[Congressional Record (Bound Edition), Volume 155 (2009), Part 21]
[Senate]
[Pages 28719-28781]
[From the U.S. Government Publishing Office, www.gpo.gov]




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

  The PRESIDING OFFICER. Under the previous order, the Senate will 
resume consideration of the motion to proceed to H.R. 3590, which the 
clerk will report.
  The bill clerk read as follows:

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

  The PRESIDING OFFICER. Under the previous order, there will be debate 
until 6 p.m., with the time controlled in alternating 1-hour blocks, 
with the majority controlling the first hour.
  The Senator from Vermont.
  Mr. LEAHY. Madam President, I am glad to see my colleague and 
neighbor from New York in the chair, an extraordinarily hard-working 
Member of the Senate. I am not surprised, on a Saturday morning, that 
she is here.
  Before I begin, I wish to state my appreciation for the kind words 
from the majority leader for the Senator from Vermont. He and I have 
been friends for decades. I am glad to see the work he has done in 
bringing this bill to the floor. I intend to work closely with him.
  Decision time is near on health insurance reform. I will vote today 
to end the filibuster so the Senate can begin this important, historic 
debate to improve and reform our Nation's health insurance system. 
Let's not duck the debate. Let the debate begin. Let's not hide from 
votes. Let's have the courage to vote. Stand up and vote on the 
amendments. Let the American people know where we stand and not say: 
Well, it never came up because of the filibuster. We can end the 
filibuster today. We can get going. We can let every American know 
where we stand.
  The sentries of the status quo again have spared no effort to kick 
the can down the road, as they have done before. The country suffers 
when there is a failure to act on serious challenges that millions of 
ordinary Americans face in their daily lives. This is a defining moment 
for the Senate and for the country. I rank this along with other major 
decisions such as the creation of Social Security and Medicare and the 
Civil Rights Act. We have been talking about health insurance reform 
for more than 70 years, before I was born. The Senate should not now 
prevent a real debate on health reform by hiding behind the figleaf of 
a procedural filibuster.
  A bill worthy of this debate has been produced, after months of 
arduous work. Opponents of reform, unfortunately, have wasted much of 
the public's time by provoking arguments over their distortions about 
what health reform means. Spurious rumors were spread about death 
panels. One mailing opposing this bill claimed that reform would mean 
denying care to people based on their voting records. How desperate can 
these entrenched powers get, those who want to stop health care reform? 
These are the tactics of obstruction in the service of the status quo.
  Meanwhile, what the American people yearn for are constructive 
solutions. They want an honest debate, not a filibuster. That is what 
they deserve, and that is what we owe them.
  A Vermonter came by my office to talk about health reform, as so many 
have over the last several months. I hear this every time when I am 
home in Vermont. If I am in the gas station putting gas in my car, if I 
am in the grocery store, if I am coming out of church on Sunday, I hear 
this. This Vermonter is a physician. He has a special perspective from 
inside the system. He recalled stories about his father, also a very 
respected doctor, who practiced in the days before Medicare. He 
remembered the devastation his father felt when he was forced to turn 
away elderly Vermonters because they did not have health insurance.
  It may be difficult today to even imagine this, but before Medicare, 
older Americans were routinely driven into poverty during their 
retirement years by health expenses. Before Medicare was launched in 
1964, nearly half of seniors over 65 had no health coverage and more 
than one in three lived in poverty. Today, because of Medicare, 
virtually everyone 65 and older has health insurance. The poverty rate 
among seniors has plummeted. More than 100,000 Vermonters have Medicare 
insurance.
  The arguments that were made against creating Medicare may sound 
familiar. Opponents of Medicare, when it first came up, tried to 
demonize the plan. They claimed it would never work. How could 
government run a program like this? They ignored those older Americans 
living in poverty. But eventually Members from both sides of the aisle, 
Republicans and Democrats, worked together. They passed a bill that is 
one of the most successful and popular programs in America today. 
Vermont's entire congressional delegation, which at that time was 
Republican, supported passage of that landmark legislation.
  Today, we have a health system with contradictions. Federal 
investments in research and private investments in development have 
produced modern medical marvels in the equipment, training, techniques, 
and drugs that are available to many Americans. Yet in the prices we 
pay, in the lack of access to basic medical care, in the loopholes and 
the redtape that plague ordinary Americans in our health insurance 
system and in overall results in so many categories, we get far less 
for our enormous health care spending than do the citizens of countries 
whose health care costs are only a fraction of what ours are. Tens of 
millions of Americans have no health insurance at all. Employers who 
want to offer health insurance to their workers are being priced out of 
even having that option anymore. Self-employed Americans must pay 
dearly to afford any insurance, and they can lose their coverage at the 
whim of an insurance company's bureaucracy. In no modern nation except 
ours are families actually driven into bankruptcy by illness. In fact, 
medical expenses are one of the top reasons for bankruptcy in America 
today.
  In the absence of a fair and sensible health insurance system, 
families, businesses, and taxpayers have been dragged along by an 
inflationary curve that only worsens with time. Next year, small 
businesses, already suffering from skyrocketing medical costs, will see 
their premiums rise by an average of 15 percent. That is twice the rate 
of last year's increases. Drug companies have boosted prices of brand-
name drugs by about 9 percent over the last year--the steepest increase 
in years. All you have to do is look at the huge salaries paid to their 
executives, and you know where that money is going. It is not going to 
help the health care of the average American.
  Can't we fashion an American-made solution so our citizens can have 
high-quality, affordable care and access to basic health insurance? Of 
course we can. We are Americans. We can develop that.
  The bill introduced this week by the majority leader and by Senators 
Baucus, Dodd, and Harkin will give millions more Americans access to 
quality, affordable health care. It would end discriminatory treatment 
of those who change jobs or have preexisting conditions.
  I have pushed and will continue to push to accomplish the three c's 
of choice, competition, and cost control, as we reform our health 
insurance system.
  I am encouraged that the Senate bill includes a public option that I 
have strongly supported. I might say, the majority of Americans 
strongly support it. I will stand with others as we make our case for 
keeping it in the reform plan as part of this process.

[[Page 28720]]

  I was proud to join Senator Brown and a core group of more than 20 
other Senators who introduced a resolution affirming our support of a 
public option. A public option would give consumers more choices to 
select affordable and quality health insurance plans, while helping to 
drive down overall medical costs through real competition in the health 
insurance market.
  To further enhance the advantages of a competitive market, I have 
introduced the Health Insurance Industry Antitrust Enforcement Act of 
2009. This would repeal the antitrust exemption for health insurance 
and medical malpractice insurance providers. Closing this loophole in 
our antitrust laws is long overdue, and I will offer my legislation as 
an amendment to the bill to do that. Antitrust enforcement promotes 
competition. It helps to lower prices and expand consumer choice.
  Another factor that contributes to the rising medical costs all 
Americans face is fraud within the health insurance system. The scale 
of health care fraud in our system today is staggering. Studies 
estimate that between 3 percent and 10 percent of all our health care 
spending, both public and private, is wasted through health care fraud. 
That is somewhere between $60 billion and $220 billion each year--money 
we should have for health care, not going in the pockets of crooks.
  To help wring this waste out of our system, Senator Kaufman and I and 
others have proposed the Health Care Fraud Enforcement Act. Our bill 
would toughen sentences for those who commit health care fraud, 
strengthen support for prevention, investigation, and prosecution of 
health care fraud, and sharpen the legal tools we need to go after this 
fraud. It would prevent waste in spending. It would hold accountable 
those who do the stealing. Experience shows antifraud efforts give 
taxpayers a superb return on investment, with a payback of between $6 
and $14 for every dollar we spend on enforcement.
  I am pleased the majority leader included provisions in this bill to 
address the issue of health care fraud. I will work with Senator 
Kaufman and others to strengthen that bill.
  Vermont has helped pave the way for some of the reforms included in 
this bill, and now, for the third year in a row, Vermont has been 
ranked as the healthiest State in the Nation. Vermont is one of the 
earliest leaders in expanding the State Medicaid Program, under reforms 
led by former Gov. Howard Dean and others. Yet under the current form 
of this bill, Vermont would not share the enhanced Federal match to be 
offered to other States. That would amount to a regressive policy with 
adverse practical ramifications for Vermont, a State that is a leader 
in expanding access to health care. I was heartened in my conversation 
this morning with the majority leader when he told me he will try to 
correct that problem. But we cannot correct any of these problems until 
we debate the bill. Let's not hide under our desks because we are 
afraid to stand up and vote and debate.
  The people of Vermont have given me the honor of representing them in 
the Senate for 35 years. I have joined in many debates that were 
contentious yet ultimately productive. I have been on the winning side. 
I have been on the losing side. But as we leaf through the pages of 
history, we can read of many times when the Senate has shown its 
remarkable ability to rise up to reflect the conscience of the Nation. 
Those moments were forged in the crucible of national need, against the 
anvil of the tempered will of the Senate's membership.
  This Senate can do that again. Our dear friend, Senator Ted Kennedy, 
said it so well in the letter about the health reform imperative that 
President Obama read to a joint meeting of Congress. This is what 
Senator Kennedy reminded us:

       What we face is above all a moral issue; that at stake are 
     not just the details of policy, but fundamental principles of 
     social justice and the character of our country.

  This is such a time. It is my hope and belief the Senate I love will 
once again rise to the occasion.
  Madam President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Colorado.
  Mr. BENNET. Madam President, I would like to first thank the Senator 
from Vermont for his excellent remarks in support of what is, after 
all, just a vote to get us started on the debate on health care, a 
procedural vote to allow us to be able to amend and improve the bill in 
the coming weeks.
  Madam President, virtually every single Member of this body in the 
Senate is a Member of the baby boom generation. In my view, it is a 
generation of Americans--I was born in the last year of that 
generation--given more opportunity than any generation of people in the 
history of this planet because our grandparents and our parents were 
willing to make hard choices, understanding that part of our national 
creed, part of our legacy is assuring that we are expanding opportunity 
for those who come after us.
  We are having this health care debate at a moment in our country's 
history beset by incredible economic difficulties. This is the worst 
recession since the Great Depression. But we now know even during the 
period of economic growth before our economy fell into this terrible 
recession that working families were struggling.
  During the last period of economic growth, median family income in 
the United States actually declined. As far as I know, it was the first 
period of recovery in the history of the United States when median 
family income actually went down. It was at the same time the cost of 
health insurance was soaring--in my State by 97 percent--with the cost 
of higher education in my State going up by 50 percent.
  We were saying to working families: You are living in an economy with 
incredible weakness, where the growth is surging ahead of a mountain of 
debt, but you are not getting ahead.
  Just this week, we learned that in the great State of California they 
are increasing the tuition for their universities by 30 percent. The 
University of California, the California system has been the envy of 
the world for decades, and now it is being put out of the reach of 
working families.
  So we have much to do--much to do--to make sure we honor the legacy 
of our parents and our grandparents. We honor the legacy of the 
``greatest generation'' and this generation, the baby boom generation, 
to ensure that we leave behind us not diminished opportunity but more 
opportunity for our kids and our grandkids.
  There is much we need to do to make sure we have a health care system 
that works not just for a few people but for everyone, an education 
system that works not just for a few kids but for everyone, and that we 
have an economy in the United States that values the contribution that 
everybody can make.
  My sense in this health care debate is that the people of my State--
and I know people around the country--are deeply dissatisfied with 
business as usual. They hate the current system. They know it is not 
working for them and their families. They know they are not able to 
make the choices they need to make to have stability for their families 
so they can get ahead economically.
  But, on the other hand, they are deeply worried about our capacity to 
make it worse. It is hard to blame people when you hear the special 
interests' rhetoric coming out of Washington, DC, or when you turn on 
your cable television set at night and watch what people have to say. 
You can understand why people are concerned that we have the capacity 
to make it worse.
  But that is why I am so pleased about the piece of legislation the 
majority leader has brought before us. We have never been closer to 
reforming our health care system, so we can address runaway health care 
costs, enact insurance reform, construct stability and predictability 
in health care for families and small businesses.
  The Senate legislation before us is that promising new way forward. 
Coloradans, as I said, have not been shy at all about letting me know 
about their views of the current system and what their concerns are 
about what we might do.
  Like people across the country, they know the current system does not 
work

[[Page 28721]]

for them. But they are worried, as I said a minute ago, that we are 
going to make it even worse.
  This bill represents a substantial improvement over business as 
usual. I congratulate the majority leader for listening to not just a 
small group of people but to people across the aisle, to people all 
across the country in crafting this piece of legislation.
  First of all, the most important principle of the bill is that it is 
paid for. We already had about $5 trillion of debt when the last 
President became President. We are now at $12 trillion. There has been 
an unbelievable spike between 2000 and today. We have put an enormous 
burden--as the father of three young girls, I feel this very personally 
and very keenly--an enormous burden on our kids and our grandkids.
  Our debt is now $12 trillion. Our entire gross domestic product--our 
entire economy--is $14 trillion. Our deficit is $1.4 trillion, 12 
percent of our gross domestic product. That is utterly unsustainable. 
We know the biggest driver of our medium-term deficits is rising 
Medicare and Medicaid costs, and the biggest driver of those is rising 
health care costs.
  This bill, unlike Medicare Part D--a very worthy program passed 
during the last administration--this bill is paid for. That drug 
program for seniors was not paid for. Instead of paying for it, instead 
of making hard choices, what we said to our kids and our grandkids was: 
You pay the bill. By the way, that is what we have said about tax cuts. 
That is what we have said about the wars in Afghanistan and Iraq. We 
have to put an end to this. This bill at least starts to head us in the 
right direction. It does not fix our fiscal crisis, but it is an 
important step forward.
  As I mentioned a few minutes ago, for working families, the current 
system has been a complete disaster, as their income has remained flat 
or gone down, as their health care premiums have gone up by 97 percent. 
Even though there is a lot of conflict out there about what the way 
forward should be, about a specific policy choice here versus a 
specific policy choice there, I can tell you, one thing everyone in my 
State agrees with is that their health care has not improved by 97 
percent over the last 10 years. They are paying more and getting less. 
Coverage is getting weaker, as it gets more expensive.
  Small businesses are getting crippled by the system we have today. 
They pay 18 percent more than large businesses to cover their 
employees, just because they are small. Sometimes people say to me: 
Well, Michael, don't you know that is because the pool of employees is 
smaller? It is harder to spread the risk. I say: I understand that. But 
as a businessperson, from a business perspective, that is ridiculous--
the idea that a small businessperson, trying to execute their business 
plan, trying to execute their vision to grow their business, is going 
to spend 18 percent more for something and not get 18 percent more 
productivity out of it, or not get 18 percent, in this case, better 
health care coverage out of it. In fact, the reverse is true. It is 
ridiculous.
  By the way, one of the things that is interesting to me about this 
debate over a public option is that people do not seem to understand 
what is actually happening before our eyes. As the costs of insurance 
are going up every year, few and fewer people are able to get insurance 
through their employer, fewer and fewer employers are able to offer 
insurance to their employees, which is heartbreaking for many of our 
small business owners because these are family businesses that for 
years have provided health insurance to their employees. They view it 
as part of their pact with their employees to help them get ahead. But 
they cannot do it. So they are dropping them from the rolls.
  Where are these folks ending up, those who are now uninsured? Well, 
two places: Medicaid, if they are poor enough, or in the emergency 
room, getting covered with uncompensated care that we, the taxpayers, 
are paying for.
  We have a public option. It is the least intentional and most 
expensive public option you can imagine. When we are talking about the 
changes we are making here, we need to understand what is going on in 
the daily lives of people all across our country.
  The figures we have from the Congressional Budget Office show that 
this bill will reduce the deficit, not add to it, will cut our deficits 
over the first 10 years by $130 billion, over the next 10 years by $650 
billion. That is $780 billion.
  One thing we know about those numbers is they are not going to turn 
out to be exactly accurate. But here is the goods news: The CBO is 
unable to score the benefit of prevention. They are unable to score the 
benefit of wellness. They are unable to score or focus on primary care 
instead of emergency room care. There is good reason for that because 
that comes down to execution--how well is the program implemented. 
Those of us who are proponents of reform carry a very heavy burden to 
make sure the execution is good and that we carry this through. But the 
good news is, if we do a good job, we will save money.
  I want to say a word about Medicare because there has been a lot of 
discussion from people who are opposed to reform who are saying we are 
cutting Medicare. They are saying we are hurting seniors. But what they 
will not tell you is that the worst possible scenario is not taking 
action now on critical Medicare reform. As I said earlier, and said in 
many speeches, our Medicare Program, on its current path, is headed for 
fiscal crisis.
  Policy experts on both sides of the aisle have said we need to reform 
our Medicare delivery system. We need to stop basing payments on every 
procedure and every test. Instead, we should look at successful models 
such as our own Denver Health, the Rocky Mountain Health System, and 
the Mayo Clinic in Minnesota. We know they have better quality and 
better outcomes, not just for seniors but for everyone.
  This bill builds on what works locally. That means protecting the 
guaranteed Medicare benefits for every senior, and for years to come. 
It improves Medicare solvency. We make sure doctors will not see a 20-
percent cut in their payments. It makes the entire Medicare system more 
affordable and will save taxpayer dollars.
  Critics say no to reform. They are content with a system that pays by 
the test, test after test, instead of outcomes and patient-centered 
care. That approach will assure that Medicare is bankrupt by 2017. We 
need to do better than that for seniors. We need to protect Medicare.
  Included in this health care reform bill is a version of a bill I 
introduced based on great work being done in Colorado. It is called the 
Medicare Care Transitions Act. We looked at the $17 billion Medicare 
was spending on hospital readmissions. Currently, one out of every five 
patients leaves the hospital and returns within the same month. We 
looked at places in Denver and Grand Junction where the readmission 
rates are 2 percent compared to the national rate at 20 percent. What 
we saw was that they coordinate care. As people go from place to place, 
these health care systems track where they go with a system of 
electronic medical records, what medications they use, what doctors 
they see. They focus on patients--on patients--when making decisions. 
So when we talk about these delivery systems being unnecessary, tell 
that to the 12 million Medicare seniors who got readmitted to the 
hospital within the very first month they were let out of the hospital. 
We owe so much more to these seniors, and we owe a lot more to the 
American people.
  Health care reform must stop the rising costs that are bankrupting 
working families, small businesses, and our economy. If you like your 
coverage, you should be able to keep it. We need to put an end to 
denials based on preexisting conditions. We need to give people more 
affordable options, including a public option. One thing is clear. 
Business as usual cannot be an option. The debate is bigger than 
politically charged issues. We have to keep our eye on the ball and not 
get distracted by the same old, tired, special interest politics that 
have kept us from reforming our health care system since Harry Truman 
was President.
  Health care reform should not be about changing our laws on abortion. 
I

