often cannot afford 
it. Small businesses cannot afford the price increases for health care. 
So what do we do about that?
  If there is a sick child, should a sick child who is crying because 
of pain be told: Your visit to a doctor depends on how much money your 
parents have? I don't think so. So we passed legislation dealing with 
that, providing health care opportunities for children who come from 
families of meager means.
  The question for us now is, Is there a way for us to extend health 
care coverage and also to put the brakes on these relentlessly 
increasing costs? If at the end of the day legislation that is 
considered here does not put the brakes on price or cost increases, I 
don't want to be a part of that. I am not going to be supporting things 
that really do not put the brakes on these relentless increases in 
health care costs. That is the purpose of all of this, is to try to get 
a handle on costs somehow.
  There was an author named Barbara Ehrenreich who described visiting 
with a friend of hers from a European country. She told her friend that 
she had breast cancer and had difficulty getting insurance because she 
had breast cancer. She said: But isn't that when you would most need 
insurance? Not understanding, of course, in our country you are least 
likely able to get what you need when you need it the most.
  That is another question in this set of issues, preexisting 
conditions. Is there a way for us to make it easier for people to 
access health insurance when they really need health insurance because 
they have a debilitating illness? I would hope so.
  What should happen when you pay an insurance company premiums for 10 
or 15 years? You pay every month and all of a sudden the insurance 
company says: We are going to terminate you. What should happen? Is 
that fair? I don't think so.
  Shouldn't there be some opportunities to address those kinds of 
things--the denial of coverage, the termination of coverage? I think 
so.
  Let me also say as we discuss these policies, there is another 
element that is not very often discussed that I want to amplify, and 
that is the issue of personal responsibility--personal responsibility 
that goes well outside legislative activities.
  Two-thirds of the people in this country are overweight. One-third 
are obese, according to statistics. I invited someone from Safeway 
Corporation to meet with our caucus. The CEO of Safeway, Steve Burd, 
has met with folks in both caucuses in the Senate. He told of a very 
interesting program at Safeway.
  I think there were about 45,000 employees in this group, and he did 
the following. He said: Here is your health insurance plan. Here is the 
amount the Safeway company will pay, and here is the amount that you 
pay. So that amount the employee pays is X. But the company said to the 
employees, you can reduce the amount you pay if you do four things. You 
can reduce it in four steps: Do you have high blood pressure? You have 
to be on medicine to control it, and we will pay for the medicine.
  Do you have high cholesterol? You have to be on medicine to control 
it, and we will pay for it.
  Are you overweight? Then you have to be on some sort of weight 
reduction program, and we will pay for that.
  Are you smoking? Then you have to stop or be in a smoking cessation 
program, and we will pay for that.
  If you don't do any of those things, you don't want to do those 
things, you have high cholesterol, high blood pressure, smoke, and are 
well overweight, that is all right, here is your copay. It will be 
higher. But if you do all four of those things, and the company will 
pay in each instance for the cost of it, you will pay four steps below, 
less money every single month.
  He says with that program, they have had flat health costs for 5 
straight years. Think of that: 5 years flat cost. While the rest of the 
country is seeing these relentlessly increasing costs, that program 
provided flat costs, no cost increases. Why? Because they incentivized 
personal behavior in the right way: Do this, improve your health, we 
will pay the cost of it and save yourself some money. That is exactly 
the right thing to do.
  I hope as we have this discussion, a fair amount of that impulse can 
be a part of what we are trying to do--incentivize the right behavior, 
personal responsibility. That makes a great deal of sense to me.
  One of the things I have always supported is the issue of health care 
coverage at the workplace. That is where most Americans get their 
health care coverage. I don't want to do anything to disincentivize 
that. I want, whether it is small, medium, or large businesses, for us 
to say: You know what, good for you. You are providing health care to 
your employees. We support that. I don't want to disincentivize that; I 
want to incentivize that.
  I know it is hard for small businesses during tough economic times to 
pay 10 percent more this year than last year and 10 percent more next 
year than this year. That is what they are seeing in health care costs. 
That is why it is important for us to put the brakes on these cost 
increases, for small businesses, medium-size businesses and large 
businesses as well, to help them be competitive.
  We have to find a way to do that. I am not talking about diminishing 
the quality of health care. I am saying let's put the brakes on the 
price increases year after year. Let's find out what is causing it--and 
I have some ideas about that--and let's put the brakes on it. That is 
what this debate needs to be about.
  I want to talk about an amendment I intend to offer as soon as we are 
able to offer amendments. It is an amendment, by the way, that is 
bipartisan, unlike a lot of things in this Chamber. My amendment was 
cosponsored by the late Ted Kennedy. It is also cosponsored by Senator 
Olympia Snowe, Senator John McCain, Senator Chuck Grassley, Senator 
Debbie Stabenow, and the list goes on including Republicans and 
Democrats. The amendment is about prescription drug prices, and I want 
to describe it.
  It says let's give the American people the freedom to access the 
identical FDA-approved drugs when they are sold for a fraction of the 
price everywhere else in the world. The American consumer is charged 
the highest prices in the world for brand-name drugs.
  By the way, here is what is happening to price increases for 
prescription drugs. We see the rate of inflation in this country. That 
is the yellow line. Take a look at drug prices, the red line. By the 
way, this past year, there was a 9 percent increase in prescription 
drug pricing.
  This issue is not some irrelevant issue. There are a whole lot of 
folks who use prescription drugs to manage their disease and keep them 
out of a hospital. I understand many of these drugs are miracle drugs. 
I don't want to slow the ability of companies to create drugs, do 
research and so on.
  A substantial amount of the research goes on at the National 
Institutes of Health, which is publicly funded. The knowledge from that 
research is made available to the drug companies, and that knowledge 
leads to a product. Good for them.
  But what I don't like is the fact that those same pharmaceutical 
companies charge the American consumers the highest prices in the 
world. They will say: If you offer an amendment, you Senators, 
Republicans and Democrats, that tries to give the American people the 
freedom to access the same identical FDA-approved drug when it is

[[Page 28687]]

sold in Spain or Italy or Canada--name the country--when it is sold in 
a number of countries for a fraction of the price, then somehow it will 
harm research and development on new drugs.
  That is not true at all. Those name-brand drugs are sold for a much 
lower price in Europe, and they do more research in Europe--at least 
that was a couple years ago. I haven't seen recent data. The fact is, 
they have lower prices and they have done more research.
  In any event, there is more money spent on advertising, promotion, 
and marketing than there is on research. Watch television tonight and 
see when you see the next commercial that says: Shouldn't you be taking 
some Flomax--whatever that is. Shouldn't you ask the doctor whether the 
purple pill is right for you? Go find a doctor and say: I don't have 
any aches and pains, there is nothing wrong with me, but isn't the 
purple pill right for me? That is what the commercial tells you to do.
  I haven't the foggiest idea what the purple pill is used for, but 
they relentlessly push this advertising. Knock it off. Maybe they 
should use some of that money for a little more research and 
development, I say.
  To put a finer point on it, if I might, this is the price of Lipitor. 
This is the new price, by the way--$4.78 in the United States for a 20-
milligram tablet and $2.05 in Canada.
  By the way, here is what the two bottles look like. The same pill is 
put in these bottles, made by the same company--Lipitor. It is the same 
manufacturing plant in Ireland. They put the same pill in these two 
bottles. This one goes to the United States; this one goes to Canada. 
The American consumer has the privilege of paying $4.78 per tablet, and 
the Canadian buys it for $2.05. That was June 4, 2009, when I priced 
it.
  It is not just Lipitor, although Lipitor is the most popular 
cholesterol-lowering drug. But Zocor, a 20-milligram tablet, the same 
thing, $5.16, $2.45, U.S. price versus Canadian price. I used Canada 
because it is a close neighbor. I could have used Spain, Italy, France, 
Germany.
  By the way, some folks on the floor of the Senate will support the 
pharmaceutical industry's pricing policies of pricing their brand-name 
drugs the highest in the United States--I don't support that. Some 
will. They will say you can't really import drugs safely. The fact is, 
in Europe they have been importing drugs for 20 years. They have 
something called parallel trading. If you are in Germany and want to 
buy a prescription drug from Spain, no problem. If you are in Italy and 
want to buy it from France, no problem. You have parallel trading of 
prescription drugs. The consumers have the freedom to buy it where it 
is least expensive.
  In our country, consumers don't have that freedom, and our amendment 
gives the American consumer the freedom to shop for those prescription 
drugs where they are sold for the most reasonable prices. I am not 
interested in having consumers buy their drugs from other countries. I 
am interested in the opportunity to buy drugs at a fraction of the 
price, forcing the pharmaceutical to reprice their drugs in this 
country.
  I sat on a straw bale once at a farm where we had a town meeting. We 
all sat around on these bales and talked. An old codger there, about 80 
years old, said to me: My missus--he meant his wife--my wife has been 
fighting breast cancer for 3 years. Every 3 months, we have driven to 
Canada to buy Tamoxifen. That is the medicine my wife has taken to 
fight breast cancer. Every 3 months, we drive to Canada to buy 
Tamoxifen.
  I said: Why do you drive to Canada?
  He said: Because it costs me 20 cents for what I would pay a dollar 
in the United States. I can't afford it in the United States, so we 
drive to Canada.
  The fact is, they will allow someone like that to drive across with 
90 days of use. But most Americans do not have that opportunity and 
most Americans could not access that drug from Canada because it would 
be against the law at this point.
  I want to give the American people the freedom to be able to access 
FDA-approved drugs, and the legislation I will introduce with my 
colleagues has the most substantial safety provisions, including batch 