[[Page 28722]]

think the House went astray when it adopted new language with 
unintended consequences for women. The Senate bill already makes sure 
we do not use taxpayer dollars to fund abortion. That is why I opposed 
the House Stupak language.
  I want to end this morning on what I am for. I am for insurance 
reform. I am for making our small businesses more competitive by 
reining in skyrocketing health care costs. I am for reducing premiums 
for working families. I am for more consumer choice, including the 
ability to voluntarily choose a public option. By the way, one thing I 
have noticed is that as people start to understand they are going to be 
required to have health insurance as part of this plan, what they are 
saying is, I want all the options. I want a private option, a public 
option, a nonprofit option. I want to be in a position to make the best 
decision for my family.
  I am for reform that squeezes our wasteful spending so we can reduce 
our deficits in the long term. Throughout this entire debate, my focus 
has been on our working families and small businesses. There is plenty 
in this bill for you.
  The time for talking is over. We should pass this bill. But tonight 
what we should do is make sure we allow the Senate to debate the bill, 
to improve the bill. There are things in this bill I want to change and 
things I want to make better in the coming weeks. But I believe that if 
we pass this reform, we will have taken a very important step forward 
to saying we are here to honor the legacy of our parents and our 
grandparents. We are here to say as one generation to the next that we 
are going to carry that legacy forward and make sure we are making the 
hard decisions to provide more opportunity for you, not less. This is 
only one step of that.
  I mentioned education earlier. I mentioned our economy earlier. My 
hope is that in this debate, what we can do is begin to learn how to 
set the special interests aside for the benefit of the American people. 
If we can do that, there is not a doubt in my mind that we will honor 
our grandparents' legacy.
  Thank you, Madam President. I yield the floor.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. WYDEN. Madam President, even though America has the best doctors 
and the best nurses, our Nation spends too much on health care for what 
it gets. Because the problem in American health care will not cure 
itself, I rise in support of this motion to proceed to beginning the 
debate about how to fix American health care.
  Before I lay out the many provisions in Majority Leader Reid's bill 
that constitute real reform, I wish to talk for a couple of minutes 
about how the Senate can come together, Democrats and Republicans, to 
fix American health care. I have had a chance to visit with almost 
every Member of the Senate in their office on this issue, to listen to 
them, and it is very clear to me that both Democrats and Republicans 
have valid points. I believe my party is absolutely right in saying you 
cannot fix American health care unless all Americans get good quality, 
affordable coverage. If you don't cover everybody with that kind of 
coverage, what happens is those who are uninsured shift their bills to 
the insured folks who are already getting shellacked, and there is an 
underemphasis on prevention. So my party is right that to fix this, we 
have to offer all Americans secure, quality, affordable coverage.
  I think colleagues on the other side of the aisle have valid points 
as well. They focus on the need for marketplace forces, for choice, for 
competition. I subscribe to each of these principles as well.
  I think many believe it is an absurd fantasy that before the Senate 
completes its work on this legislation, the Senate could actually come 
together, Democrats and Republicans. I simply don't share that view. 
Let me be clear: It is my intent when this bill gets to the floor to 
work very closely with Majority Leader Reid and with all of our 
colleagues to finally break through, to get beyond some of the 
polarization, the near brawling we have seen in townhall meetings where 
folks sit in opposite sections depending on their political points of 
view. That is not the American way to face big challenges. This 
certainly is such a challenge.
  I believe fixing the economy and fixing American health care are two 
sides of the same coin. We can't spend more than 16 percent of our 
gross product on health care, spot our foreign competition hundreds of 
millions of dollars a year, and have enough money left over to focus on 
education, transportation, and domestic needs. The reason so many 
Americans don't see their take-home pay go up is because health care 
gobbles up all the costs in sight. So this is certainly a big enough 
challenge that it demands that the Senate get beyond the fighting--near 
brawling--about this subject across the land. On the basis of the 
conversations I have had with colleagues, I continue to believe the 
Senate can break through and produce a bipartisan bill, working with 
Senator Reid, working with colleagues on both sides of the aisle.
  In terms of the real reforms that are in Senator Reid's bill, some of 
the most important have to do with the delivery system--the way 
American health care is essentially experienced across the land. The 
fact is that today's delivery system essentially rewards inefficiency. 
Payments are based on volume rather than quality. In my part of the 
country, we have plans like Kaiser and Group Health, and we have 
actually been in the forefront of trying to move away from a system 
that rewards inefficiency, rewards volume. What we have shown is that 
changing these incentives pays off. People can be healthier and America 
can do it for less money.
  Senator Reid's bill begins to move in the direction of what we have 
been doing in our part of the country for some time. His bill promotes 
what are called accountable care organizations. There are also changes 
in reimbursement. Probably folks on Main Street are not familiar with 
what is called ``bundling.'' In effect, instead of paying for each 
specific service, under bundling there is essentially one payment to 
reward trying to deliver care in an integrated fashion.
  We have been able to have included in the legislation incentives to 
care for folks at home. The majority leader included a version of the 
bill I introduced called the Independence at Home Act that is backed by 
many colleagues on the other side of the aisle, and many Democrats as 
well. When we think about the challenges of American health care going 
forward, we certainly ought to agree it makes sense to deliver more 
good quality, affordable care at home, rather than forcing the sickest 
Americans to spend a big chunk of their day fighting through traffic 
simply to get to a doctor's office, and we have the technologies, we 
have the trained physicians and nurse practitioners to offer these 
kinds of services at home. I highlight the fact that this is real 
reform, it is in Senator Reid's bill, and Republicans and Democrats 
alike are behind it.
  The majority leader makes a number of long overdue changes in the 
private health insurance market. In many respects, today the private 
health insurance system is simply inhumane. What we have is a system 
that rewards cherry picking; where the private insurance companies take 
only the healthy people and send the sick people over to government 
programs more fragile than they are. What we need is a very different 
system where the private insurance companies compete on the basis of 
price, benefit, and quality, and not who is the best at selecting out 
the good risks.
  Senator Reid's bill does away with the unconscionable practice of 
pre-existing condition exclusions and the practice of rescission where 
the insurance companies abruptly drop coverage for the sick. The bill 
also does away with charging a person more simply because they are 
sick, because they are a woman, or because they work in a high-risk 
job.
  These are very constructive insurance reforms. We are going to try to 
build on those as we go forward in the legislation. Colleagues should 
make no mistake about it: The insurance changes in Senator Reid's bill 
are very real reform.

[[Page 28723]]

  I wish to focus for a few minutes, though, on what I think is the 
great promise of this legislation for health care in the future. Since 
World War II, there has essentially been no market for American health 
care. Back in the days of wage and price controls, we didn't have a way 
to get good health care to Americans and we simply said we will put it 
on the backs of employers. They were patriotic citizens then, like 
there are patriotic citizens now, and they said, We will figure out how 
to do it. We are going to have to pass on the costs in the form of 
higher prices for goods and services. That probably made sense back 
then. We had people essentially work at a job for 20 or 25 years, and 
after their last day at work they got a gold watch and a dignified 
retirement. Today, there is a very different economy. The typical 
worker changes their job 11 times by the time she is 40. She needs a 
different set of health care choices. She needs the opportunity to be 
empowered to go into the marketplace to hold insurance companies 
accountable and to get more value for her health care dollar. The 
majority leader in his bill lays the foundation for this kind of 
system.
  He establishes a system of what are called health insurance 
exchanges. They are kind of like farmers markets for health insurance. 
Senator Reid has improved this so that these farmers markets, these 
exchanges, could only let in good-quality plans, and under Senator 
Reid's bill, it will be possible to more easily compare the plans in 
these exchanges. This is something I have been interested in for years, 
really going back to the days when I was co-director of the Oregon Gray 
Panthers, because I think it is simply bizarre that it is possible in 
other parts of American life--in a Costco store or any other big 
store--to compare products, look at alternatives, have a measure of 
uniformity, and not have that in American health care.
  What Senator Reid's bill does is set the foundation for a marketplace 
so that health care in 2009 will be dramatically different than it was, 
say, 60 years ago, in 1949, when I was born. I don't see anybody 
outside the Capitol driving a car from 1949, but much of American 
health care still resembles the middle of the last century. Senator 
Reid, through his legislation, lays the foundation for modernizing 
that.
  I would like to see more people in these new marketplaces, the 
exchanges, more quickly. Under the estimates we have been given, only 
about 10 percent of our population would be able to enjoy the fruits of 
real choice and real competition. Real choice and real competition in 
that marketplace is the path to holding premiums down. My goal in the 
years ahead is to allow every consumer--every consumer, for example, in 
New York and Oregon--to be able to deliver an ultimatum to their 
insurance company. That ultimatum should be: Treat me right or I am 
taking my business elsewhere. It is that simple. That is the way we do 
it in every other part of American life.
  By the way, that is the way it works for all of us here in the 
Senate. We belong to a real marketplace. We belong to a real exchange 
called the Federal Employees Health Benefits Program. If a Member of 
the Senate doesn't like his health care coverage in November of 2009, 
come January of 2010, that Member of the Senate can take his business 
elsewhere, to another insurer that does a better job. I think that kind 
of marketplace--the marketplace every Member of the Senate now enjoys--
ought to be available to everybody else in the country. I think there 
ought to be public choices. I think there ought to be private choices. 
I think all Americans ought to be able to have access to all of those 
choices. We are not going to be able to have real insurance company 
accountability, real choice, and real competition unless we make the 
exchanges robust and get more people in.
  To illustrate the fact that the majority leader and other leaders, 
such as Chairman Baucus, are open to new ideas, just yesterday the 
majority leader and Chairman Baucus and I agreed on an approach that 
will allow more people to enjoy the marketplace, the fruits of a 
competitive system, more quickly, when they indicated yesterday they 
would support my legislation to expand access to the exchanges for 
those who otherwise would have forgone having health insurance under 
health reform. Let me emphasize that--letting folks get to the 
exchanges who otherwise would have no health insurance at all. We have 
been able to do it. According to the CBO, we will be able to add an 
additional million people, middle-class folks walking on an economic 
tightrope, at 10 percent or less of what it would cost to have those 
people get their coverage through Medicaid or through subsidies. It is 
my intent to work with the majority leader and Chairman Baucus closely 
to allow others to have a chance to be part of this kind of competitive 
system. I commend the majority leader and Chairman Baucus for their 
commitment to work with me, as this bill goes to the floor, to expand 
access to the marketplace.
  Let me close with one last point. I see my colleague from New Mexico 
in the Chamber, and he is a welcome addition to the Senate.
  A lot of Americans listening may wonder why the Senate is turning its 
attention to health care when there is so much economic hurt in our 
land. The fact is, fixing the economy and fixing American health care 
are literally two sides of the same coin. We have to rein in these 
costs. We have to rein in these costs for Americans to have more take-
home pay, to be in a position to pay for essentials, and to allow our 
workers to compete in ferociously challenging markets around the world.
  It is time to move beyond the townhall brawls of this past summer and 
for the Senate to work with Senator Reid and all colleagues to break 
through and deal with this critical issue, the premier long-term 
challenge of our time for our economy, and do it in a bipartisan way. I 
urge my colleagues to vote for the motion to proceed.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from New Mexico is recognized.
  Mr. UDALL of New Mexico. Madam President, I appreciate very much 
listening to Senator Wyden and his comments on health care reform. He 
has been one of the leaders when it comes to working in the Finance 
Committee and looking for significant reforms on health care. I look 
forward to working with him in that capacity.
  The health care reform we are debating today will impact every person 
in this country. Whether you are searching for affordable insurance for 
yourself or watching helplessly as a loved one is denied coverage, 
every American stands to gain something through this historic 
legislation.
  In my home State of New Mexico, the people I represent don't just 
have a lot to gain from this reform, they also have a lot to lose if 
this reform is not enacted. For New Mexicans, the status quo isn't an 
option. That is because without this health care reform our State is 
expected to experience the largest increase in insurance premiums of 
any State in the Union. In 2016, without this reform, a family of four 
in New Mexico can expect to pay an astounding $28,000 a year in health 
care premiums. That will consume more than 56 percent of that family's 
projected income for the year. Affordability is already one of the key 
barriers to obtaining coverage in my State. Since 2000, premiums for 
residents have risen 110 percent. As a result, almost one in four 
people doesn't have insurance, giving us the second highest uninsured 
rate in the Nation.
  Enactment of this reform legislation would make as many as 249,000 
middle-class New Mexico residents eligible for premium credits to ease 
the burden of these high costs. In addition, almost 238,000 New 
Mexicans would be eligible for new private coverage through the 
exchange or through their employer and another 124,000 would be 
eligible for the new expanded Medicaid coverage. For the families who 
already have insurance, they win too. They will likely see lower 
premiums, thanks to the increased competition in the market. The bottom 
line is that with this reform the vast majority of New Mexicans would 
have access to quality, affordable health care for themselves and their 
families.
  Reform will also benefit New Mexico's small businesses. In 2006, less 
than

[[Page 28724]]

35 percent of small businesses in my State offered coverage for their 
employees. That figure means our State ranks dead last in employer-
sponsored insurance in the Nation--a dubious distinction, to say the 
least. I have talked to a lot of these small business owners over the 
past month. They all tell me pretty much the same thing: I would love 
to offer coverage to my employees, but it is just too expensive. They 
say they are having a hard time affording insurance for their own 
families. To those small business owners, I say that help is on the 
way. The Patient Protection and Affordable Care Act will help you 
provide insurance to your employees by providing Federal tax credits of 
up to 50 percent of premiums should you choose to offer coverage.
  In addition to lowering costs for individuals and families and 
helping small businesses, this reform would also give our rural 
communities additional tools to provide quality, affordable health care 
for all of their residents.
  Of the 2 million people who call New Mexico home, about 700,000 live 
in rural areas. They are more likely to be uninsured and often must 
travel hundreds of miles for preventive or emergency care--if they are 
able to find any care at all.
  In this bill, we have included pay incentives to recruit more 
physicians to serve in these underserved rural areas. We will improve 
dental services in rural areas, we will extend Medicare payments for 
ambulances in rural areas, and we will expand the Telehealth Program so 
that rural residents may receive specialized treatment not available in 
their local areas.
  Finally, we make sure this legislation won't result in an unfunded 
mandate for our State government, which is already experiencing the 
pain of budget cuts, thanks to the economic downturn. This legislation 
would require the Federal Government to cover 100 percent of the cost 
of the Medicaid expansion from 2014 to 2016 and 95 percent of that cost 
after that.
  When it comes to health care today, too many New Mexicans are living 
on a cliff, teetering on the edge of financial ruin. All it would take 
is an illness or job loss, and they could fall into the abyss of 
medical invoices, bill collectors, and bankruptcies. For these New 
Mexicans, the status quo isn't an option. This bill offers a life rope 
to these New Mexicans to pull them back from the precipice. Passing it 
would provide stability and security to those who have insurance, 
affordable coverage to those who don't, and lower costs for families, 
businesses, and government.
  This is a historic moment. I urge my colleagues to join me in seizing 
it. Let's begin the debate on this long-overdue legislation to reform 
our broken health care system.
  With that, I yield the floor.
  The PRESIDING OFFICER. The Senator from New Hampshire is recognized.
  Mr. GREGG. Madam President, I ask unanimous consent to be allowed to 
speak in a colloquy as it evolves on our side.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. GREGG. We are joined by a number of the distinguished members of 
our caucus. They have thoughts they want to express. We want to discuss 
a couple of points.
  Before I turn to the Senator from Missouri, I want to make a point, 
because I have been listening to a lot of the discussion on the floor, 
and I have participated and listened to a lot of it on television, from 
my colleagues on the other side of the aisle. They continue to use this 
number. They claim this bill will cost $800-some-odd billion and that 
is the number that has been reached as the expenditure on this bill. 
That is a totally dishonest number. That is the ultimate shell game. 
That is Washington cynical politics.
  Do you know how they get to that number of $800 billion as a cost of 
the bill? It is a 10-year number, by the way. That is a lot of money, 
$800 billion. That would run the State of New Hampshire for probably 
100 years. Missouri is a little bigger, but it would run that State for 
a while, and it would probably run Alabama for a little while. South 
Dakota could probably run for 200 years on that. That is not the real 
cost of this bill, though. That is not the cost of the bill.
  The way that number was arrived at--and I think the American people 
need to understand this. If that number was so dishonestly arrived at 
for the number of the bill, what is wrong with the rest of the bill 
that they haven't been told about? That was a 10-year score for what 
the bill cost was, but they don't start spending money under this bill 
until the fourth and fifth year. In fact, the cynicism exceeds that. 
They couldn't get the score they wanted--they couldn't get the score 
they wanted from CBO, so they moved back another year in the 10-year 
cycle. They went from 4 years to 5 years as to the starting point of 
most of the spending in this bill.
  What they claim to the American people is the 10-year bill is going 
to cost about $800-plus billion. But what they don't tell the American 
people is they are not spending anything in the first 4 or 5 years of 
the bill. No, they do raise your taxes throughout the 10-year period. 
They do cut Medicare throughout the 10-year period. But they don't 
spend the money. They don't start the programs until the year 2014, 
when this bill is fully phased in.
  When all these new programs, this massive expansion of entitlements 
is created, brand-new entitlements, when all this new spending occurs, 
this bill will cost $2.5 trillion over that 10-year period--$2.5 
trillion. That is the real cost of this bill. That is how this 
government is going to grow in a 10-year window as a result of this 
spending.
  I say to my colleagues, I think most of us understand we already have 
a huge debt problem in this Nation. We are passing on to our kids a 
country with so much debt they are not going to be able to afford it. 
Every year for the next 10 years, without this health care bill, the 
President has proposed budgets which will run a $1 trillion deficit, 
every year, on average, for the next 10 years. Sometime this month, we 
are going to have to raise the debt ceiling of this country because we 
reached $12 trillion in debt. Then it is going to have to be raised 
again because we are running up these massive deficits.
  The debt owed by this country will exceed 80 percent of our gross 
national product--80 percent of our gross national product at the end 
of that 10-year period--and will exceed 60 percent of our gross 
national product within 2 years. Those are unsustainable numbers. Yet a 
bill is being proposed that is going to expand the size of government 
by $2.5 trillion.
  It is alleged it is paid for, and we are going to get into a 
discussion in some depth because I think that is an equally cynical 
number as a result of bait and switch.
  I just wished to clear the air as to the real cost of this bill 
because I found it uniquely cynical that it would be represented that 
this bill costs $890 billion, whatever the number is. It does call into 
issue the credibility of the rest of the numbers that are being thrown 
out by the other side of the aisle when they use that number, which is 
a 5-year number that they claim covers the 10-year cost, when they 
don't do anything in the first 5 years.
  I appreciate the indulgence of the Senator from Missouri. I 
understand he wishes to speak and then we will go to the Senator from 
Alabama and then the Senator from South Dakota and then have a 
discussion about some of the issues, such as costs, how it affects 
Medicare, how it affects small businesses, how it is going to affect 
your personal insurance.
  Mr. BOND. Madam President, I thank the Senator from New Hampshire. I 
wish to clarify some things he said because they are truly important. I 
wish to make sure everybody understands it because Senator Gregg, in 
his position on the Budget Committee, as well as his other positions in 
writing this bill, is intimately acquainted with the costs of this 
bill.
  The cost for 2010 to 2019, how much was the cost for that 10-year 
period?
  Mr. GREGG. That is $1.2 trillion because between the period 2010 and 
2014, there are no expenditures because they don't start the programs 
until 2014.

[[Page 28725]]


  Mr. BOND. Is this the total expenditure or are these just the 
expenditures that are not covered after 2014, that are not covered by 
the so-called tax or revenue raisers? In other words, does this all go 
onto the debt?
  Mr. GREGG. No, those are total expenditures which are represented to 
be offset by cuts in Medicare, increased fees, and increased taxes.
  Mr. BOND. Cuts in Medicare. How much are the cuts in Medicare?
  Mr. GREGG. When fully phased in, in the 10-year period, 2014 to 2023, 
the Medicare cuts are $1.1 trillion.
  Mr. BOND. Madam President, $1.1 trillion cuts in Medicare. How much 
are the taxes and the other ``revenue raisers'' in that period?
  Mr. GREGG. The taxes and fees during that period--this period, when 
it is fully phased in--are approximately $1.5 trillion.
  Mr. BOND. So how much will go onto the debt? How much is uncovered?
  Mr. GREGG. Actually, if you accept these assumptions that we are 
going to cut Medicare by $1 trillion and take that to create a new 
entitlement instead of using it to help Medicare be more solvent and 
then we are going to raise taxes and fees by $1 trillion--remember, 
most of this is not going to come out of the wealthy. It is going to 
come out of small businesses and higher premium costs to people on 
insurance or it is going to come out of HI taxes. If you accept that 
logic, which I find to be a bit of a reach, then it will not have any 
impact on the deficit in that timeframe because they have cut Medicare 
to pay for it, and they have raised all these taxes to pay for it.
  Mr. BOND. My friend has been very active in the Budget Committee. How 
many times have we cut Medicare, have we allowed Medicare cuts to go 
into effect? I think that is a rather rare occurrence, isn't it?
  Mr. GREGG. That is a fascinating question because I was chairman of 
the Budget Committee the last time we tried to do something in the area 
of the rate of Medicare costs because we received a directive from the 
Medicare trustees that Medicare had to be made more cost-effective or 
else it was going to go broke. So we suggested, when I was chairman of 
the Budget Committee--and everybody in this room voted for it, by the 
way--that we should reduce the rate of growth of Medicare by $10 
billion on a $1 million timeframe. In other words, Medicare was going 
to spend $1 trillion over a period, 5 years. We were going to suggest a 
$10 billion reduction in that rate of growth which was going to be paid 
for by requiring people who were getting Part D premiums and had high 
income to pay for part of their premiums--people such as Warren Buffett 
would not be subsidized by people working down at the local restaurant.
  We did not get one vote from the other side of the aisle. We passed 
it by having the Vice President sit in the chair and break the tie. 
That was $10 billion over 5 years.
  So I think this idea that you are going to do $1 trillion over 10 
years and pay for this--first off, if you are going to reduce spending 
or raise Medicare taxes, it should go to pay for Medicare solvency 
because Medicare is insolvent. It shouldn't go to create a new 
entitlement. Senior citizens, paying into Medicare all their lives, 
should not have their money taken to start a brand-new entitlement for 
other people, and that is what this bill does.
  As a practical matter, we are not going to do that. We know that. We 
know this is all going on the debt. Ninety percent of this is going to 
end up on the debt.
  Mr. BOND. I thank my colleague from New Hampshire because he has been 
a very solid, consistent, credible voice. What he is pointing out today 
is that the legislation we are debating has major implications for 
every American family, every American taxpayer, every American small 
business.
  In the 1992 election, President Clinton's famous slogan was: ``It's 
the economy, stupid.'' Seventeen years later, it is again the economy 
that is a major issue facing the people. But this time the majority 
party does not seem to be paying attention. Instead, the majority has 
used its supermajority position to spend trillions of dollars that we 
don't have, including a misnamed stimulus that stimulated the growth of 
the deficit and the Federal Government but not jobs. We had takeovers 
and bailouts of banks, insurance companies, and major auto 
manufacturers. They have adopted a budget that would double the debt--
the debt our grandchildren owe--in 5 years and triple it in 10.
  It is little wonder that the unemployment rate has skyrocketed, 
because employers are afraid to hire. Families are seeing their budgets 
strapped such as never before. But the bill before us is a crowning 
achievement of the drive to destroy our economy and hope for the 
future.
  Just 1 year after a narrowly averted financial collapse, with 
unemployment at its highest level since 1983, instead of how to create 
jobs, we are debating a bill that will take over one-sixth of our 
economy and likely kill jobs.
  Don't get me wrong, our health care system is in need of reform. It 
costs too much, too many people are uninsured, there are too many junk 
lawsuits and too much defensive medicine and not enough focus on 
prevention and wellness.
  While we all agree reform is necessary, the American people expect us 
to answer the questions: How much will reform cost and can we afford 
it? Will it lower health care costs? Can you keep your current plan? 
What role will the government play?
  The answer to two and three on this bill is: No, it will not lower 
our health care costs; no, you will not be able to keep your current 
plan.
  Then the question is: Who will make health care decisions? We are 
seeing evidence that they have government committees that say when you 
can get a mammogram, when you should get Pap screening.
  Will Americans and Members of Congress have time to evaluate what is 
in the legislation? We hope today, as yesterday, that we will bring out 
for the American people the cost of this bill because what we are 
seeing in this massive pot, 2,047 pages, is there is a lack of 
commonsense reform. It is filled with costly budget gimmicks and asks 
the people of America to spend over $2 trillion on proposals that will 
heap a mountain of debt on our children and grandchildren.
  Two trillion dollars is an almost unfathomable amount of money. But 
in Washington, trillion is the new billion, and that is not the kind of 
health care reform Americans want. It is not reform at all. It spends 
too much, it taxes too much and it cuts Medicare too much and does not 
provide reforms we need. Nearly $\1/2\ trillion in taxes will be added 
on the backs of the American people, $28 billion in taxes on 
businesses, which will kill jobs at a time when we have over 10 percent 
unemployment and even higher if you include the number of people who 
are no longer working or underemployed. These higher costs will 
ultimately be passed on to American workers and consumers.
  Anybody who thinks you are going to tax health care insurers, device 
providers and expect that those costs will not be passed on to the 
consumers--that is you and me, Madam President. The head of the 
Congressional Budget Office and the Joint Committee on Taxation have 
said these higher taxes are passed along, and they will land on 
families, small businesses, and individuals.
  It will also force Americans into a government-run health care plan. 
It will ration care and limit access to lifesaving treatments and put a 
bureaucrat between you and your doctor. In life, two things you can 
count on are said to be death and taxes. I didn't expect to see them 
both in a health care reform proposal.
  We call this a pig in a poke. The only way to sell a pig in a poke is 
to hide from Americans what their tax dollars are buying. If I were to 
outline all the problems in this 2,000-page bill, we would be here 
until Thanksgiving. It is sort of like a mosquito in a nudist colony--
there are so many targets to attack in this bill we don't know which 
one to hit.
  Let me give you just a few. As the Senator from New Hampshire pointed 
out, the real cost of this bill to the

[[Page 28726]]

American people is a whole lot more than they admit. The majority is 
claiming that the bill only costs $850 billion, but the way the 
majority gets to say that is because they are pulling a great smoke-
and-mirrors trick.
  Even more incredible is the Democrats' claim their bill will cut the 
deficit. It is a great scheme, but no one outside Washington actually 
believes this health care bill will do anything but increase costs and 
pile more debt on our kids and grandkids, and they are right.
  Right now, as the ranking member of the Budget Committee has pointed 
out, the national debt already exceeds $12 trillion. This bill will put 
more on that. The true cost of the bill is not just a ``he said, she 
said.'' Even the nonpartisan Congressional Budget Office acknowledges 
that the majority's bill includes gimmicks that hide the true cost of 
the bill.
  Part of the majority's scheme to hide from Americans the true cost is 
the great stunt, as the Senator from New Hampshire described, to push 
back implementation of parts of the reform to 2014 but start collecting 
money in taxes now. That means tax now and pay later. That sure makes 
your numbers look good, doesn't it?
  For example, Medicaid expansion does not begin until 2014. That is in 
section 2001. Section 1311 says health insurance exchanges are not 
fully operational until January 2014. Section 1323 says a public health 
insurance option is not available until 2014. Most of the major 
insurance reforms, however, in section 1253 take effect in 2014.
  The tax on health insurance starts in 2010. That is section 9010. 
Section 9009 says the tax on medical devices starts in 2010. Section 
9008 says the tax on pharmaceutical manufacturing starts in 2010. That 
is even worse than the Senate Finance Committee bill which initially 
had it starting in 2013, but it is a great gimmick to allow them to 
hide the cost of the bill. Claiming savings of $122 billion by 
recording taxes over 10 years and only scoring costs over 6 years would 
get an officer in a publicly traded corporation sent to jail. Move 
over, Bernie Madoff. Tip your hat to a trillion-dollar scam. This is 
magnificent, and that is in this bill. I am glad all Americans can read 
it. They can check out the sections I cited.
  Even the Congressional Budget Office has called ``bull'' on this 
stunt, saying it would be difficult to maintain the savings the 
majority has been touting. No wonder. And the true cost, as the Senator 
from New Hampshire has pointed out, is $2.5 trillion. But it will also 
be increasing taxes. In fact, everyone will be taxed one way or 
another. Forget what the President promised about no taxes. Sections 
9004 and 9010 will tax Americans who have insurance. Section 1501 will 
tax Americans who do not have insurance--almost $8 billion. Taxes will 
be placed on medical device manufacturers, section 9009; and as the CBO 
has said, those taxes will be passed on in the form of higher prices 
and thus in the form of higher insurance premiums.
  Because of the tax on health insurers, section 9010, the CBO and the 
Joint Committee have said these taxes will be passed on in the form of 
higher health care premiums. Pricewater-houseCoopers says that is $487 
a year per family. That is how much these taxes on the health insurers 
and health payment plans will cost the average family.
  Employers will be taxed. About $2 billion in new taxes will be placed 
on employers who do not meet government approved health care plans. 
That is section 1513. That is where American workers are going to pay 
for it because that is where they lose their jobs. Headlines in the 
Wall Street Journal and letters I have seen from leaders of businesses 
say we are not expanding; we cannot afford to expand; we cannot afford 
to take on more employees.
  Why are we having a jobless recovery? Because the threats of 
Washington's overspending, overcontrolling, overtaxing, and 
overregulating are telling prospective employers that they are about to 
hit the ditch with all the things the Government is putting on them.
  For all of the taxes and mandates, according to CBO, about 5 million 
Americans would lose their employer coverage. That is because the costs 
would go up, the regulations would go up. Currently, 83 percent of 
Americans have health insurance, and they are concerned that it costs 
too much. Americans want affordable health care, but this bill raises 
the cost of health care. New taxes and mandates will be passed on to 
American families, the American taxpayers, and American small 
businesses.
  The bill still leaves 24 million Americans without insurance. 
According to the CBO, the government-run plan will have higher 
premiums, and the CBO said it will drive up the cost of health care. 
This was supposed to lower the cost of health care. It will not do 
anything of the kind.
  To sum up, $2 trillion in more spending gets the American taxpayer, 
in the 2,074 pages, a Federal bureaucracy that increases the cost of 
health care, raises premiums, slashes Medicare for seniors, and puts 
unfunded burdens on States.
  Let me just make two last points: The States, according to CBO, will 
get coverage for these new Medicaid eligibles for the 2 years that they 
will get covered and then they will dump it on the States--$25 billion. 
There is a $25 billion cost.
  The Senator from New Hampshire and I were both Governors of our 
States. I can tell you, States do not need that kind of burden, 
particularly in their difficult circumstances.
  Slashing Medicare for seniors? In Missouri, Medicare already only 
pays 80 percent of the costs. More and more hospitals and doctors have 
to limit the number of Medicare patients they can accept. If we 
continue, and if they push through this Medicare cut, then fewer and 
fewer Medicare patients are going to be able to get health care.
  I hope my colleagues will listen to what the American people are 
telling us and vote against the bill. That is certainly the message I 
am getting from Missouri.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Alabama is recognized.
  Mr. SESSIONS. Madam President, I thank Senator Bond. He has certainly 
delineated some of the fiscal impossibilities in this bill, as has our 
former Budget chairman, now ranking member of the Budget Committee, 
Judd Gregg. He studied this very hard. The information he provided to 
this Congress and to the American people is accurate.
  I have tried to think what I should say about this bill this morning 
and be realistic and honest and boil it down to its essence. The 2,000 
pages that sit on that desk, how should we talk about it?
  Let me just say the claim from our colleagues is that they have a 
great plan to reform health care and it will fix the problems in health 
care. We do have problems in health care that need to be fixed. They 
are going to provide methods and additional funding and provide 
millions of people with insurance who didn't have it before--although 
24 million will remain uninsured. At the same time, they will save $130 
billion over 10 years, and we are supposed to be grateful and say how 
pleased we are that you have been able to pull off this event.
  But the first reaction most American people have had, and it is a 
sound one, is, wait a minute, that is pretty dubious. How can you do 
that? Do you remember that song from the ``Sound of Music''? ``Nothing 
comes from nothing, nothing ever could,'' sang Julie Andrews.
  The result is the phrase I came up with: ``Shell game.'' Senator 
Gregg used that phrase. I think that is exactly what we are talking 
about. When it became obvious to everybody who could add that this 
great vision, the wild chimera they had that they could do all these 
things, would not work as they dreamed it, the mountebanks began their 
chicanery.
  In my remarks I will not attempt to point out all the manipulations 
in this bill, just some of the more obvious that are inescapable.
  First, you ask: Why do they do this? The answer is the numbers don't 
add up. They cannot make the numbers do what they want them to do. So 
they either have to be honest and talk about

[[Page 28727]]

massive cuts openly or massive tax increases. The American people are 
not sure about that. To add a whole new monumental health care program 
at a time of colossal financial stress in our country, with debts the 
likes of which our Nation has never ever seen before, are we now going 
to start off on a monumental multitrillion-dollar bill that will not 
pay for itself?
  We have this great promise, and it is not adding up. Do they slow 
down? Do they begin to think if they can't do everything they promised 
in the campaign, and they would love to do, and they wanted to do, what 
progress can they make step by step in a rational way that we can 
afford in this time of unemployment and unprecedented deficits? No, 
that is not what they decided to do.
  What they decided to do is go forward anyway and call anyone who had 
the temerity to say their ``emperor has no clothes,'' that they are 
``Dr. No,'' they are against everything. They don't believe in any 
reform.
  That is kind of the idea we are hearing, and that is not correct.
  The bill is just too much, it goes too far, too fast, and costs too 
much. We don't have the money. The American people know this. That is 
why they oppose this bill. They are not opposed to reform and progress. 
They are opposed to this legislation, this 2-foot tall, 3-foot tall, 
2,000-page piece of legislation.
  They don't dislike President Obama, but they don't like this policy 
he is trying to promote. You say: Let's have some facts about it. I 
can't explain everything, but I want to share a few things.
  Madam President, I ask to be notified after 5 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. SESSIONS. A critical, essential part of fixing a broken health 
care system is to end the growing problem of payments to our doctors. 
Republicans and Democrats have not been good on this issue in the past, 
but the problem grows worse each year. Essentially, in the balanced 
budget amendment of 1997 we limited the amount of payments to doctors. 
After a while it became clear the cuts were too severe, and each year 
we put money back in. But the law still mandates major cuts. In fact, 
today if we don't do what we call the doctor fix each year, they will 
have a 23-percent reduction in reimbursements, they get paid less. This 
is for Medicare. And they get paid less for Medicare than other 
insurance already, so doctors are going to quit doing it if we have a 
23-percent reduction in what they get paid for doing their work.
  How much does it cost to permanently fix that as the medical 
profession assumed we were going to do and as the President and his 
team have indicated they plan to do? It costs $250 billion. That is a 
lot of money. That is not a new program, this is an obligation that we 
have now. Does this plan fix that? It fixes it for 1 year. So it goes 
out 1 year and then the CBO score assumes the doctor payments will drop 
23 percent and be 23 percent lower for 9 years.
  If we add that up, that is $250 billion. It allows the folks in the 
know here to manipulate the numbers and hide a $250 billion debt we 
owe. We can't cut doctors that much, and we are not going to do it. We 
have not been doing it, and we will fix it every year, in fact, and 
that is--what I will say is, we will spend the $250 billion, and it 
should be in this bill. They didn't do it.
  Just a few weeks ago, they met in this secret room down the hall, and 
they got to talking and said: What are we going to do about the 
doctors? How are we going to fix the doctors?
  We could raise taxes.
  Well, we raised taxes $500 billion. We can't raise them any more. Can 
we cut Medicare?
  Gosh, we have cut it $500 billion. We can't do that.
  What can we do? We promised the doctors fix to get them their pay.
  So they offered--it would be hilarious if it weren't so serious--they 
offered legislation a few weeks ago to just pay the doctors all this 
money permanently, outside of the health care reform in a separate 
bill, every penny of it going to the debt, unpaid for.
  Even 13 Democrats couldn't swallow that. They voted no, and it 
failed. But the House did it. They passed it, did they not, I ask 
Senator Gregg, unpaid for? Horrible. Another $250 billion added to our 
debt.
  So that is a shell game. It is like you have a hole in your roof and 
you don't want to spend the money to fix it, so you move across the 
hall into another room and pretend the hole isn't there. Somehow you 
are not going to fix it when you know you have to fix it.
  They say: Don't worry. See, our plan is budget neutral. It is deficit 
neutral.
  If you take the $250 billion, one thing right there, it is not 
neutral. It is in deficit already. It is in deficit already. You have 
to watch that pea and see how it moves around in the shell. But what we 
need to have a sense of is that this is a program we have never had 
before. It not only adds to the debt by not fixing the doctor payments, 
it raids existing programs, Medicare and Medicaid, both of which are in 
serious trouble. It raids them in the first 10 years and, as Senator 
Gregg said, much more later, $549 billion. And it raises taxes $493.6 
billion. So it is pretty easy to say I have a deficit-neutral program 
if I assume I am going to take $500 billion out of Medicare and raise 
taxes $493 billion. It is budget neutral. Everybody should thank me. 
That is what the paper said the other day: Budget neutral. We are so 
proud of ourselves.
  The American public are not buying this. They are a little bit 
skeptical. Medicare is going broke. Everyone knows that. We have been 
working on that for a number of years. All of us are concerned about 
this iceberg in front of the Titanic which is Medicare's deficiency.
  The PRESIDING OFFICER. The Senator has consumed 5 minutes.
  Mr. SESSIONS. I thank the Chair.
  We need to save this program before we create a new one. It is so 
simple. If we are going to raise taxes $500 billion, has anybody asked 
where that money should go? Should the $500 billion in new taxes go to 
create a new program or maybe should it be used to put Medicare on 
sound footing or maybe it should be used to pay for military 
expenditures that have the highest budget in years, or maybe to reduce 
the debt which, I point out to friends and colleagues, is the greatest 
debt this Nation has ever seen. There has been nothing like it ever. In 
2008, our debt was $5.8 trillion. In 5 years, 2014, it will be $11.8 
trillion. In 2019, it will be $17.3 trillion, tripling in 10 years. 
According to the Congressional Budget Office score, it does not include 
money to fund the health care program.
  How big are those numbers? I won't spend a lot of time on it. I will 
point out that people can understand when you borrow money, this debt 
doesn't come from thin air. You borrow it. China, other places loan us 
money. We owe them money. That is how we get the money. And look at the 
interest rate. My goodness. Alabama's budget is about $8 billion a 
year; $800 billion in this year is 100 years of our budget. The 
interest the United States paid on our debt in 2009 was $170 billion. 
That is a lot of money. The Federal highway bill is $40 billion. All of 
the Federal highway spending is around that amount. But in 10 years, 
according to the CBO, we are going to be paying in that 1 year interest 
of $799 billion. It is like nothing we have ever seen before. That is 
why people say our spending is on an unsustainable course.
  The first thing we need to do to bring spending under control is to 
fix the critical problems that must be met. You don't start new 
programs that are likely to spiral out of control and far exceed the 
prognostications we have seen today.
  I thank the Chair for the opportunity to share my thoughts. I am glad 
our colleagues are here. I know others would like to talk.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from South Dakota.
  Mr. THUNE. Madam President, I appreciate the great job done by my 
colleagues from Missouri, Alabama, and New Hampshire in pointing out 
many of the concerns we have with regard to this bill and why we think 
this is a bad direction to go.
  You have heard my colleagues talk about a massive expansion of 
government, tax increases, premium increases; obviously, the very 
serious