lots and pedigrees on these drugs that will make the entire drug supply 
much safer than it is now.
  Price increases in 2009. The paper this week described what is 
happening with the pharmaceutical industry in pricing drugs. Enbrel, an 
arthritis drug, increased 12 percent this year. Nexium, for ulcers, 
increased 7 percent this year. Lipitor is up 5 percent this year. 
Singulair is up 12 present this year. Plavix's price increased 8 
percent this year; that is an anticoagulant. Osteoporosis--if you are 
taking Boniva, there was an 18-percent increase this year. What is the 
deal? Does anybody understand what the reason for this is, these kinds 
of unbelievable price increases?
  I am going to offer this amendment with my colleagues. My expectation 
is if you want to say at the end of the day that you have really done 
something to address the issue of skyrocketing prices in health care--
you can't say that if you decide you are not going to do something to 
put the brakes on prescription drug pricing, because the American 
people should no longer pay the highest prices for brand-name drugs in 
the world. That is not something that should be allowed. It is 
certainly not something that is fair to the American people and not 
something that we ought to turn a blind eye to when we are talking 
about legislation here.
  My legislation will be about giving the American people freedom--the 
freedom to access those drugs from a number of other countries named in 
our bill that have an identical chain of custody to our country, where 
it will be safe and secure for the American consumer to access those 
drugs at a fraction of the cost.
  I want to say that some are pointing out that the issue of health 
care is also a jobs issue because the fact is, this is a significant 
burden on employers; that is, those who hire workers and who are 
covering them with benefits, as part of their compensation including 
health care. So it is a jobs issue, and when the burden becomes too 
great, it destroys jobs. That is just a fact. So I want to talk about 
jobs for a moment because even as we describe these issues, which I 
think are very important, they relate to jobs. But I want to go further 
to talk about jobs just because I have a bit of time today.
  I have seen some things in the press recently that have bothered me, 
some stories. I want to describe them.
  First of all, Senator Durbin and I are leading a task force to talk 
about how we put together a new effort to try to create jobs. What 
kinds of incentives will allow small- and medium-size businesses to 
create new jobs? What are the things that will get the economic engine 
restarted, not just in GDP but putting people back on payrolls, putting 
people back to work?
  I noticed that small- and medium-size businesses are having great 
difficulty in this country, even those that want to expand, because 
they can't find the financing to do it. I saw a report this week about 
the large financial institutions that got TARP funds, the bailout 
funds. The 22 banks that got the most help from the Treasury's bailout 
programs cut their small business loan balances by a collective $10.5 
billion over the past six months. And the fact is that Wells Fargo got 
$73.8 billion in TARP funds, and in the last 4 months they have cut the 
amount of financing of small business loans by 3.9 percent. Think of 
that--a company gets $73.8 billion in TARP funds and cuts lending 
needed by small businesses by 3.9 percent. Bank of America, $41.9 
billion in TARP funds, and they cut small business lending by 5 
percent. I am quoting from a Treasury Department report, by the way, 
comparing 4/30/90 to 9/30/09. JPMorgan Chase, $25.4 billion in TARP 
funds, and they cut lending to small business 2.9 percent. American 
Express--the list goes on. I don't understand this at all.
  So the question is, How do we try to give some help to small- and 
medium-size businesses and see if we can restart this economic engine 
so that they can put people back to work? They are the job generators 
in this country. And we are looking for a mix of ideas. What are the 
best ideas we can use to try to put people back on payrolls?