[[Page 28728]]

problem we have with our national debt and the deficits we are racking 
up every single year, to the tune of about $1 trillion or north of 
there, $1.4 trillion last year, on a pathway to hit that target this 
year.
  I have heard my colleagues on the other side talk repeatedly about 
Republicans not having their own solution. I have to say, maybe the 
reason they haven't been seeing the Republican solution is because they 
have been hiding behind this voluminous 2,100-page bill at a cost of 
$1.2 billion per page. Republicans--hundreds of times, if not 
thousands--have come to the floor and outlined a step-by-step solution 
to dealing with the health care crisis and the concerns most Americans 
have which is the high cost of health care. Unfortunately, many of my 
colleagues on the other side perhaps have not been able to see that 
because they can't see around this $2.5 trillion expansion of the 
Federal Government they seem intent on pushing through the Senate. 
Republicans have talked about buying insurance across State lines, 
small business health plans, tort reform, incentives for wellness and 
chronic disease management. There is a whole range of things that could 
be done to address the concerns of the American people about the high 
cost of health care that do not involve a $2.5 trillion expansion of 
the government, a 2,100-page bill, at a cost of $1.2 billion per page.
  The other thing I have heard my colleagues say is we have to do 
something. People in this country are dealing about the high cost of 
health care. They are. We all hear it. We hear it from small 
businesses, from families, and from individuals. Everybody is concerned 
about the high cost of health care. In fact, a number of my colleagues 
on the other side have said of all the bankruptcies that occur every 
year, most occur because of the high cost of health care. Get this, 
America: Under their proposal, you will go bankrupt sooner. Because 
they drive the cost of health care up. They don't do anything to bend 
the cost curve down.
  I want to show a chart which points out what happens to the cost 
curve under the Democratic plan we are talking about. The blue 
represents the current cost curve. That is the increase in health care 
costs we would see if nothing is done, year-over-year increases into 
the future. What we would expect, if we were going to reform health 
care, is that line starting to bend down a little bit so that health 
care increases go down over time instead of up.
  What happens? Under this proposal--and this is the CBO; this isn't 
what I am saying or any of my Republican colleagues, this is what the 
Congressional Budget Office says--the Democratic plan we are talking 
about increases the cost of health care. It bends the cost curve up; 
$160 billion more will be spent on health care if their plan gets 
enacted. All those people who are concerned about the high cost of 
health care today are not getting any relief under the Democratic plan. 
In fact, their lives will get much worse--in particular, those who 
already have health care.
  There are some in this proposal who will get some subsidies to buy 
insurance in a health care exchange. That affects about 19 million 
Americans. But there are 182 million Americans who currently have 
health care who, if this bill passes, are going to be faced with higher 
taxes and higher premiums. That is the way it works. They are 
ineligible to get any subsidies to buy insurance. In fact, they don't 
have any more options available to them. What they are facing is higher 
taxes that they will be faced with under this bill, as well as higher 
premium costs.
  If you are the average person who is worried about cost, which I 
think most Americans are, and you are watching what is happening here 
in Washington, you have to be asking yourself: What is the whole 
purpose of going through a health care reform debate if, in fact, it 
doesn't do anything to drive down the cost of health care?
  My colleagues have pointed out that when you spend $2.5 trillion, 
when you expand the Federal Government by that amount, when you raise 
taxes on medical device manufacturers, on prescription drugs, on health 
plans themselves, and when you cut Medicare providers and, if you 
believe this, this is something that seems hard to fathom, that any of 
this would ever take effect, but this $2.5 trillion is paid for in the 
form of Medicare cuts and tax increases, tax increases when it is fully 
implemented over a 10-year period, as the Senator from New Hampshire 
pointed out, about $1.2 trillion, about $1.1 trillion in Medicare 
cuts--who in this Chamber believes that $1.1 trillion in Medicare cuts 
is going to occur? There was a discussion between the Senator from New 
Hampshire and the Senator from Missouri about what happened a few years 
ago when the Senator from New Hampshire was chairman of the Budget 
Committee and proposed cutting $10 billion out of Medicare over a 5-
year period, which amounts to $2 billion a year. What we are talking 
about here is $1.1 trillion over 10 when fully implemented or $100 
billion a year. When he proposed cutting $2 billion a year over 5 out 
of Medicare, there wasn't a single Democratic vote in support of that. 
In fact, the Vice President had to come back from a trip to Pakistan to 
vote on it to try and reduce Medicare by $10 billion. They are talking 
about, when it is fully implemented, $1 trillion in Medicare cuts. Do 
you know who that hits?
  Mr. GREGG. Will the Senator yield?
  Mr. THUNE. Yes, sir.
  Mr. GREGG. It is important to know where that cut is proposed to 
primarily fall. Is Medicare Advantage used by a number of seniors in 
South Dakota?
  Mr. THUNE. It is. I assume it is in New Hampshire.
  Mr. GREGG. Under this plan, it will be eliminated for all intents and 
purposes.
  Mr. THUNE. That is where a big share of the savings is going to hit, 
senior citizens, right squarely between the eyes, if they get benefits 
under Medicare Advantage. In addition, $135 billion comes from 
hospitals; $15 billion from nursing homes; $40 billion from home health 
agencies; $8 billion from hospices. Does anybody believe all that will 
happen? And if it doesn't happen, guess what, it all goes on the 
Federal debt.
  I thought it was interesting that last week when the President was in 
Asia, the Chinese raised the issue with him about what happens if 
health care reform passes. They weren't worried about universal 
coverage or a public option. They were worried about what impact it is 
going to have on the deficit.
  According to the New York Times and their reporting on his trip:

       The Chinese wanted to know in painstaking detail how the 
     health care plan would affect the deficit, said one 
     participant.

  They are worried about their investment because they are the biggest 
buyer of American debt. What happens to all these Medicare cuts that 
are proposed? We couldn't get 51 votes to cut $2 billion a year out of 
Medicare a few short years ago, and they are talking about cutting, 
when it is fully implemented, $100 billion a year. Does anybody believe 
we will cut $15 billion out of nursing homes? I don't think so. Here we 
are. How do we pay for it?
  If it isn't paid for in Medicare cuts or tax increases, it all goes 
on the Federal debt which is growing at over a trillion dollars a year.
  This is a bad deal for the American taxpayer. It is a bad deal for 
the 182 million Americans who already have insurance. They don't get 
anything out of this. What do they get? Higher taxes and higher 
premiums.
  Listen to what CBO says: $160 billion in additional health care costs 
over this time period. It bends the cost curve not down but up. That is 
what we get. That is why so many business organizations have come out 
opposed to this, because they know the impact it will have on small 
businesses. The best way to get health care coverage to more people in 
America, as long as we continue to have an employer-based health care 
system, is to get people a job. People who are struggling with the 
economy right now and losing jobs, the thing we ought to be doing is 
figuring out how can we provide incentives for small businesses to put 
people back to work, not how can we kill jobs by raising taxes on small 
businesses.
  That is exactly what we are doing right here. That is why every 
business

[[Page 28729]]

organization--the National Federation of Independent Businesses, to the 
Chamber of Commerce, the National Association of Wholesaler-
Distributors, right on down the list--is opposed to this bill. They 
know the impact it would have on small businesses and their ability to 
create jobs. The best way--best way--you can get health insurance today 
in America is to get a job. This bill kills jobs.
  I yield to the Senator from Louisiana.
  The PRESIDING OFFICER. The Senator from Louisiana.
  Mr. VITTER. Madam President, I rise to share the same sorts of 
concerns as my colleague from South Dakota. I share the concerns, more 
importantly, of citizens all across Louisiana who have echoed those 
same thoughts to me over and over again as I have traveled the State. 
Like so many of my colleagues, I have spent a lot of time these last 
few months reaching out to my constituents, my fellow citizens in 
Louisiana, in every part of the State.
  During the August recess, obviously, there were lots of townhall 
meetings around the Nation. I held 21 in Louisiana, in every corner of 
the State. Since then, I have held six more townhall meetings. I 
continue to do other types of outreach. For instance, yesterday--since 
we had a 1-day opportunity--I flew home specifically to do a few 
things, including having a roundtable of doctors, including two past 
presidents of the AMA, other health care providers, small business 
representatives, leaders in the pro-life community, and it was a 
roundtable discussion specifically to focus on the Reid bill.
  In all that process, since the August recess and even before, I have 
heard certain themes over and over again, no matter where I was in 
Louisiana. One of those themes was great concern about what this 
Congress is thinking of doing on health care but not just because of 
the significance of health care, which is vitally important, which is 
personal to every American, but also because of how it fits into a 
trend so many Louisianians and so many Americans are seeing over the 
past year--a trend of dramatically increasing Federal Government power 
and intervention and dramatically increasing Federal Government 
spending and debt.
  People have been passionate about health care. Again, part of that is 
because that is a very personal issue, and a bill such as this affects 
literally every single American. But, again, a big part of it has been 
that Louisianians are also connecting the dots. They see a bigger 
picture, which concerns them. Louisianians have been connecting the 
dots to a government takeover of banks and insurance companies and car 
companies, with the CEO of GM literally being fired and hired in the 
Oval Office, and now, potentially, one-sixth of the U.S. economy 
through health care.
  So there is a broader concern and theme I have heard over and over, 
which is an explosion of Federal Government power and intervention and 
an explosion of Federal Government spending and debt. This bill, 
unfortunately, does nothing except to confirm my constituents' worst 
fears in that regard. It is more of the same. It is more of that theme. 
It is another big dot they will be connecting in that trend, and I 
share that concern.
  One specific issue that goes to that concern is the so-called 
government option or public option because that strikes a lot of 
people, including me, as a big, open door to dramatically increasing 
the Federal Government's role and dominance in health care in our 
country--one-sixth of our economy. Why do I say that? I truly believe 
the government option--if this bill passed or anything similar to it 
passed--would be the dominant option overnight and, perhaps, the only 
option in a few years.
  Let me explain why. I will just point to one provision, which is the 
so-called pay-or-play mandate on business. Under this Senator Reid 
bill, as under previous versions of this idea, such as the Senate HELP 
Committee bill, a business--virtually any business in the country--
would, for the first time, have a legal mandate, and the mandate would 
be to provide health insurance up to a certain minimum defined by 
Federal bureaucrats or the business would have a choice. The choice 
would be, if you do not want to provide that health insurance, well, 
you can write a penalty or fee check to the government instead.
  What is wrong with that? Well, the penalty or fee check in this bill 
is pretty much set at $750 per employee per year. How does that equate 
into a business's bottom line in the choice businesses would face? 
Well, businesses that do provide health insurance nationally pay an 
average of not $750 per employee per year but $6,100 per employee per 
year. So what sort of choice do you think that is going to present to 
business? What sort of result would you expect?
  In this brave new world, if the bill passes, everyone is guaranteed 
coverage in some form or fashion, and business has a choice: $6,100 per 
employee per year or $750 per employee per year. I think, for a lot of 
small businesses under extreme competitive pressure, that is not going 
to be a hard choice. It is going to be an easy choice. The result for 
tens of millions of Americans who have coverage now they are reasonably 
satisfied with through their employer, the result is going to be 
getting dumped off that coverage, with businesses saying: Well, there 
are other options now. There is the government option. Good luck. We 
can't afford it. We have to be competitive. We have to go with our 
bottom-line decision--$6,100 per employee per year or $750 per employee 
per year. I think the clear result will be tens of millions of 
Americans getting dumped off coverage they have now that they are 
reasonably satisfied with.
  Do not take my word for it. Other outside experts, the Lewin Group 
and others, say dumping will occur and could, in fact, be massive; tens 
of millions of Americans--under their analysis of a previous bill that 
had largely the same provisions--over 110 million Americans. So that is 
a problem with regard to ballooning Federal Government intervention, 
power, domination of the marketplace.
  Again, as I said a few minutes ago, another part of that theme and 
concern I heard over and over was ballooning Federal Government 
spending and debt. Here again, this Reid bill does nothing to allay 
those fears. In fact, it does a lot to increase those fears.
  There has been a lot of talk and a lot of reports of the CBO score of 
$848 billion over 10 years. First of all, $848 billion is a lot of 
money. That is a lot of Federal Government spending and growth. It is 
hard to get your hands around that figure. What does that mean? If 
someone had started spending $1 million a day when Jesus Christ was 
born and kept spending $1 million a day, we would not yet be up to that 
figure. So that is a lot of money.
  But what is worse, that figure is artificially low. The true cost of 
the bill is much greater. There are a number of budget gimmicks the 
ranking member on Budget, Senator Gregg, and others have talked about 
that prove that $848 billion figure is truly low compared to the full 
cost of the bill.
  What am I talking about? Well, the biggest budget gimmick is the fact 
that the spending side of the bill does not kick in for the first 4 
years. The tax side, of course, as always, kicks in immediately. So the 
tax increases, the fee increases, et cetera, kick in immediately. But 
the benefit spending side of the bill does not kick in for the first 4 
years. So that is what will occur in the first 10 years of the bill's 
life, should it be passed. Therefore, in that CBO score of the first 10 
years, what the CBO is scoring is 10 years of tax increases and only 6 
years of spending. So that is a huge budget gimmick which helps produce 
that artificially low $848 billion or so.
  In fact, we should be looking at the first 10 years of full 
implementation; in other words, the first 10 years when not only all 
the tax provisions are kicked in but everything on the benefits 
spending side is kicked in. That is basically from 2014 to 2024. What 
are the numbers there when you look at the real first 10 years, the 
first 10 years of full implementation? The real numbers are not $848 
billion--as big a figure as that is, spending $1 million a day since

[[Page 28730]]

Jesus Christ was born and you still would not be up to it--but there 
the analysis is $2.5 trillion over 10 years.
  Again, Louisianians see this, Americans see this as another big dot 
to connect, part of a huge trend of exploding Federal Government power 
and exploding Federal Government spending and debt. What does that 
represent in terms of that explosion of spending and debt? It also 
represents enormous new taxes, and that goes to the cost issue my 
distinguished colleague from South Dakota was talking about.
  When I talk to Louisianians specifically about health care--not just 
these broader trends and these broader concerns they are very focused 
on but specifically health care; OK, we have to fix certain issues in 
health care--what is the top issue? Virtually everyone in Louisiana 
says cost, ballooning cost. Whether they have coverage now or they are 
struggling to get coverage, the issue is cost. What can we do about 
cost?
  Again, this bill does nothing to fix that. It makes it worse. As was 
illustrated with Senator Thune's graph, it pushes the cost curve up and 
not down. Part of the reason it does that is, in that $2.5 trillion of 
activity there are enormous taxes, and those taxes become built into 
health insurance premiums. So premiums do not go down, they go up. They 
go up in a major way.
  What are some of these we are talking about--again, enormous tax 
increases, enormous tax increases across the board, taxes on choice and 
well-being. Flexible spending which allows individuals to have a tax-
free account for medical needs, that is limited. That is downgraded and 
capped at $2,500 a year. Taxes on over-the-counter medicines that many 
patients' families and seniors depend on, that is a tax increase of $5 
billion; reduced deductions for health expenses, again, another tax 
increase; higher Medicare payroll taxes; the rate on wages in excess of 
$200,000, a very large tax increase; over and over again, major tax 
increases. The bill would impose $28 billion in new taxes on employers 
that do not provide government-approved health care plans. There is a 
tax increase of $53.8 billion, over 10 years, in terms of the Medicare 
population.
  So, again, there are huge tax increases that are part of that, and 
that is the major reason that cost curve is not being pushed down. In 
fact, it is being pushed up.
  As I approach this bill, after looking at it carefully over the last 
few days, my first bottom-line question is: How does it respond to 
those dominant concerns I have heard over and over again from Louisiana 
citizens all across the State over the last several months? What does 
it do about ballooning Federal spending and debt? What does it do about 
the growth of government power and intervention and the cost of health 
care?
  Sadly, it fails on all those accounts. It moves us in the wrong 
direction on all those accounts. So I urge my colleagues to adopt a 
different approach, to vote no tonight, to not move to this approach, 
to adopt a far more focused, positive approach that responds directly 
to those concerns of the American people.
  I yield back my time.
  Mr. GREGG. Madam President, what is the regular order?
  The PRESIDING OFFICER (Ms. Cantwell). The Democrats control the next 
hour. The Republican time is expired.
  Mr. GREGG. Thank you, Madam President.
  Mrs. GILLIBRAND. Madam President, I ask unanimous consent that the 
next hour be under the control of the majority controlled as follows 
and in the order listed: Senator Gillibrand, 5 minutes; Senator 
Whitehouse, 20 minutes; Senator Landrieu, 17 minutes; and Senator 
Cantwell, 18 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mrs. GILLIBRAND. Madam President, as I rise today to speak in support 
of the Patient Protection and Affordable Care Act, I wish to say that 
this is truly historic legislation which I am very proud to support 
which will ensure all Americans will have access to quality, affordable 
health care. It will at long last make the necessary changes to contain 
costs that have truly spiraled out of control, and it will make 
enormous progress to address the many disparities in our health care 
system that are discriminatory toward women.
  The Congressional Budget Office has determined this bill will provide 
coverage for more than 94 percent of Americans--98 percent when 
accounting for the elderly population--while reducing the spiraling 
costs of health care and trimming the deficit over the next 10 years 
and beyond.
  Sixty years after Harry Truman first talked about the need to 
guarantee affordable, quality health care for all Americans, we are on 
the brink of a historic vote to move one step closer to achieving this 
goal.
  In 1994, the last time we seriously considered health care reform, 
opponents argued that if we reformed our health care system, health 
care spending would skyrocket and health care quality and access would 
decrease. The opponents succeeded in 1994, and health reform was 
defeated. But in the absence of reform, look at what has actually 
occurred. Since 1994, family premiums have risen by over 150 percent. 
In 1993, the average annual premium for employer-sponsored family 
coverage was $5,000. This year, the cost for coverage is over $13,000 
per year. By 2016, family health insurance is expected to reach over 
$24,000. In my State of New York, that is simply unaffordable.
  Today, we spend more than 16 percent of our gross domestic product on 
health care, nearly twice the average of other developed nations--an 
astounding $2.2 trillion every year. What do we get in return? More 
than 47 million Americans are uninsured. In 2007 and 2008, 86.7 million 
Americans--1 out of every 3 Americans under 65--went without health 
insurance for a period of time. Every day, 14,000 Americans lose their 
health insurance.
  Many of the same opponents who defeated reform in 1994 are trying to 
do it again. I ask them to please consider what has actually occurred 
over the last 15 years. Think about the damage that has been caused to 
our economy, our families, our workers, and consider taking a stand 
that is on the right side of history this time.
  The bill before us lays a foundation for truly reforming our health 
care system. I commend Majority Leader Reid for his work in merging the 
two Senate committee bills.
  This bill includes a robust public plan for which I have strongly 
advocated. I believe this will increase competition and lower costs 
across the system. Through a public plan and the establishment of 
health insurance exchanges, the bill makes quality health care truly 
affordable and accessible to everyone--all Americans. The health 
insurance exchanges will streamline the system and offer insurance at 
affordable premium rates, capped by income, for low- and middle-income 
Americans. No longer will health care be out of the reach of millions 
because of cost.
  This bill also ends discrimination against women, which we have faced 
in our health care system for far too long. Women shoulder the worst of 
the health care crisis, including outrageous discriminatory practices 
in care and coverage. The National Women's Law Center reports that a 
25-year-old woman pays up to 45 percent more for the same health 
insurance coverage than a man her age. Some of the most essential 
services required by women are simply not covered by insurance plans, 
such as childbearing, Pap smears, and mammograms. A standard in-
hospital delivery costs between $5,000 and $10,000, and much more if 
there are complications. This bill ends the practice of denying health 
care to those with preexisting conditions. In the current system, 
pregnant women are often turned down for health care coverage because 
insurance companies would rather evade this cost. Pregnancy should 
never be the basis for losing coverage. In America, this sort of 
institutionalized discrimination is wrong. This reform bill ends the 
practice of charging women more than men and requires that these basic 
health care services are included.
  The bill also lays the groundwork to reward health care providers for 
the

[[Page 28731]]

quality of care they provide, not necessarily the quantity. Hospitals 
and clinics across the country will model the success at places such as 
Bassett Healthcare in Cooperstown in upstate New York. It also uses new 
methods to reduce medical errors and prevent costly illnesses.
  Some would prefer that we continue on the current path, leaving 
millions without insurance and paying for it through a hidden tax that 
all insured Americans pay to cover the cost of emergency care. But the 
majority of Americans think the time has now come to address this 
problem and fix our broken system.
  The vote today is an important step on the road to reform. In the 
next few weeks, we will all have the opportunity to debate this bill 
and make important modifications. I am encouraged to see improvements 
from previous bills in the merged bill before us, including better 
protections for middle-class families' benefits and increased funding 
to States for Medicaid, both of which I look forward to continuing to 
improve.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mrs. GILLIBRAND. May I have an additional 30 seconds?
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mrs. GILLIBRAND. I thank the Chair.
  I welcome the opportunity to work with my colleagues on this historic 
legislation. For the next few weeks, I will work to strengthen the 
provisions for States such as New York that have strong Medicaid 
Programs, and I will also work to ensure that funding for our safety 
net hospitals remains intact.
  Now is the time to act. The bill before us provides quality 
affordable health insurance for every American, reins in the high 
costs, makes our system more efficient, and addresses some of the grave 
disparities in the system that discriminate against women. I urge my 
colleagues to join me in voting yes on the motion to proceed on this 
bill.
  The PRESIDING OFFICER. The Senator from Rhode Island.
  Mr. WHITEHOUSE. Madam President, I had the occasion to listen to some 
of the remarks of our colleagues on the other side of the aisle. It 
forces the conclusion that the irony department of the Republican Party 
is working overtime these days.
  The criticisms of this bill are over deficit and cost. We are hearing 
these criticisms about deficit from the party that, when it had control 
in the Bush years, ran up over $8 trillion in our national debt--$8 
trillion, the biggest spendthrifts in history, an orgy of fair-weather 
debt. They didn't have any hesitation about deficits then. On the wars 
in Iraq and Afghanistan, we have never heard any interest in having 
those paid for on a current basis. Borrowing for wars is completely 
satisfactory to them, it appears. When they had the chance to amend 
Medicare, they added Part D, and they ran up the cost immensely by 
providing a special protection for the pharmaceutical industry so that 
it can dictate prices to the Federal Government. The Federal Government 
can't negotiate with the pharmaceutical industry for Part D 
pharmaceuticals. That costs the Federal Government a fortune. Do they 
mind? No. They spend on deficits over and over. Now, when at last we 
take on the insurance industry, suddenly they discover a concern about 
deficits. Well, I would urge that based on that trajectory, these 
remarks have a lot less to do with the deficit than they do with 
protecting the insurance industry.
  There is another clue of this as well, and that is the concern about 
cost. We all, indeed, are concerned about cost. But I think the best 
thing we could do about cost in health care is to pass a public option. 
Why do I say that? I say that because the Director of the Congressional 
Budget Office has said that changes in government policy which we 
adhere to in this bill have the potential to yield large reductions in 
both national health expenditures and Federal health care spending 
without harming health. It is not just a possibility. He goes on to 
say: Many experts agree on the general direction in which the 
government must go to get those cost savings. But they conclude they 
can't put a specific score on them yet for the following reason: The 
specific changes that might ultimately prove most important cannot be 
foreseen today and could be developed only over time through 
experimentation and learning.
  Now, who is going to develop those changes that will save costs while 
improving the quality of our health care system over time through 
experimentation and learning? The public options. There will be public 
options, if the original health plan is followed, in all 50 States. 
Each would have to stay within its State on balance, solvent, could not 
go to the Federal Treasury to make up losses. So they have to look for 
reform in order to continue to succeed. They would be 50 engines of 
reform, of experimentation, and of learning.
  Who is against the public options? The insurance industry, because 
they don't want the competition. They love an environment in which they 
are immune from the antitrust laws--almost uniquely in American 
business--and in which they have incredible market share. In many 
cases, there are only two dominant insurers in the entire market around 
this country. So they love having these huge market shares to be able 
to dictate price, to be immune from the antitrust laws, and they don't 
want the competition.
  Guess who else is against the public options. Our Republican friends. 
It is very hard to find any daylight between the position of the 
insurance industry and the position of our Republican friends.
  The problem with this is that it is not just about numbers and it is 
not just about statistics; it is about people. It is about people by 
the hundreds of thousands, but it makes their stories better when you 
actually come down to cases. So let me mention a few cases.
  I talked a few weeks ago about one of my very dearest family members 
who fell victim to the system when his insurance company tried to deny 
him the indicated treatment prescribed by a world-class physician from 
the National Institutes of Health on the grounds that it was so-called 
``not the indicated treatment.'' This was an individual who had 
received a devastating diagnosis. He had gone to the top expert for 
that diagnosis in the country at the National Institutes of Health. He 
had been told what he should do. He had been told, indeed, that was 
very standard. This was not anything exotic; this was essentially the 
automatic way you should treat a particular condition. When he filed it 
with his insurance company, some faceless bureaucrat said: No; we know 
better than the top expert at the National Institutes of Health. That 
is not the indicated treatment.
  From that, and from thousands and thousands of Americans who have had 
their claims denied and have had insurers try to intrude between them 
and their doctor and interfere with the care their doctor thinks they 
need, we can tell one thing: the insurance companies do this for a bad 
motivation, which is to save costs. Of all of the stories I have heard, 
of all of the stories our colleagues have related here on the Senate 
floor, never once has there been a story of an insurance company that 
stepped in and said: Oh, wait a minute, that is not the indicated 
treatment; the indicated treatment is actually more expensive than what 
your doctor has indicated. Always, it is less expensive. Go figure.
  I wish to share another story today about a person who is close to 
me, a member of my staff. His name is Richard Pezzillo, and he has 
hemophilia. He has gotten the treatment he has needed so far, but he 
has been lucky, and it illustrates how luck now enters into our 
equation in health care.
  In 2003, after a very turbulent airplane flight, Rich unfastened his 
seatbelt from the airplane, collected his things, and suddenly realized 
things were going badly wrong. He started to feel tremendous pain. He 
started vomiting blood. Simply wearing his seatbelt in that turbulent 
aircraft had caused Rich to begin to bleed internally, inside of his 
stomach, eventually requiring that his gallbladder be removed.

[[Page 28732]]

  Rich is a kind and thoughtful young man from North Providence, RI. He 
was hospitalized in very serious condition. He spent nearly 3 weeks in 
the hospital. Thankfully, he received excellent treatment, and today he 
works here in my Washington office. The doctors, the nurses, and the 
hospital staff in Rhode Island gave Rich the best treatment. He now 
leads an energetic, vigorous life and does well at a challenging job.
  But the stunning part about Rich's story is his treatment and his 
treatment cost--$1.5 million. At least that is what they said. If you 
look at a copy of the billing sheet, you will see that the insurance 
company said that his billing, here, for instance, was $366,240.
  The insurance company allowed only $106,000. That is what was 
actually paid, which gives you a sense of how much funny business is 
going on in the private health insurance industry and in the health 
care sector, when an insurance company can get away with paying about 
one-third of the bill's cost.
  We have heard a lot of talk about how burdensome it is for Members of 
Congress to make it through a 2,000-page long health care bill. If you 
actually reduce its size to the substantive language--and I am 
elaborating on what the House bill would do, which is about the same as 
ours--the substantive language is less than a Harry Potter novel. My 
daughter could read Harry Potter novels when she was 13. I don't think 
it is asking too much of our colleagues to plow through a bill that 
represents one-sixth of our economy--when it is the size of a Harry 
Potter novel. It would be a good idea.
  Rather than fighting about the 2,000-page bill, how about Rich's $1.5 
million health care bill? The hard truth is, Rich was able to get 
lifesaving treatment because he was lucky, since he hadn't graduated 
from college yet and was still covered by his parents' insurance 
policy. Because he was covered, the hospital only charged his insurer 
less than half of that--$106,000. What if things had been different? 
What if he needed treatment a couple of years later when he wasn't on 
his parents' policy and couldn't afford his own? What if he had applied 
for his own coverage but was denied by an insurance company because his 
illness was deemed a preexisting condition? What if Rich's father lost 
his job and his health insurance along with it or what if Rich's 
parents' policy had a limit on benefits, and they had to pay the rest 
of the $1.5 million out of pocket?
  Rich would have been a victim not just of his illness but of the 
health care status quo. If he or his family had been uninsured, they 
almost certainly would not have been able to afford the full care Rich 
needed. Their financial future would have been irrevocably altered--
probably ruined.
  Luck is no way to run a health care system. Unfortunately, Americans 
need all the luck they can get when dealing with health insurance 
companies that use every bit of their bureaucratic guile and financial 
might to delay and deny health insurance benefits they are obligated to 
provide.
  For example, in March 2006, the Arizona Department of Insurance 
ordered health insurance giant United Healthcare to pay fines of more 
than $364,000--the largest in the department's history. Regulators 
found that the company illegally denied more than 63,000 claims by 
doctors without examining all of the information needed to accept or 
deny a claim. It looks as if they were just on automatic pilot to deny 
them.
  In January 2008, California insurance regulators found that a 
subsidiary of United Healthcare had committed more than 130,000 
violations of law in handling claims. For example, the company 
inappropriately denied more than $750,000 in claims on the grounds that 
insureds had a preexisting condition. The regulators found that the 
companies ``made large-scale and willful decisions to use broken 
systems to process claims and respond to providers, while continually 
and effectively collecting premiums.'' The total potential liability of 
the company for all violations is $1.3 billion.
  Last year, United Healthcare's CEO, Stephen Helmsley, made $3.2 
million and holds almost $120 million in stock options.
  The health care reform bill we are talking about today would right 
this massive power imbalance between the health insurance industry and 
ordinary Americans who are getting rolled over by it. It would empower 
average Americans to take control of their health and financial future. 
Rather than taking their health insurance premium dollars to the health 
insurance ``casino,'' they could take them to the bank.
  Unfortunately, many on the other side of the aisle wildly 
misrepresent both the status quo and how reform would empower 
consumers. The opponents of reform depict our bill as an Orwellian 
takeover of the system.
  Madam President, let me close with a story that illustrates how 
ironic and completely wrong these cries of ``death panels'' or 
``government interference'' really are.
  In 2000, Christiane Hymel--insured by a subsidiary of Blue Cross Blue 
Shield of Louisiana--scheduled an appointment for a routine physical. 
During the examination, she reported to her doctor her history of back 
pain and weakness in her legs over the past year and a half. Her doctor 
ordered x rays of her spine and referred her to a neurologist.
  The neurologist, after detecting troubling symptoms, ordered an MRI. 
In accordance with her insurance policy, the doctor sent Blue Cross a 
request to preauthorize the MRI. The day before the MRI was scheduled, 
Blue Cross denied that request on the basis that the service was for a 
preexisting condition--Mrs. Hymel's back pain.
  Mrs. Hymel appealed the insurance company's decision in accordance 
with the terms of her policy, but Blue Cross never processed the 
appeal.
  After Blue Cross denied coverage for the MRI, Mr. and Mrs. Hymel were 
told that the MRI would cost about $4,000. They started saving up for 
it. It took 3 months to save up the money necessary to pay cash for the 
procedure, but they eventually did. The MRI showed that Mrs. Hymel had 
massive tumors involving ``nearly the entire cervical and thoracic 
[spinal] cord.'' She was immediately scheduled for surgery. Helpfully, 
Blue Cross stepped in to deny coverage for that as well, stating it was 
for a preexisting condition.
  Mrs. Hymel's neurosurgeon later testified at trial:

       Tumors inside the spinal cord are growing tumors, as they 
     grow, they cause damage to vital structures in the spinal 
     cord, which are important to walking, sensation, and 
     breathing.

  The longer the wait in removing a tumor, the more damage the tumor 
will cause to the spinal cord. The doctor testified:

       Two-thirds of Mrs. Hymel's current condition and 
     disabilities were the direct result of the growth of the 
     tumor during the 3 to 4-month delay between the time Blue 
     Cross denied the MRI until the time Mrs. Hymel was able to 
     pay for it by herself. Additionally . . . this delay also 
     caused the tumor's quick recurrence, necessitating the second 
     surgery.

  In ruling for Mrs. Hymel in her lawsuit against Blue Cross, the court 
described the consequences for Mrs. Hymel of this 3-month delay the 
insurance company caused by denying her MRI:

       Mrs. Hymel testified that when she first woke up from 
     surgery, she could not move her arms or head and she thought 
     she was paralyzed. She felt painful burning sensations in her 
     body. . . . While she was in the surgical ward, she 
     contemplated committing suicide. During her hospital stay, 
     she suffered from bowel obstruction, fecal impaction, and had 
     to wear diapers. Mrs. Hymel didn't see her children in the 
     hospital until two weeks after the surgery, and when her 
     children finally saw her, they were scared of her and would 
     not touch her. Mrs. Hymel spent approximately eight months in 
     a wheelchair after her surgery.
       Mrs. Hymel is house-bound, she cannot take a shower, work 
     in her garden, ride a bike, swim, or drive, as she had 
     frequently enjoyed prior to the surgery. . . . Mrs. Hymel 
     must also take large doses of medication to relieve the 
     burning and shocking sensations from which she suffers. She 
     cannot be touched on her back or leg, because the second 
     something touches her lower back, it's like fireworks that go 
     off.

  Every day that insurance companies delay or deny payment is another 
day they earn interest on your premiums,

[[Page 28733]]

adding to their profits and adding to the funds that support their 
massive executive pay packages. When Blue Cross of Louisiana failed to 
pay for Mrs. Hymel's MRI, it wasn't just making a mistake, it was 
making a calculated decision--a heartless, profit-maximizing decision. 
Christiane Hymel's story isn't just a sad tale, it is a symptom of a 
disease that is spreading through the private health insurance system.
  For many Americans like Christiane and Rich, our health care system 
is a casino, where a roll of the dice or spin of the roulette wheel 
determines one's fate. Such an irrational and random system doesn't 
comport with the society that Franklin Roosevelt described in his 1944 
State of the Union:

       We have come to a clear realization of the fact that true 
     individual freedom cannot exist without economic security and 
     independence. Necessitous men are not free men.

  These days I think it would be more proper to say necessitous men and 
women are not free men and women.
  By passing health care reform, we will take health insurance off the 
casino floor for the average American family and make it a reliable 
part of every family's economic foundation. No longer will happenstance 
or chance determine whether treatment will be paid for. No longer will 
the casino wheel determine whether Rich Pezillo gets his treatment or 
that Christiane Hymel does not. Parents of kids like Rich Pezillo would 
not worry whether their son's illness could lead him to be turned down 
for that preexisting condition or whether a layoff or lack of insurance 
could deny their son the treatment he needs.
  Necessitous men and women are not free men and women. Let's redeem 
FDR's promise by passing health care reform. Let's bear in mind, as we 
go forward, the nature of the arguments that are made against health 
care reform and the astonishing coincidence between the arguments made 
between health care reform by our Republican colleagues and by the 
barons of the health insurance industry. There seems to be literally no 
daylight between those arguments.
  If we are going to turn around the extraordinary spiraling costs of 
health care, we are going to have to do it by reforming the delivery 
system. The best way to do that is the public option. Yet they oppose 
it.
  Madam President, I yield the floor and suggest the absence of a 
quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Ms. CANTWELL. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER (Mr. Whitehouse). Without objection, it is so 
ordered.
  Ms. CANTWELL. Mr. President, my colleague, Senator Landrieu, was 
going to be next, but I will switch times with her. She will join us on 
the floor shortly.
  I want to join my colleagues this morning and talk about this 
important issue of controlling health care costs. That is why we are 
here. We know Americans are facing higher and higher health care costs 
and that we can do something to drive down the costs of our health care 
system. We know health care costs are not only strangling us, but they 
are impacting our constituents, our budget, and they are leaving 47 
million Americans without insurance.
  Our aim is to promote better quality care and get costs under 
control. Whether those costs be to consumers struggling to pay 
insurance premiums or to our government, we need to make sure we are 
doing all we can. Doing nothing in this debate is allowing health care 
costs to continue. I want to make sure my colleagues on the other side 
of the aisle who talk a lot about this legislation understand that if 
we do nothing, we are going to leave the American people and our budget 
in serious danger by not controlling health care costs.
  As always, in this debate we must keep in mind Federal spending, and 
the numbers on Federal spending are stark.
  In terms of doing nothing, if the U.S. Government does nothing, 
health care spending will double in the next decade. That is, we spend 
about $810 billion on health care. That is one-third of our total 
Federal budget. If we do nothing, Federal spending is going to go to 
$1.56 trillion. That is because we are not controlling health care 
costs, baby boomers are reaching retirement, and Medicaid and Medicare 
costs are ballooning. One-third of our Federal budget is a big enough 
bite. But if we do nothing, then our health care priorities are going 
to push out other priorities of our Federal Government.
  The biggest area where we could control costs is in Medicare. 
Medicare is 57 percent of all Federal spending, and it is getting 
bigger. By 2020, Medicare spending alone will reach $1 trillion, 
doubling the $466 billion we spend today. That is to say that Medicare 
spending has been doubling in the last 10 years, and if we do nothing 
as our colleagues on the other side of the aisle are suggesting by not 
moving forward on this legislation, then it is going to double again. 
This is unsustainable because if we do not address this, Medicare is 
going to bankrupt us.
  The prospects are just as daunting when it comes to our Medicaid 
budget because Medicaid spending over the next several years will also 
double, and it has doubled in the last 10 years. States are struggling, 
as many of us know, with what they can do to help sustain Medicaid 
since they pay for part of that for individuals.
  So we see we are in a situation where doing nothing is an 
irresponsible way to go. In fact, for our constituents, they are seeing 
a 120-percent increase in insurance premiums. While we are worried 
about the impact on the Federal Government, they are worried about the 
impact on them, on their individual budgets. That means the average 
family today pays about $7,000 more per year for the same health care 
benefits than they did a few years ago. If you think about that, that 
means that is less money for them, less money for their families, less 
money to meet the other bills in the family.
  Why has this happened? If we look at what has happened in our 
country, we see that wages have not gone up. In fact, during that same 
10-year period of time, wages have only gone up 29 percent, health 
insurance premiums have gone up 120 percent. And where has the 
insurance industry been? The insurance industry has seen a 428-percent 
increase in profits over the last 10 years.
  That is why we need to do something about controlling health care 
costs. We cannot let the American people continue to be subject to such 
huge increases in premiums and then have the insurance industry walk 
away with huge profits and American consumers make less and less.
  What is going to happen if we do nothing, if we do not advance this 
bill to control health care costs? Those same premium increases we have 
seen in the last 10 years are also going to go up again. In fact, they 
are projected to go up another 7.9 percent in annual growth. That is, 
every year, they are going to go up another 8 percent. That is 
unsustainable. That means somebody is going to be paying $10,000 or 
more than what they are paying for their health insurance today for the 
same health care benefits. That is why doing nothing and not advancing 
this bill is just acquiescing to the fact that everybody is going to 
pay more for health care.
  What makes this number so scary is that it is four times the rate of 
inflation over the same period. That means what we need to do is look 
at general inflation, which is usually about 2 percent. But health care 
inflation, as is shown on this chart, is more like 8 percent. If we do 
nothing to change this, Americans are going to continue to do with less 
because health care costs are demanding more and more of their budget.
  What do we do about this? We certainly want to make sure that we 
change the system, and that is one of the reasons I support driving 
down costs by having a public option. We know that two factors are 
involved: We don't have enough competition and there are very 
concentrated markets in health insurance across the country. Many times 
there are only one or two insurance providers providing coverage