[[Page 28688]]

  But what I want to talk about just for a moment is something I saw in 
the Washington Post this week when the President was in Asia. It talks 
about:

       [Folks from the] 21 Pacific Rim Nations at an annual event 
     that this year has put some of America's policies in the line 
     of fire.
       A chorus of complaints about U.S. trade policies . . . in 
     the hour before the President's arrival [in Singapore]. 
     Leaders of Mexico, China and Russia broadly condemned 
     protectionism . . . endorsing free trade as the best engine 
     of growth--

  And so on.

       The bluntest criticism . . . [said] America is moving in 
     the opposite sense of free trade.

  China and others have said the same.
  Let me just say, it takes an unbelievable amount of gall to suggest 
that we are moving in the opposite direction of free trade. We have an 
unbelievable trade deficit, and this is a trade deficit with China. It 
is a sea of red ink that has gotten worse and worse--a $266 billion 
deficit last year, a $266 billion trade deficit with China, and China 
is telling us we have a problem with free trade? They are the ones that 
have closed markets. We are the sponge for all the goods China wants to 
send us, only to find out we can't get into their markets. This is 
about jobs. This is about jobs that leave our country and go there. 
When we start talking about how to create jobs, maybe we ought to 
straighten out this trade mess.
  Let me say, there is a discussion in the same story about Korea and 
the trade agreement with Korea. I think it is pretty interesting. This 
is what happened with Korea last year. They sent us about 600,000 cars. 
They put them on ships and sent them to America to be sold. We were 
able to sell them 100,000 cars. Why? They don't want American cars on 
the streets of Korea. Ninety-eight percent of the cars on their roads 
are made in Korea because that is what they insist and that is what 
they want. They are criticizing us about the lack of free trade? That 
is unbelievable.
  Let me describe the Cash for Clunkers Program in this country. We did 
a Cash for Clunkers Program. Yes, it put people in some showrooms and 
sold some cars. The Chinese and the Koreans had cash for clunkers 
programs. A lot of us would have liked to have said: You know what, if 
you are going to spend some money on cars, maybe at least spend it on 
cars that are made in manufacturing plants in this country. But that 
was not a requirement because it was so-called illegal under the WTO 
rules.
  For example, when Japan and Korea decided, for their own economy, on 
a cash for clunkers program, they figured out a way to favor their 
domestically produced cars.
  In Japan, only 5 percent of the cars were imports and 95 percent were 
made in Japan because that is the way they wanted it in 2007. After the 
cash for clunkers program, even fewer cars came from imports. Why? 
Because Japan had what was called a certification requirement that was 
open to only a small number of foreign vehicles. For example, they 
would allow the sale of a Toyota Land Cruiser, but you couldn't buy a 
Ford Explorer in Japan under the cash for clunkers program.
  Yet we have these folks saying to us that we are not for free trade? 
Excuse me? How much gall do you have to suggest that a country with a 
$600-plus billion annual trade deficit, $260 billion of which is from 
China--to have our President go overseas and have others suggest that 
somehow we are not owning up to our responsibilities in trade?
  The reason I make this point is this is about jobs. I think 
restarting the economic engine is an unbelievable priority in this 
country. A good job that pays well makes almost everything else 
possible. There is no social program in America as important as a good 
job that pays well. That is what makes everything possible for you and 
your family.
  When we see the millions of people who have been laid off as a result 
of the deepest recession since the Great Depression, we need to get 
about our business. Senator Reid and Senator Durbin and I are working 
on that need, to address it. One of the ways to address it is with this 
trade issue as well.
  Let me conclude as I started, talking about the bill that is before 
us. The legislation we are dealing with is health care, and the vote 
that will occur is on the motion to proceed. There is a lot of 
hyperbole about these issues. This is a motion to proceed to a piece of 
legislation that we will then debate for weeks and we will amend, I 
expect.
  I just described one of my amendments that I feel very strongly 
about. It will be bipartisan. I fully expect it to pass. I have a 
couple of other amendments as well that I will offer.
  I don't want health care to be concluded by the Congress in some way 
or another without the Indian Health Care Improvement Act, which has 
been languishing for many years here in the Congress, being a part of 
it. These are the first Americans, and too often these days the first 
Americans have second-class health care despite the fact that we signed 
the treaties on the dotted line and we owned up to the trust 
obligations that we have, that we have never quite delivered in health 
care, housing, and education. I have spent a lot of time, as have some 
of my colleagues, on the subject of the Indian Health Care Improvement 
Act. I hope very much that in this discussion--and I certainly will 
raise it as an amendment--we will have the opportunity to do what we 
need to do with respect to Indian health care.
  I know there will be a lot of opportunity in the coming weeks to 
describe virtually all the things people want to describe about every 
single issue. I want to come back to something I mentioned in the 
middle of my presentation; that is, personal responsibility.
  We can do all we want to do. We can have all kinds of legislation. 
But there also has to be some personal responsibility with respect to 
health care. I hope, whatever we do legislatively, if, in fact, at the 
end of the day the legislation moves forward, I hope we remember the 
lessons we have learned from some companies around the country that are 
deciding that personal responsibility and the incentives for that kind 
of personal behavior is the right way to address some of these rising 
costs of health care. Certainly the Safeway example I described is in 
that genre.
  Our time is about up. I want to say again that we will vote tomorrow 
night, come back after Thanksgiving, and my guess is that for 3 or 4 
weeks we will have a substantial, generous amount of discussion about 
how best to put the brakes on health care costs. This has to be done in 
a way that is fiscally responsible. It has to be done in a way that is 
effective. If not, there ought not be legislation passed, in my 
judgment. If so, if we can do this in a way that is fiscally 
responsible, in a way that helps the American people and begins to put 
the brakes on the skyrocketing health care costs, then I would want to 
be part of that.
  I yield the floor.
  Mr. WYDEN. Mr. President, transforming American health care so that 
more Americans get good health care at home, instead of only in a 
doctor's office, is an idea whose time has come.
  Quality, affordable home-based care makes sense for patients. It 
generates good-paying jobs for our people and sparks development of 
exciting technologies through research that will pay even bigger 
dividends in the years ahead. Care at home is an idea that Democrats 
and Republicans, conservatives and progressives, can all come together 
on and get behind.
  Right now, getting to see a doctor in their office can be an onerous 
process. You start by calling the doctor's office and testing your 
patience while you sit through menu after menu of options just to get 
past the doctor's voicemail system. You are in trouble if you don't 
listen carefully and miss the option you wanted. You might get sent to 
records or accounting and have to start all over again. After you have 
run that gauntlet, you have to match your schedule up to whatever days 
the doctor's in. With doctors having other obligations like surgeries 
or teaching, you could be up against a schedule where the doctor only 
has office hours a few days a week. That will lead to your getting an 
appointment two months from now. That won't do much good if you are 
sick today.