[[Page 28734]]

in a market. They might have 94 percent of the market. It is too 
concentrated. We know if we provide an alternative in the marketplace, 
we can help drive down costs.
  One provision in this bill of which I am very supportive is the basic 
health plan because it lets States negotiate with private insurers for 
lower costs. In my State, this program has been in place for 20 years. 
It has been able to provide those who participate in the program--about 
70,000 people today--a 30- to 40-percent savings if they had to buy 
that plan as an individual from a private insurer. That is incredible 
success in driving down the cost.
  Why? I call it the Costco model because like when you go to Costco 
and you buy in volume, the State of Washington, buying in volume on 
behalf of those individuals, was able to drive down the cost of health 
care for those individual citizens. They were able to choose between 
four different plans, and they were able to get access to a very good 
proposal for health care for them.
  The underlying bill includes language that says you could provide 
this basic health plan if States opted into it and cover 70 percent of 
the currently uninsured in America. I like this proposal because it 
gets us cheaper insurance for that population.
  Why subsidize insurance companies by giving tax incentives to buy 
more expensive insurance when what Americans want is to drive down the 
cost of health care by having the same negotiating clout that big 
businesses or other entities have?
  I hope we can continue to work and maybe even expand this provision 
to make it even more robust and to drive down costs.
  What is clear is that the cost of the uninsured is adding to our 
health care costs. In fact, the fact there are people in America who 
are uninsured is adding about $1,000 to our health care premiums 
overall. That is about $43 billion a year to our health care system.
  If we can change our health care system and get more people into 
something such as the basic health plan, we would be able to drive down 
costs, and that is why that plan is so valuable.
  We should not forget that our current system, besides insurance 
reform, needs provider reform. The reason why provider reform is so 
important is because our current health care system is flawed. It is 
driving up the cost of Medicare and health care in general because of 
the payment system. Basically, the current payment system perpetuates 
more spending. In fact, there is something like $700 billion in waste 
in our current system. If you think about it, it is this fee-for-
service loop that I call it where you order more and you end up having 
more waste in the system, you have more spending, you have more use, 
and it keeps going. That is primarily because we pay doctors on volume. 
We pay doctors for how many patients they see every day, and we pay 
them for how many tests they order. Consequently, the cost continues to 
spin out of control.
  As I was saying, we spend about $700 billion on health care that we 
do not need to spend. That is in duplicated tests, unnecessary 
procedures, excessive insurance overhead, uncoordinated speciality 
care, and preventable hospitalization.
  We heard from many people during the health care debate that we have 
to do something to change this system. In fact, one of the witnesses 
before the health care committee said:

       We have to go after how we reimburse physicians. The 
     current system is the most broken part of Medicare.

  What are we doing in this legislation to fix that? We are changing 
the way we reimburse for health care. In fact, we are going to look at 
how to get lower costs with better results. This is important because I 
don't think there is a person in America who doesn't know what it is 
like to go into a doctor's office and feel they are always in a hurry 
or feel as if the doctor didn't hear everything you had to say. This is 
about changing and rewarding physicians on the outcome of your health 
care so you can have shorter waiting times, better access to doctors, 
more coordinated care, and better outcomes.
  We think if you change the health care system, which this bill does, 
to drive down costs and get better outcomes, we are going to have 
better health care in America.
  We can continue on the path which I think my colleagues on the other 
side of the aisle want by not voting to move forward on this 
legislation, we can have less coordinated care, going from specialist 
to specialist without having that care coordinated and have unnecessary 
tests, but then everybody in America is going to be paying for those 
costs. Everybody is going to be paying higher health care premiums 
because of it.
  What we need to do, which is what exactly this bill sets us on a 
course and path to do, is to pay for value not for volume, to pay 
physicians on the value they deliver and the outcome of their patients 
instead of volume.
  If we did nothing else in health care reform but to change our 
payment structure to focus on this premise--paying for value and not 
for volume--then we would be delivering great long-term savings to our 
health care system.
  We have other things we need to do, and that is in the area of long-
term care and Medicaid because in our long-term care system, we are 
seeing a doubling in health care costs, primarily because of long-term 
care. When you think about our Medicaid budget, everybody thinks 
Medicaid is this program to help the low-income population. Medicaid is 
turning into a long-term care program for the elderly in America. That 
is, they cannot get long-term care access so they are spending down so 
they qualify under Medicaid to basically get on that system to cover 
their long-term care.
  We can see that right now Medicaid is paying half of its funds, and 
that is an expense that is going to continue to grow.
  We have made some reforms in the State of Washington to make that 
cheaper. We have said let's invest in home care instead. Instead of 
having everybody go to nursing homes, whether they need to be there or 
not, let's focus on the long-term care system reforms that keep people 
in their community and instead use the Medicaid budget to advance other 
things while keeping patients at home.
  I think every senior in this country would rather have their health 
care delivered at home than in a nursing home, but our current Federal 
system continues to reward long-term care in nursing homes instead of 
in community-based care. This legislation starts us on a path to change 
that direction, to move closer to long-term care community services.
  We did this in the State of Washington, again, over 20 years ago and 
have reaped huge benefits. If we took an individual in the system 
today, the cost is only about $22,000 per individual. If we had not 
reformed the system as we did 20 years ago, we would be paying $42,000 
for that same individual. So we have been able to drastically cut the 
amount of money we are spending on long-term care.
  This legislation includes the same kind of cost control reforms in 
long-term care as some States have already implemented. That is why we 
have to get at controlling health care costs. If we do not control 
health care costs in this area of long-term care, we are not going to 
control health care costs overall in America.
  What does reform mean? Why are we here today to talk about the cost 
of health care and what we need to do? Why are we here talking about 
advancing this legislation so we can get this debate on the floor for 
the American people?
  It is clear we need to have more competition through a public option, 
we need smarter reimbursement rates to incentivize value, and we need 
better use of Medicaid dollars.
  The PRESIDING OFFICER. The Senator's time has expired.
  Ms. CANTWELL. I thank the Presiding Officer. I hope my colleagues on 
the other side of the aisle will consider the important cost controls 
in this measure.
  I yield the floor.
  The PRESIDING OFFICER (Ms. Cantwell). The distinguished Senator from 
Louisiana is recognized.

[[Page 28735]]


  Ms. LANDRIEU. Madam President, I first want to commend my colleague, 
Senator Cantwell, the Senator from Washington State, who has worked so 
hard and so long and in such a professional way. She has been extremely 
helpful to me through this process, and I want to acknowledge that and 
thank her.
  Before I make a statement, I also want to comment about a few other 
colleagues who have been extremely helpful and supportive, not just to 
me but I think to the entire Senate, beginning with Senator Harry Reid, 
our leader, who, with patience and persistence and care, has led us to 
a bill that is before the Senate. The question today is whether we 
should proceed. I would like to say that, in my view, no other Member 
of the Senate could have accomplished what he has today. I think many 
Senators share that sentiment.
  No. 2, I want to recognize the extraordinary work of the Senator from 
Oregon, Senator Ron Wyden, who, 2 years ago, before the Presidential 
election had really gotten underway, before it was really ever clear as 
to who might win, Senator Wyden put down a bill called the Healthy 
Americans Act, which I was very proud to support, and I still am so 
proud of that effort today. That bill has the support of seven 
Republicans and seven Democrats. It is a truly bipartisan effort that 
would accomplish, in my view, what many Americans are asking for: a 
marketplace that is fixed and reformed, more affordable choices for 
individuals and small businesses and families, and a real effort to 
curb the rising and alarming cost to the Federal taxpayers, given that 
the percentage now of our GDP spent on health care is almost exceeding 
16 percent, twice as high as any nation in the world. That is alarming. 
The Healthy Americans Act went a long way to help frame my thoughts on 
this debate. We are going to continue to work together through this 
process.
  I also thank Senator Blanche Lincoln who, because of her persistent 
leadership, has pushed and prodded Members of this body to ensure that 
we had the time necessary to review this bill. In so doing, she helped 
to assure our constituents, whether they are for or against the 
direction we are moving, knew that we had the time necessary to make an 
informed decision. I think I have used that time very well these last 
2\1/2\ days. I have been in meetings with economists, on the phone with 
health care experts, talking with people from my State as well as 
around the Nation. I have used that time well and wisely. Senator 
Lincoln led the charge to ensure that we had the time we needed, and I 
am glad to have supported her in that effort. I know she will be 
speaking on the floor later today, giving her final views on where we 
are. I commend her for her leadership.
  Madam President, I come to the floor today to acknowledge to speak on 
the business before the Senate today, and that is the question of 
whether to proceed to debate on the Patient Protection and 
Affordability Act, a bill that is the best work of the Senate to date 
on a subject of significant importance to the people of my State and 
the country. I have decided to vote today to move forward on this 
important debate.
  My vote should in no way be construed by the supporters of this 
current framework as an indication of how I might vote on the final 
bill. My vote is a vote to move forward, to continue the good and 
essential and important and imperative work that is underway.
  After a thorough review of the bill, as I said, over the last 2\1/2\ 
days, which included many lengthy discussions, I have decided that 
there are enough significant reforms and safeguards in this bill to 
move forward, but much more work needs to be done before I can support 
this effort.
  Over the past many years, and in particular the last 6 months, I have 
heard from people all across Louisiana that their insurance premium 
costs are simply too high and continue to rise without warning, 
threatening the financial stability of their families and their 
businesses. I have also heard the pleas and cries of many people who 
need health coverage but they cannot find it anywhere within reach of 
their budgets.
  Through months of public meetings in VFW halls, school gyms, and in 
hospitals and health clinics from New Orleans to Shreveport, and in 
large and small communities throughout my State, it is clear to me that 
doing nothing is not an option, nor is postponing the debate.
  Spirited debate and good-faith negotiations in this Senate have 
produced a bill that contains some amazing and cutting-edge reforms 
that will, I am hopeful, reduce costs for families and small businesses 
while reducing the debt burden of the Federal Government. But these 
reforms must be implemented properly and carefully, and they must be 
put in place in a timely fashion.
  Small business owners across the country have told me time after time 
that in order to grow their businesses and create jobs, they need 
affordable health insurance and they need stable and predictable costs. 
Yes, they would like their costs to be lowered, and I am going to stay 
focused like a laser on doing just that. But what they also need is 
predictability--they need to be able to plan for the future, something 
they cannot do when the cost of healthcare spikes violently from year 
to year.
  As we all know, today, under the status quo, small business owners 
are frequently confronted with impossible choices when an employee or 
employee's family member gets seriously ill. They can expect exorbitant 
cost increases of up to 20 percent in their premiums when just one of 
their employees gets sick. Then they are confronted with the 
excruciating choice of going to that employee and those family members 
and saying: I am sorry, to save my business and the other 10 employees, 
we need to let you go. Here is $1,000 or $2,000 or $5,000. You are on 
your own. Good luck.
  That is a tragic story, painful, depressing, and it has to stop.
  I appreciate the hard work of many business owners and organizations 
that have helped to craft portions of this framework because they have 
remained at the negotiating table. They didn't run and hide, they 
remained at the table. I am asking them today to stay at this table.
  Before I discuss the work that needs to be done to improve this bill, 
I would like to discuss some of the points in this bill that encourage 
me to move forward.
  Small business owners, under the current framework of this bill, 
would no longer be confronted with these kinds of volatile costs. This 
bill prevents insurance companies from escalating their rates or 
dropping their coverage after someone gets sick. That important change 
goes a long way in stabilizing the amount small businesses will have to 
pay for their health plans, and it allows business owners to do what 
they do best--plan smart investments, grow their businesses, and then 
help us grow our economy.
  In recent years, economists have found that workers' wages have 
remained largely stagnant. Why? Because employers are paying more and 
more for health care that we are indirectly subsidizing through the 
current Tax Code and so have less and less money to pay real wages that 
workers in large and small businesses could actually take home, put in 
their pockets, and spend in much more productive ways. The bill we are 
debating would encourage employers to move away from high-cost benefit 
plans, and instead increase the amount that working families can take 
home. That is an important change from the status quo.
  In addition, this bill would ensure that the majority of Louisiana 
families would pay no more than 10 percent of their income for health 
care. That is still high. But today families in Louisiana pay an 
average of 30 percent of their income on healthcare costs. And 
economists project that if we do nothing, that total will climb to 60 
percent of an average family's income that will have to be spent trying 
to afford health care. This bill changes that trajectory. So while some 
people still think that 10 percent or 12 percent may be too high, it is 
a lot better than 60 percent, which

[[Page 28736]]

is the direction we are heading today if we do nothing. That is real 
progress.
  These reforms I have just mentioned are necessary and are too 
important a goal for the Senate to abandon its work. But, as I have 
said, there is a great deal more work that needs to be done.
  I would like to mention briefly just a few of the significant changes 
I would like to see be made to this bill.
  No. 1, in order to increase choices for small businesses, we must 
enhance and expand tax credits that are in this bill for small 
businesses, particularly for business with 25 fewer employees. If we 
can expand tax credits for slightly larger small businesses with 
between 25 and 50 employees, that would be significant progress. 
Current projections are that 96 percent of all businesses that have 
more than 50 employees have coverage. That is a good statistic, and 
those larger businesses have some choices. But we need to give small 
businesses more choices. It is these small businesses that are leading 
the country on its way out of this recession. And we need to help them 
in that effort.
  In addition, I will continue to fight for more tax equity for the 27 
million Americans who are currently self-employed. Every chairman of 
the Small Business Committee--both Republican and Democrat, I 
understand, for the last 25 years--has asked for this to be addressed. 
It is time to make progress on that effort now.
  No. 2, in order to really deliver our promise to hold down costs for 
families, we should think about focusing on ways to prevent premiums 
from being excessively raised between the time this bill is enacted, if 
it ever is, and the time it actually goes into effect. Many of the 
provisions in this bill, because of cost considerations, which I 
understand, do not go into effect until 2014. Well, today is 2009. 
That's a long time between now and then, and we need to make sure that 
companies do not jack up their premiums in anticipation of the market 
reforms this bill will make, as we have seen the credit card industry 
do in anticipation of the important reforms we made earlier in the 
year. Americans cannot afford to allow that kind of predatory behavior.
  Finally, I remain concerned that the current version of the public 
option included in this bill could shift significant risks to taxpayers 
over time unnecessarily, and I will continue to work with my colleagues 
to find a better and bipartisan solution for this issue. I have 
suggested that a freestanding, premium-supported, competitive community 
option that would trigger on a date certain, if our private market 
reforms fail to work, might be a possible compromise. That would 
include language that Senator Snowe and other of my colleagues have 
been working on for several months.
  Because I am hopeful we can make progress on each of these concerns 
and others through an amendment and debate process that is open and 
transparent, I believe that it is incumbent upon me to allow the bill 
to move to debate on the Senate floor.
  I stand ready to work together with my colleagues to fashion a 
principled and hopefully bipartisan compromise in the end to achieve 
what the people in my State need, and what many Americans need, and 
which we really have to do our best to try to give them.
  Finally, I know my time is up, but I would like to ask a personal 
privilege for just 1 more minute to address an issue that has come up, 
unfortunately, in the last 24 hours, driven by some very partisan 
Republican bloggers. So I think I need to respond and will do so now.
  One of the provisions in the framework of this bill has to do with 
fixing a very difficult situation that Louisiana is facing. For reasons 
that are simply beyond my comprehension, some partisans have decided to 
attack me for leading an effort to address a serious budget shortfall 
facing my state.
  The reason for this situation goes back to the disastrous hurricanes 
of 2005. I am not going to review the horrors of Katrina and Rita. The 
levees broke, and by the way, the courts have just ruled that the Corps 
of Engineers was, as I have said from the beginning, responsible. But I 
will comment more on that at another date.
  But, nonetheless, in 2005 Louisiana experienced two of the worst 
natural disasters in recent memory. In an effort to aid the recovery, 
Congress stepped in with a massive aid package for Louisianans--thank 
you--that infused grant dollars and direct assistance.
  Some of necessary one-time recovery dollars, in addition to the 
increased economic activity, were calculated into our State's per 
capita income. The result has been that Louisiana's per capita income--
--
  The PRESIDING OFFICER. The time of the Senator has expired.
  Ms. LANDRIEU. I ask for 1 additional minute?
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Ms. LANDRIEU. The result is Louisiana's per capita income was 
abnormally inflated. You can understand that. There were billions of 
dollars that came in from insurance and road, home, and community 
development block grants.
  In addition, labor and wage costs went up because there was a 
constriction in the market, which any economist can tell us always 
happens after a natural disaster. As a result, when we did the 
calculation under the law, it made us seem as if we were a state with a 
high per capita income like Connecticut and not a state with a low per 
capita income like Louisiana, almost as if we had become rich 
overnight. That was not the case. Our State is still as poor as it was, 
if not poorer as a consequence of those devastating storms. I am not 
going to be defensive about asking for help in this situation. It is 
not a $100 million fix, it is a nearly $300 million fix. It is the No. 
1 request of my Governor who is a Republican. He explicitly asked that 
I pursue these funds. It is unanimously supported by every Member of 
our delegation, Democratic and Republican. I am proud to have asked for 
it. I am proud to have fought for it. I will continue to. But that is 
not the reason I am moving to debate.
  The reason I am moving to the debate, as I expressed in this 
statement, is that the cost of healthcare is bankrupting families and 
it is bankrupting our government. We cannot afford the status quo.
  I thank my colleagues for their graciousness. I know I have gone over 
my time, but I wanted to get that on the record. I support moving 
forward with the debate and look forward to working with them to 
improve it.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Utah.
  Mr. HATCH. Madam President, I wish to express my deep concerns about 
Senator Reid's bill on two very critical issues. These are not the only 
things of which I am critical but I wish to focus on two issues: 
coverage of abortion and conscience clause protections for medical 
providers opposed to abortion.
  As we can see, the Stupak compromise amendment, which was supported 
by 64 House Democrats and a majority of Republicans, reads:

       No funds authorized or appropriated by this Act may be used 
     to pay for abortion or to cover any part of the costs of any 
     health plan that includes coverage of abortion.