[[Page 28689]]

  Once you have won that prized appointment, you have to navigate to 
the doctor's office on the day in question. In rural areas, you might 
end up driving yourself and your family long distances to get there. In 
urban areas, workers lose a big part of their day getting themselves, 
or maybe their elderly parent, to and from the doctor's office or 
hospital. That can be a difficult task if your parents have a hard time 
getting around at home--never mind getting them from the car to the 
doctor's office safely. By the time you get to the doctor's waiting 
room, you feel like you have run a marathon. It's the opposite of the 
well-oiled machine you would expect from a country that leads the world 
in health care innovation.
  Our current health care system seems modern, but it is actually based 
on a 19th century model of institutionalized health care. It is like 
riding a horse-drawn wagon all the way from here to Oregon. Just 
because the Pioneers did it and found the beauty of Oregon at the end, 
it doesn't mean that is the best way to get there in 2009. Likewise, 
just because the majority of American health care is delivered in a 
doctor's office or hospital doesn't mean that is the best way either.
  There is a lot of wasted time and effort spent on services that could 
be done more easily--and in some cases, more effectively--done from 
home thanks to something called ``telehealth technologies.'' Telehealth 
technologies are simple-to-use, home-based systems that use tools, such 
as home security sensors and the internet to connect patients to their 
medical providers. Home telehealth has already been used by the 
Veterans' Administration and has lowered costs for treating patients 
with multiple chronic diseases like diabetes and high blood pressure.
  Here's how it works. Some systems help patients with chronic 
conditions like diabetes or high blood pressure send their daily blood 
sugar or blood pressure readings straight to their medical 
professional. There, the readings can be checked and monitored for 
signs that the patient's care needs to be adjusted. Sudden weight 
gains, which can be a sign that someone's about to go into congestive 
heart failure, can also be noted and addressed right away, so that the 
patient can be treated and avoid that outcome.
  These are just a few of the ways that telehealth technologies can 
help patients better manage their health issues from home, instead of 
waiting for their occasional checkup in a doctor's office, when it 
might be too late to correct their health problems. Telehealth 
technologies give medical professionals a new tool by increasing the 
amount of data they can collect on their patients over a long period of 
time. That aggregated information improves the quality of care that the 
patient then receives when they do visit the doctor's office.
  Some of these telehealth technologies are so advanced they sound like 
science fiction, but they are real, they are here today and they need 
to be part of building our new health care system. They offer more than 
just unique, time-saving solutions. Telehealth technologies also open a 
new world of jobs and services that will shore up our economy with 
good-paying work right here at home.
  Researchers from around the country are working to tap the potential 
of these technologies, and I am proud to report that much of the 
cutting edge work is being done in the Pacific Northwest. Their 
discoveries address everything from depression to neurological 
disorders. For example, new technologies can help isolated seniors stay 
connected to the world through a variety of social networking sites. 
This would be a simple, high-tech fix that can help cure the loneliness 
that so many seniors suffer from, and that often leads to depression. 
Some seniors with cognitive issues are being taught how to use personal 
computers to play games that exercise the brain, like Sudoku puzzles. 
Neurologists can then analyze the changes in patients' success at the 
games over time and to understand how and when their cognitive 
abilities start to deteriorate.
  Technologies like this give us the chance to learn about devastating 
diseases like Alzheimer's so that, hopefully, we can one day find new 
drugs and treatments for those who suffer from it.
  Other technologies are moving forward to help those with memory loss 
and help to improve the quality of life for our seniors. ``Caller ID on 
Steroids'' is what one technology has been called that would be life-
changing, and give them more confidence as they age, despite possible 
memory loss. It is a system that brings up a whole host of information 
on a senior's telephone every time someone calls. The system would show 
a photo of the person and their name. It would tell them the last time 
they spoke on the phone--and even a brief description of what they 
talked about. Another new invention would help seniors remember to take 
their medications on schedule.
  There is a day-a-week pill caddy with sensors built it to tell 
whether or not a patient had come close to it or opened the particular 
day's drawer. A screen on the caddy displays reminders or hints about 
how to take the medication. This kind of technology improves patients' 
adherence to taking their medications as prescribed, which increases 
their effectiveness and improves their overall health. Imagine the 
differences these kinds of technology would make in the life of a 
senior who is suffering frightening and debilitating memory loss.
  In the case of neurological illnesses like Parkinson's disease, 
telehealth has been shown to be a better way to manage medications and 
personalize treatment. Parkinson's patients can perform neurological 
tests on a laptop at home and have their success at these tasks 
reported to the doctor in real time. No longer will an annual visit to 
the doctor be the only opportunity to demonstrate how their illness is 
progressing and be the basis for the prescription the doctor writes. 
This kind of innovation could improve the quality of life for such 
patients and reduce the physical and economic toll that unnecessary 
medications cause.
  But telehealth technologies do more than just help patients. There 
are some that also help the people who care for them. Many caregivers 
for people with Alzheimer's find themselves, caring for their patients 
in the middle of the night. Telehealth technologies have been developed 
to let someone else from their caregiver support group know that 
they're up and available to talk, even at 3:30 in the morning. A 
``presence lamp'' system uses simple home security sensors and the 
internet to turn on a lamp in one person's home when their friend also 
happens to be awake in the middle of the night, and vice versa. It 
becomes a lifeline between family caregivers who could reach out for 
emotional and social support, even in those darkest and bleakest of 
hours.
  All these innovations point to the fact that a technological 
revolution is going on right now in home health care solutions, and 
it's time health care reform brought those solutions into the mix. If 
done right, reform should do more than give affordable, quality care to 
all Americans. As these technologies prove, health care reform should 
also stimulate the economy with new jobs and industries that will allow 
us to care for our rapidly aging population.
  Home health care will help put America at the forefront of a new 
health care services industry that will generate more than a million 
new jobs that can never be outsourced. Those jobs will come from 
inventing new home-based care technologies and using those technologies 
to deliver virtual and remote care services here at home and abroad.
  I have already introduced legislation that uses the concept of 
coordinated home health care to help people on Medicare live healthier 
by managing their chronic conditions and reducing duplicative and 
unnecessary services, hospitalization, and other health care costs. 
This bill has broad bipartisan support, from Senators Burr and 
Chambliss to Senators Stabenow, Mikulski, and, previously, the late 
Senator Kennedy.
  My bill, the Independence at Home Act, establishes a 3-year Medicare 
pilot

[[Page 28690]]

project that helps Medicare beneficiaries with multiple chronic 
conditions remain independent for as long as possible in a comfortable 
environment. It provides for coordinated-care programs that hold 
physicians, nurse practitioners, physician assistants, and other team 
members accountable for quality, patient satisfaction, and mandatory 
minimum savings. The act was accepted into the Senate Finance Committee 
health reform bill and I will pull out all the stops to see it included 
as part of the final health reform legislation that the Senate will 
vote on.
  Before Congress finishes writing the bill for 21st century health 
care reform, it is important to define what Americans are paying for, 
how best to deliver much-needed personalized care to patients where 
they live, work, and play, and how to make the U.S. a world leader in 
home-based care industries. The home can become a fundamental location 
for health and wellness and also a priority for reform. In addition, 
all this can be done with a focus on stimulating our economy with new 
jobs, technologies, and services for a world that will share the 
challenge of caring for an aging population.
  I encourage my colleagues to ensure that health care reform is about 
new approaches to patient care, quality of life, and growing old with 
independence and dignity, not just about who's paying the bill. This is 
a chance to redesign our health care system with a new vision that sees 
the patient as the center of a more efficient and effective system. It 
is a chance to change our health care system to one that helps prevent 
disease, treat patients, support family caregivers, and enable seniors 
to maintain their independence, by bringing health care reform home.

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