  That is all it says. It should be abundantly clear to each Member of 
this body. The House of Representatives overwhelmingly passed pro-life 
language exactly 2 weeks ago that is markedly different from that 
contained in the Reid proposal. The House provisions, in contrast to 
the terribly flawed provisions in the Reid bill, contain language that 
would not only safeguard the rights of the unborn but would also 
prevent medical providers from being coerced into performing procedures 
that violate their conscience. The Stupak-Pitts amendment was adopted 
by a significant margin, 240 to 194. That represents 55 percent of the 
House of Representatives, including 25 percent of the Democratic 
caucus.
  Even more telling happens to be two polls released this week by the 
Washington Post and ABC News and CNN. They confirmed that 61 percent of 
the American population do not support Federal funding for abortion. 
This vote

[[Page 28737]]

should serve as a strong signal to each Member that these protections 
cannot be ignored and must be contained in any measure we adopt. 
Unfortunately, the language in the Reid bill explicitly allows what the 
Stupak-Pitts language would prevent. The Reid language authorizes 
abortion in the government-operated health plan or the public option 
and Federal subsidies for insurance coverage that include abortion. It 
is not the Stupak-Pitts language.
  The sanctity of life is not an issue that can be traded away for 
political expediency. During committee consideration of the health 
reform legislation, I offered two important pro-life amendments. The 
first amendment, which I offered in both the HELP Committee and the 
Finance Committee, strictly prohibited Federal dollars being used to 
finance elective abortions. The second amendment provided conscience 
clause protections to medical providers opposed to abortion. In other 
words, we should never force people who have a conscience against 
abortion to have to perform abortions or participate in abortions. This 
language was based on the Hyde-Weldon provision contained in every 
Labor-HHS appropriations bill since 2004. It also was included in the 
House-passed bill. Both my amendments were defeated.
  I notice my colleagues, Senators Brownback and Johanns, are in the 
Chamber. I ask both of them: What is wrong with including the Stupak-
Pitts language in the Reid bill?
  Mr. BROWNBACK. Madam President, I, first, thank my colleague for 
offering these amendments in committee.
  In both the HELP and Finance Committees, you said: Let's put in the 
Hyde language, and both times the amendments were defeated in 
committee. I appreciate my colleague raising it. Proponents of the Reid 
bill will tell us the abortion funding language is essentially the Hyde 
language included in the annual Labor-HHS appropriations bill. That is 
plain wrong. The Hyde amendment specifically removes abortion from 
government programs. The Reid bill specifically allows abortion to be 
offered in two huge new government programs. The Reid bill tries to 
explain this contradiction by calling for segregation of Federal 
dollars when Federal subsidies are used to purchase health plans. This 
segregation of funds, though, actually violates the Hyde amendment, 
which prevents funding of abortion not only by Federal funds but also 
by State matching funds within the same plan. Simply put, today Federal 
and State Medicaid dollars are not segregated, and the Reid bill 
specifically authorizes something the Hyde amendment specifically 
rejects.
  Mr. JOHANNS. If I might join in, it is enormously important we lay a 
good record as to what this is all about and why the Hyde amendment has 
been the law of our Nation for so long. It is important. Therefore, I 
direct a question to Senator Hatch.
  Please, if you would, describe how the Hyde amendment works today.
  Mr. HATCH. Today's Hyde language, which has been in every annual 
Labor-HHS appropriations bill since 1976, specifically prohibits 
Federal dollars being used to pay for abortions except if the pregnancy 
was the result of rape, incest, or the life of the mother is in danger. 
The Hyde language applies to all five of the federally funded health 
care programs: Medicare, Medicaid, Indian Health Services, TRICARE, and 
the Federal Employees Health Benefits Program or the FEHBP. However, it 
is important to note that today there is no segregation of Federal 
funds in any Federal health care program--none. For example, the 
Medicaid Program receives both Federal and State dollars. There is no 
segregation of either Federal Medicaid dollars or State Medicaid 
dollars. States that do provide elective abortions for Medicaid 
beneficiaries must do so from a completely different account; that is, 
State-only dollars. No Federal or State dollars from the State Medicaid 
Program may even be placed in that ``State only'' pot of money.
  Mr. JOHANNS. That was an excellent explanation of what Hyde is about. 
It underscores why we are so upset about the unbelievable expansion 
that is going to occur if this Reid bill is passed. You mentioned the 
Federal Employees Health Benefits Program. Let me take a minute to talk 
about how that works because, again, I think it underscores the point 
we are making today. Let me give an example. The current Federal 
Employees Health Benefits Program does this. It has 250 participating 
health plans that do not cover abortion. Federal employees pay a share 
of the cost.
  The Federal Government, through tax dollars collected, pays the 
balance. So it is a mixture of Federal employees' contributions through 
their paychecks and the Federal Government getting the money through 
tax dollars. Federal employees cannot opt for elective abortion 
coverage because taxpayer dollars are subsidizing the cost of their 
employee plan. You can see how we have tried to remain true to the 
distinction you talked about. As many have said during the debate, if 
it is good enough for Federal employees, then why isn't it good for the 
rest of the citizens?
  I ask Senator Brownback, what is in the Reid bill that does not 
reflect the current Hyde language? And if I could maybe direct that to 
both of you or to Senator Hatch.
  Mr. BROWNBACK. Well, if I could follow up quickly on the last point, 
I think it is clear that if we are not going to put this in the Federal 
employees benefit insurance system, then we should not put it in this 
system. Yet this is a billing expansion that is taking place. The 
Democratic health bill would explicitly authorize abortion to be 
covered in the government option. It also mandates that there must be 
abortion coverage in every insurance market in the country. This is an 
enormous expansion, a radical departure from the 30-year policy that 
represents the Hyde amendment. The abortion language that was included 
in the bill is a huge departure from 30 years of bipartisan Federal 
policy prohibiting Federal tax dollars paying for elective abortions. 
The language in the Senate bill explicitly authorizes the Secretary of 
Health and Human Services to include abortion in the public option and 
permits government subsidies for plans that pay for abortion.
  The Capps language, commonly referred to in the Senate bill, contains 
a clever accounting gimmick that proponents say separates private and 
public funds for abortion coverage. However, it has been proven over 
and over by outside reviewers that the Capps measure would include both 
abortion coverage and funding in the government-run public option as 
well as for those plans in the insurance exchange. Representative Bart 
Stupak, a Democrat from Michigan, explained the issue very clearly in 
an op-ed he wrote yesterday. He wrote:

       The Capps amendment, which is the basis of the Senate 
     language, departed from Hyde in several important and 
     troubling ways: By mandating that at least one plan in the 
     health insurance exchange provide abortion coverage; by 
     requiring a minimum $1 monthly charge for all covered 
     individuals that would go towards paying for abortions; and 
     by allowing individuals receiving Federal affordability 
     credits to purchase health insurance plans that cover 
     abortion. Hyde currently prohibits direct Federal funding of 
     abortion. The Stupak amendment is a continuation of that 
     policy--nothing more, nothing less.

  I would like to ask Senator Hatch about this provision, about what we 
need to talk about on the exchanges and the types of plans that will be 
included in the exchanges and about how this is an expansion of the 
abortion language.
  Mr. HATCH. Isn't it true that one health plan must be offered in the 
exchange that covers elective abortions? Isn't that a departure from 
Federal policy?
  Mr. BROWNBACK. The Reid health care reform bill would require at 
least one health care plan to offer elective abortions in each State 
health insurance exchange. However, nothing in the Reid bill ensures 
that the one plan that must cover elective abortions be the plan that 
is most affordable or least affordable. In other words, if I do not 
wish to have a plan that covers elective abortions but all I can afford 
is that plan, where does that leave me? Should my constituents have to 
compromise their own moral code in order

[[Page 28738]]

to receive health care; in other words, that they would have to buy a 
plan that covers abortion?
  Mr. HATCH. That is right.
  Mr. BROWNBACK. Today, no Federal health program requires the coverage 
of elective abortions. This is a clear departure from current law, and 
I cannot imagine us forcing people to pay for insurance that covers 
abortions when it is so unconscionable to so many of the American 
people.
  I also would like to make one other point perfectly clear. The 
Stupak-Pitts compromise amendment would not prohibit the ability of 
women to obtain elective abortions as long as they use their own money 
to purchase these policies. I think it is important we get that piece 
of it clear as well.
  Mr. HATCH. I am glad the Senator did clarify that.
  I say to Senator Johanns, isn't it true that the Stupak amendment, 
passed in the House by a considerable margin, allows women to purchase, 
with their own money, separate supplemental health coverage that may 
include the coverage of elective abortions--if they do it with their 
own money?
  Mr. JOHANNS. I say to Senator Hatch, I am glad you raised that issue. 
Yes, that is correct. Your understanding is correct. Women would be 
allowed to purchase separate elective abortion coverage with their own 
money.
  I ask Senator Brownback, do you have a comment on that, or a 
question?
  Mr. BROWNBACK. Well, I think this is a key thing for us to keep in 
mind, that it is true that women can purchase separately, with their 
own money, use their own funds to be able to provide for their own 
abortion coverage. But what we are saying here today is that we should 
not have this as part of the Federal Government. We should not have it 
as part of the Federal funding program. We should not be using taxpayer 
dollars to fund abortions, as we have not done for 30 years. That has 
been the longstanding bipartisan program. But it is not prohibited that 
an individual could go ahead and buy this service on their own.
  Mr. HATCH. Well, I would add, too, it is absolutely correct that the 
Stupak language allows women to purchase both a supplemental policy for 
the coverage of elective abortions and a comprehensive health care plan 
that includes coverage of elective abortions as long as they pay for 
their plan with their own money. It allows that.
  Mr. JOHANNS. Let me just interject something here because I think 
this is a very important point to make, following up on what Senator 
Hatch just said. Some say that a person would never want to purchase a 
separate rider to cover abortion. It just would not happen, they say. 
But they misunderstand what the Stupak language actually allows.
  Let me be clear about this. If a woman wants her health insurance 
plan to provide elective abortion services, she does have the choice to 
purchase a health insurance plan that provides that on the exchange. 
She just has to pay for it with her own money. Am I correct in that 
interpretation or have I misunderstood that?
  Mr. HATCH. That is correct. A woman may purchase with her own funds 
either a supplemental policy that covers elective abortions or an 
entire health plan that includes the coverage of elective abortions. 
Look, a woman has always been able to do that, and frankly, we do not 
deny her the right to do that. What we say is, taxpayers should not be 
paying the cost of it. They should not be called upon to pay for 
elective abortions.
  Mr. BROWNBACK. I say to Senator Hatch, as someone who has been in 
this body for some years and as someone who has followed this issue 
courageously for many years, what we are asking for, again, is just 
what has been established since 1977 in this body and in the House.
  Mr. HATCH. Yes. That is current law, that Federal funds may not pay 
for abortion or plans that cover abortion. Now that is the fundamental 
component of the Hyde language. And to be clear, the Stupak language 
does not prevent people from purchasing their own private plans that 
include elective abortion coverage.
  Let me just change for a second here. I would like to now talk about 
the conscience clause. To me, this is extremely important: the 
conscience clause protections for medical providers. The conscience 
clause protections in the final House bill for pro-life providers are 
not included in the Reid bill. They are in the House bill but not in 
the Reid bill. The House adopted language that codified the essence of 
the Weldon-Hyde conscience protections, including in the annual HHS 
appropriations bills since 2004.
  This summer, the House Energy and Commerce Committee accepted these 
protections unanimously during consideration of their bill. Let me 
emphasize that point: unanimously, there was not one objection to it. 
That means all members of the committee--with ideologies ranging from 
the chairman, Henry Waxman, who represents Hollywood, CA, to the 
ranking Republican, Joe Barton, who represents a conservative 
congressional district in Texas--they all recognized the importance of 
adopting this language.
  In contrast, the Reid bill has stronger protections for abortion 
providers than for providers who have conscience objections to 
abortion. On one hand, abortion providers may not be ``discriminated'' 
against for performing any abortion anywhere. On the other hand, pro-
life providers must cite a particular ``moral or religious belief'' to 
prevent discrimination. This is narrower than current law under Hyde-
Weldon.
  Moreover, it does not extend the protections to pro-life health 
plans. In other words, a Catholic health system that requires a local 
hospital to stop providing abortions in order to become part of its 
health system could be accused of discrimination.
  What is wrong with this picture?
  Let me ask Senator Johanns, don't you think it makes sense to protect 
health care providers who have objections of conscience to abortion so 
they are not forced to provide abortions?
  Mr. JOHANNS. Absolutely. As the Senator offers this explanation about 
a Catholic health care provider, it hits right to the heart of this 
issue. I most certainly agree with the Senator and I want him to know 
that many Nebraskans agree with him and agree with me on this issue.
  I got a letter recently from a gentleman out in western Nebraska, 
from a little community called Ainsworth--a great area of our State. He 
wrote to me and said this:

       I urge you to support freedom of conscience which protects 
     professionals from being forced to participate in abortion 
     and other anti-life practices, which include end-of-life 
     issues.

  I had another constituent from Gretna, NE, more on the eastern side 
of our State, and this constituent wrote to me and said this:

       I am also very disturbed to learn that health care workers 
     may be forced to act and speak contrary to their own 
     consciences. I find it shocking to believe that this is being 
     considered within a serious conversation/debate.

  We are going to put up a chart. President Obama has weighed in on 
some of these issues. President Obama gave a speech to a joint session 
of Congress. We all remember that was on September 9 of this year. He 
said this:

       And one more misunderstanding I want to clear up--under our 
     plan, no federal dollars will be used to fund abortions, and 
     federal conscience laws will remain in place.

  The President has gone on to state on multiple occasions that he 
would not support abortion in a health care bill. The President has 
stated that over and over. The President has also stated on multiple 
occasions--both as a candidate and as President--that it is his goal to 
lower the incidence of abortion. That is what he says, not what the 
Democrat-led Senate has done, though, relative to this bill, which he 
has embraced. And it is not what the leadership has done in this bill.
  You see, my colleagues, I see this as a radical abortion approach, a 
radical piece of language. And you can go right to the bill itself, to 
pages 116 to 124 of this 2,074-page bill, and you can read it yourself.
  I have to tell you, there is so much about this bill that is bad 
policy, but

[[Page 28739]]

this is especially damaging. The President promised us he would not let 
it happen. Do the President and the Members of his party, who control 
the Senate, who wrote the bill behind closed doors, do they really 
believe abortion is health care? Why didn't they just strip this 
language out? Why didn't they adopt the Stupak language, which was 
voted upon in the House, the Stupak compromise? Why didn't they adopt 
that, knowing that 64 Democrats had signed on to that language?
  What do you think about the President's commitment and his promise to 
us not to use Federal dollars to fund abortions? I say to Senator 
Brownback, I would like to hear his thoughts on that.
  Mr. BROWNBACK. I was there that evening, along with the Senator and 
Senator Hatch and almost all of the Senators, when the President was 
addressing us on health care. I remember vividly sitting there and 
listening to these words, the ones you just mentioned. He was very 
clear, very concise; there was no fudging around on it:

       And one more misunderstanding I want to clear up--under our 
     plan, no federal dollars will be used to fund abortions, and 
     federal conscience laws will remain in place.

  Yes, that is specifically violated in the bill, and they had a very 
simple route to change it. They could have just put the Stupak language 
in that has already passed the House. That is the Hyde language that 
has been agreed to by this body and others for 30 years here. Instead, 
they put in this abortion-expansion language.
  I will show another chart here a little bit later on. The last time 
we funded abortions here was between 1974 and 1977, right after Roe v. 
Wade and before the Hyde language in 1977. Do you know how many 
abortions were funded annually by the Federal Government at that period 
of time? If we are going back to that policy, if we are looking to go 
back to that era where the Federal Government was funding it, Medicaid 
funded as many as 300,000--300,000 annually. Now, I would ask 
everybody, pro-choice or pro-life, do you want your taxpayer dollars to 
pay for 300,000 abortions a year? I do not think anybody wants to see 
us do that.
  President Clinton we all remember very clearly saying often that he 
wanted to make abortion safe, legal, and rare. Adding 300,000 does not 
do that.
  So the President took the time, in a carefully tailored and vetted 
speech that all of us were there to hear--the Presiding Officer, as 
well; it was nationally televised in prime time--to tell Congress the 
words we have quoted here today and to make that specific promise. And 
that promise is broken in the Reid legislation before us today. We sat 
there in the House Chamber and heard him say those words. Our 
constituents watching the speech at home heard those words. I have to 
believe these are the kinds of broken promises that are making our 
constituents lose their trust in government.
  But the fact is, as so many people have pointed out, abortion is very 
much in this health care bill. Many Democrats and Republicans 
acknowledge this. Mr. Stupak, whom I have quoted several times, is just 
one of them.
  If we want to do more than just pay lipservice to lowering the 
incidence of abortion, we need to oppose the motion to proceed, and we 
should have had the Stupak compromise language included in the bill in 
the first place since the President clearly stated he did not want 
Federal dollars to be used for the funding of abortion.
  Consider the fact that when Federal funding is not available for 
abortion, fewer abortions occur. When Federal funding is available, as 
we have seen in the past, thousands more will occur.
  As shown on this chart, here is why the Hyde amendment is so 
important. The administrators running the Medicaid Program funded, as I 
noted, over 300,000 per year. That is almost 1 million abortions paid 
for by the country's taxpayers out of their pockets when the Hyde 
language was not the law of the land. That was until the Hyde amendment 
was enacted in 1976 because the American people disagreed with being 
forced to pay for abortions. Whether they are pro-choice or pro-life, 
they did not want taxpayer dollars to go for this.
  One other example of government ushering abortion policy through 
health care legislation is when the Commonwealth of Massachusetts 
recently passed its State-mandated insurance, Commonwealth Care. They 
failed to include an explicit exclusion of abortion, like Senator Hatch 
tried to get in committee or like they had in the House language, the 
Stupak language, so abortions there were funded immediately in 
Massachusetts. In fact, according to the Commonwealth Care Web site, 
abortion is considered covered under ``outpatient medical care.''
  The Federal Government should not go down this road. The President 
made a commitment to the American people, and the Democrat-led Senate 
has failed to include that commitment in this bill. They included 
radical language that will increase the incidence of abortion.
  I say to Senator Johanns, don't you think it makes sense to protect 
health care providers, when we look at that issue here, who have 
objections of conscience to abortions so they are not forced to provide 
abortions?
  Mr. JOHANNS. Absolutely. It absolutely makes sense. I say to Senator 
Hatch and Senator Brownback, one of the things that has been very 
remarkable to me--this bill just came out, as you know. It was behind 
closed doors for weeks and weeks and came out in the middle of the 
night, actually.
  Mr. JOHANNS. Madam President, pro-life groups weighed in on this bill 
immediately. For all of the complexity, for all of the definitions, for 
all of the buried language, they saw immediately what this bill was all 
about. Pro-life groups across the board have opposed the provisions of 
this legislation. No pro-life group has taken the bait. They represent 
millions of Americans across this great country.
  Let me, if I might, take a moment and quote from what they have said. 
The National Right to Life Committee--and again I am quoting--says 
this:

       Senate Majority Leader Harry Reid has rejected the 
     bipartisan Stupak-Pitts amendment and has substituted 
     completely unacceptable language that would result in 
     coverage of abortion on demand in two big, new Federal 
     Government programs.

  The United States Conference of Catholic Bishops has weighed in. They 
said this one is the worst bill so far--the worst one so far on this 
issue. Again, I am quoting:

       The conference believes the bill violates the long-standing 
     Federal policy against the use of Federal funds for elective 
     abortions in health plans that include such abortions, a 
     policy upheld in all health programs covered by the Hyde 
     amendment: the Children's Health Insurance Program, the 
     Federal Employee Health Benefits Program, and now in the 
     House-passed Affordable Health Care for America Act. We 
     believe legislation that violates this moral principle is not 
     true health care reform and must be amended to reflect it. If 
     that fails, the current legislation should be opposed.

  The Family Research Council says this, describing the legislation as 
a:

       . . . direct attack on the principles set forth in the Hyde 
     amendment over 30 years ago. This bill is one only an 
     abortionist could love.

  Concerned Women for America said the following:

       In a dramatic departure from current policy, the Patient 
     Protection and Affordable Care Act will provide government 
     funding for elective abortions. Over all, this bill raises 
     serious pro-life concerns.

  Senator Hatch referred to polls. The polls indicate the majority of 
Americans do not want their tax dollars paying for elective abortions. 
According to that CNN/Opinion Research Corporation survey, 6 in 10 
Americans favor a ban on the use of Federal funds for abortion. It also 
indicates that the public may also favor--literally favor--legislation 
that would prevent many women from getting their health insurance plan 
to cover the cost of abortion even if no Federal funds were involved. 
This poll indicates that 61 percent of the public oppose the use of 
public money for abortions for women who cannot afford the procedure.
  I have to ask the question of Senator Hatch: When will we listen to 
the American people on this important issue?
  Mr. HATCH. I ask Senator Johanns, have you seen similar polls 
indicating

[[Page 28740]]

that a majority of Americans do not want their taxpayer funds used for 
paying for elective abortions? Have the Senator seen those national 
polls?
  Mr. JOHANNS. I have. We have seen the polls. We have gotten letters 
from our constituents. Consistently, in poll after poll, we can see 
what the American people are saying. They do not want their tax dollars 
to fund abortions.
  Mr. HATCH. Madam President, let me ask a question to both Senator 
Brownback and Senator Johanns. I know my constituents are very upset 
about the possibility of their tax dollars being used to pay for 
elective abortions. I even brought a few of their letters down to the 
floor so I could read them. If you don't mind, I wish to read them. Can 
I take a few minutes to do that?
  Mr. BROWNBACK. Please do.
  Mr. HATCH. These are just a few. We have all kinds of letters. I 
thought I would mention a few of these since they are on point here, as 
far as I am concerned.
  Here is one from a woman, a Ph.D., the President of AUL Action, 
Charmaine Yoest:

       Dear Senator: On behalf of Americans United for Life, AUL 
     Action, I write to express our strong opposition to the 
     Senate proceeding to Majority Leader Reid's health care 
     reform bill, the Patient Protection and Affordable Care Act. 
     Majority Leader Reid's bill does not include the Stupak-Pitts 
     language added to H.R. 3962, which is necessary to prevent 
     Federal funding of abortion. AUL Action will score against 
     all votes to proceed to this bill because it does not contain 
     the Stupak-Pitts language. Majority Leader Reid's bill 
     explicitly allows the Secretary of the Department of Health 
     to include abortion coverage in the ``community health 
     insurance option'' and allows Federal subsidies to go to 
     private insurance plans that include abortion coverage. In 
     addition, the bill also requires that at least one private 
     plan in each exchange provide coverage for all abortions. The 
     passage of a health care reform bill without language 
     explicitly excluding abortion coverage and funding is 
     unacceptable to pro-life Americans. We strongly encourage you 
     to vote against all procedural motions to move to the 
     majority leader's bill, including cloture on the motion to 
     proceed.
           Sincerely,
                                           Charmaine Yoest, Ph.D.,
                                  President and CEO of AUL Action.

  Here is another one. It is from one of my personal constituents.

       Dear Senator: As an American with a growing disdain for the 
     heavy handedness and disregard for the wishes of the American 
     people, I adamantly oppose any plan brought to the table that 
     would require me to pay for abortions with my tax dollars. 
     Any government-run health care system with this provision is 
     bad for America and violates the deep convictions of many 
     Americans. Furthermore, I am infuriated by Senate Majority 
     Leader Harry Reid's deceptive course of action in secretively 
     creating his own version of a health care reform plan. Reid's 
     underhanded tactic diminishes the opportunity for public 
     debate and scrutiny which flies in the face of our 
     legislative process. I strongly oppose Harry Reid's health 
     care overhaul plan to nationalize our system. I urge you to 
     oppose any nationalized health care bill and any plan 
     containing an abortion mandate.

  Here is another one. This is an e-mail to me. It says this:

       Hello, Mr. Hatch. I am writing for 4 registered voters in 
     my family which include my husband, my parents, and myself. 
     We are very concerned about the Federal health care 
     legislation. We believe that it must support several of our 
     beliefs. We believe that life must be respected and cared for 
     from conception to natural death. As such, we do not want any 
     of our tax dollars going to abortions or euthanasia. We have 
     a desire for the continued support of the Hyde amendment of 
     1976. Our family supports charities which provide counseling 
     and material goods needed by families who have an unplanned 
     pregnancy. We want to support them in having the baby and 
     caring for themselves and the child. We do this by donating 
     things that are needed by the mom-to-be during her pregnancy. 
     We also have donated furniture and other things needed by the 
     baby. These have been given to Birthright--a program 
     supported by donations. We want access to health care for 
     all. This includes fair treatment of our immigrants. We do 
     not want any of their health care that they may be receiving 
     right now to be taken from them. In the Bible, God tells the 
     Jews to be kind to the aliens, as they themselves were aliens 
     at one time in their promised land. Our family also wants a 
     freedom of conscience clause that allows for health care 
     workers to refuse to take part in procedures involved in an 
     activity that goes against their choice. Please consider our 
     beliefs.

  Whether you agree with every word of these, they are interesting.
  Here is another one:

       During the floor debate on the health care reform bill, 
     please support an amendment to incorporate long-standing 
     policies against abortion funding and in favor of conscience 
     rights. If these serious concerns are not addressed, the 
     final bill should be opposed. Life should be respected from 
     conception to natural death. I am a retired teacher and am 
     hoping to be able to receive the care I choose to have until 
     my natural death. My care should not be based on my 
     productivity in society years from now. Thank you for your 
     stand on abortion in the past.

  Then she has a PS:

       My parents don't have and do not know how to use a computer 
     to contact you. They feel the same as my husband and I feel 
     about the above issues.

  Then she lists the names of her parents.
  Here is another one:

       Dear Senator Hatch: I am a registered Democrat strongly in 
     favor of health care reform. I am also committed to 
     protecting the unborn and to safeguarding the conscience of 
     each health care provider who is uncomfortable with providing 
     abortion services. During floor debate on the health care 
     reform bill, please support an amendment to incorporate long-
     standing policies against abortion funding and in favor of 
     conscience rights. If these serious concerns are not 
     addressed, the final bill should be opposed. Genuine health 
     care reform should protect the life and dignity of all people 
     from the moment of conception until natural death.

  Another one.

       Senator Hatch: During floor debate on the health care 
     reform bill, please support an amendment to incorporate long-
     standing policies against abortion funding and in favor of 
     conscience rights. If these serious concerns are not 
     addressed, the final bill should be opposed. Genuine health 
     care reform should protect the life and dignity of all people 
     from the moment of conception until natural death.

  I also have a petition to Senator Orrin G. Hatch opposing using 
taxpayer dollars to fund abortion. This petition says:

       One out of every three babies conceived is a victim of 
     abortion, a tragedy that has claimed more millions of 
     innocent lives since the Roe v. Wade Supreme Court decision 
     legalizing abortion on demand. Every abortion is a gruesome 
     act that ends an innocent human life and cannot be tolerated 
     in a civil society. The pro-abortion lobby is seeking to hide 
     abortion funding into virtually every piece of ``must-pass'' 
     legislation, including continuing resolutions, budget and 
     authorization bills, so-called ``economic'' bills, and even 
     the Defense authorization bill. I urge you to actively oppose 
     and, if necessary, filibuster all attempts to use the budget 
     to force Federal funding of abortion and abortionists and to 
     pack the courts with activist, pro-abortion judges.

  I thought I would read a few of those interesting letters to set a 
tone here. I have received all kinds of letters, but I chose a few, at 
random, to read on the Senate floor this afternoon.
  Mr. BROWNBACK. I was recently at a Veterans Day parade in 
Leavenworth, KS, and I had a number of people coming up to me opposed 
to the health care bill. I had one come up to me and say they were in 
favor of it and all the rest were opposed. It starts on the basis that 
it is fiscally insane what we are considering doing with $12 billion in 
debt, and then we are going to add a multitrillion-dollar entitlement 
program on top of this. The Federal Government is hemorrhaging money. 
Why on Earth would we do that? Then they are scared about what else is 
in the bill, and then this feature comes up as well.
  Finally, Senator Johanns was putting in statements from various 
groups, and I ask unanimous consent that this statement from the United 
States Conference of Catholic Bishops be included at the end of our 
colloquy.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (See exhibit 1.)
  Mr. BROWNBACK. The Catholic Bishops issued this yesterday and said 
this:

       The legislative proposal recently unveiled in the Senate 
     does not meet these moral criteria. Specifically, it violates 
     the longstanding Federal policy against the use of Federal 
     funds for elective abortions and health plans that include 
     such abortions--a policy upheld in all health programs 
     covered by the Hyde Amendment, the Children's Health 
     Insurance Program--

  SCHIP, which Senator Hatch helped to get started--

     the Federal Employees Health Benefits Program--

that Senator Johanns spoke about--


[[Page 28741]]

     and now in the House-passed ``Affordable Health Care for 
     America Act.'' We believe legislation that violates this 
     moral principle is not true health care reform and must be 
     amended to reflect it. If that fails, the current legislation 
     should be opposed.

  This is the Catholic Bishops, generally in favor of health care 
reform, and they are saying this fails on this account and must not be 
in this legislation and can't be considered as part of health care 
reform.
  Mr. HATCH. I ask Senator Johanns, where do we go from here? We are 
going to have a cloture vote at 8 o'clock tonight on the motion to 
proceed. What would be the advice on that?
  Mr. JOHANNS. I thank the Senator. Let me, if I might, before I 
address that, tell my colleagues how proud I am to stand here with 
these two champions of this issue, Senator Brownback and Senator Hatch. 
They have a remarkable history of every time they had an opportunity 
standing strong on an issue that I must admit is not the most popular 
issue in Washington, DC, to promote, and I admire their courage.
  To address the relevant question of the day, the Stupak protections, 
that compromise that was reached in the House, it is not in this bill.
  Of course, since it is not in this underlying bill, this Reid bill, 
it is very unlikely to be in the final bill. I wish somebody could 
disprove this. But, very simply, there aren't enough pro-life Senators 
to break this provision and get the Stupak amendment passed on the 
Senate floor if we propose it as an amendment--and I am sure it will 
be--there just aren't enough.
  That is why I have been making the case over the last 48 hours that 
the motion to proceed is the key vote on abortion in the health care 
debate. The most important pro-life vote that a pro-life Senator will 
cast, I believe, in the entire time they are here is on this motion to 
proceed. I have seen all the arguments from many, saying this is a 
procedural vote; that there is nothing to worry about; that it just 
begins debate, and we might potentially vote this bill down, and we can 
do some amendments and some tweaking.
  But the facts suggest otherwise. The Congressional Research Service 
has looked into this. Between the 106th and 110th Congresses, there 
were 41 cases, according to the Congressional Research Service, in 
which the Senate approved a motion to proceed and then proceeded to a 
vote on the final bill. Do you know what the end result of those 41 
cases were, when the motion to proceed was approved? It was 40 times 
out of 41--about 97 percent--went on to receive final approval. In 
other words, all but one passed into law.
  This suggests to me this vote tonight at 8 o'clock on the life issue 
is very well determinative. Some of my colleagues also argue if we 
don't like the bill, we should not block the opportunity to amend it, 
and they say let us proceed.
  I don't believe, if you are truly pro-life as a Senator, you can make 
that argument. Here is why: Everybody in the Senate knows what it will 
take to amend the Reid bill on something like this. It will take 60 
votes. It is the way the Senate operates. It will take 60 votes. Again, 
I say to Senator Hatch and Senator Brownback, I wish I could count 60 
pro-life Senators. I wish I could do that. But by anybody's count, I 
believe--mine included--there aren't 60 here.
  I believe if you are pro-life, every opportunity you get to stand for 
the life issue, you must stand for that issue. These truly are our most 
vulnerable citizens. I feel very strongly that at 8 o'clock, when we 
are gaveled to a vote, we need to stand up on this issue--this life 
issue--or there is a 97-percent chance it is lost.
  I will conclude my thoughts on this by saying this: There were many 
strong and courageous pro-life Democrats in the House. I watched that. 
That was remarkable. Can you imagine the pressure they were put under? 
This evening, we just need one--not many, just one Democrat--who will 
come here and say I am pro-life. If we don't stand together tonight, 
this bill will radically expand abortion, and I cannot live with that.
  Mr. HATCH. I thank the Senator for his remarks. I thank both Senators 
Brownback and Johanns.
  Before coming here, the Senator was the Secretary of Agriculture. He 
is from Nebraska. By any measure, he is a very sincere, dedicated, and 
principled person. We all know that, and I think the world of the 
Senator.
  I appreciate standing on the Senate floor with the Senator to chat 
about this matter. Senator Brownback, without question is a leader in 
this body in protecting the rights of the unborn. It is one of the 
things I most love about him. There are many things that cause all of 
us to hold the Senator from Kansas in very high regard and esteem. He 
is principled and dignified about it. He is friendly to everybody. But 
the Senator doesn't mince words when it comes to standing up on these 
very important issues.
  Look, all we are saying is, let's protect the Hyde language. You do 
that with the Stupak-Pitts language. What is wrong with including that 
language? All we want to do is not have federal funds pay for abortion. 
The vast majority of people in this country feel that way too.
  Second, why should people of conscience, who really and sincerely 
believe that abortions are wrong, be forced to participate in abortions 
in any way, shape, or form? Unfortunately, this bill could lead to that 
forced participation. I just do not understand what is so difficult 
about including the same language included in the bill passed by the 
House of Representatives. What is so problematic about our body doing 
the same?
  If you are a nurse, doctor, health care practitioner, Catholic 
hospital, or an LDS hospital out of Utah, if we have the Stupak-Pitts 
conscience protection language passed by the House, you cannot be 
forced to participate in abortions. These are highly religious people 
with highly religious motivations who have made this the greatest 
country in the world. If we do not change this language in the Reid 
bill, there will be Federal funding of abortion, and there will be 
people who could be pushed toward participation in abortion.
  Mr. BROWNBACK. It has been my pleasure to join Senators Hatch and 
Johanns on this effort. I have worked with both of them in many 
different capacities and jobs.
  This is as serious a pro-life vote as I have seen. If this gets 
passed, the Federal Government will be funding somewhere north of 
300,000 abortions a year. If it was 300,000 back in the 1974-to-1976 
timeframe, with the growth in U.S. population, you are probably looking 
at north of that number of Federal taxpayer dollars funding abortions. 
I cannot imagine many people in this country being satisfied about that 
kind of number taking place. I can't imagine that. But that is our past 
experience when the government funds abortion.
  Those are the numbers we are talking about. I note, too, the country 
has a longstanding ethic and moral code. We are a moral people, and we 
have been from the outset. Some people say this or that, but a big part 
of that has been that basic moral code, that basic thought within the 
Judeo-Christian ethic that we respect life. This goes back to when 
Moses talks to the people about going into the Promised Land. He is 
giving his last lecture to the Jewish people before going into the 
Promised Land. In that last lecture--Moses doesn't get to go in 
himself, but he gets the people together. They march for 40 years in 
the wilderness. He knows he is not going in, but they are, and he gives 
a lecture.
  Deuteronomy 30:19 says something that is applicable here:

       This day I call heaven and earth as witnesses against you 
     that I have set before you life and death, blessings and 
     curses. Now choose life, so that you and your children may 
     live.

  This is in the fundamental ethic and background of our country. That 
is what we have to choose today. Do we choose life or death? Choose 
life, so that you and your children might live.
  As Senator Johanns notes, we just need one vote on the other side to 
change this, and this language gets pulled out and Stupak gets put in. 
Just one vote. If we cannot get to 60--and you have to get there--and 
that one person says: I am not going to do it,

[[Page 28742]]

unless you put Stupak in this, it changes. We need just one to choose 
life, and it will change. It has been a pleasure to join with both 
Senators today.

                               Exhibit 1

                                          United States Conference


                                          of Catholic Bishops,

                                Washington, DC, November 20, 2009.
     U.S. Senate,
     Washington, DC.
       Dear Senator: On behalf of the United States Conference of 
     Catholic Bishops (USCCB), we strongly urge the Senate to 
     incorporate essential changes to the Senate's health care 
     reform bill to ensure that needed health care reform 
     legislation truly protects the life, dignity, consciences and 
     health of all. We especially urge the Senate to act as the 
     House has in the following respects:
       Keep in place current federal law on abortion funding and 
     conscience protections on abortion;
       Protect the access to health care that immigrants currently 
     have and remove current barriers to access; and
       Include strong provisions for adequate affordability and 
     coverage standards.
       The Catholic Bishops of the United States have long 
     supported adequate and affordable health care for all. As 
     pastors and teachers, we believe genuine health care reform 
     must protect human life and dignity, not threaten them, 
     especially for the most voiceless and vulnerable. We believe 
     health care legislation must respect the consciences of 
     providers, taxpayers, and others, not violate them. We 
     believe universal coverage should be truly universal, not 
     deny health care to those in need because of their condition, 
     age, where they come from or when they arrive here. Providing 
     affordable and accessible health care that clearly reflects 
     these fundamental principles is a public good, moral 
     imperative and urgent national priority.
       Sadly, the legislative proposal recently unveiled in the 
     Senate does not meet these moral criteria. Specifically, it 
     violates the longstanding federal policy against the use of 
     federal funds for elective abortions and health plans that 
     include such abortions--a policy upheld in all health 
     programs covered by the Hyde Amendment, the Children's Health 
     Insurance Program, the Federal Employee Health Benefits 
     Program--and now in the House-passed ``Affordable Health Care 
     for America Act.'' We believe legislation that violates this 
     moral principle is not true health care reform and must be 
     amended to reflect it. If that fails, the current legislation 
     should be opposed.


                  Protecting Human Life and Conscience

       Specifically, we urge you to include the House-passed 
     provision that keeps in place the longstanding and widely 
     supported federal policy against government funding of 
     elective abortions or plans that include elective abortions.
       In the aftermath of the overwhelming and bipartisan House 
     vote for the Stupak-Smith-Ellsworth-Kaptur-Dahlkemper-Pitts 
     Amendment, there has been much misunderstanding of what it 
     does and does not do. This amendment does not change the 
     current situation in our country: Abortion is legal and 
     available, but no federal dollars can be used to pay for 
     elective abortions or plans that include elective abortions. 
     This provision simply keeps in place existing policy and 
     allows Congress to honor the President's commitment that ``no 
     federal dollars will be used to fund abortions.'' The 
     amendment does not restrict abortion, or prevent people from 
     buying insurance covering abortion with their own funds. It 
     simply ensures that where federal funds are involved, people 
     are not required to pay for other people's abortions.
       Thus far, the pending Senate bill does not live up to 
     President Obama's commitment of barring the use of federal 
     dollars for abortion and maintaining current conscience laws. 
     The bill provides federal funding for plans that cover 
     abortion, and creates an unprecedented mandatory ``abortion 
     surcharge'' in such plans that will require pro-life 
     purchasers to pay directly and explicitly for other people's 
     abortions. Its version of a public health plan (the 
     ``community health insurance plan'') allows the Secretary of 
     HHS to mandate coverage of unlimited abortions nationwide, 
     and also allows each state to mandate such abortion coverage 
     for all state residents taking part in this federal program 
     even if the Secretary does not do so. The bill seriously 
     weakens the current nondiscrimination policy protecting 
     providers who decline involvement in abortion, providing 
     stronger protection for facilities that perform and promote 
     abortion than for those which do not. The legislation 
     requires each region of the insurance exchange to include at 
     least one health plan with unlimited abortion, contrary to 
     the policy of all other federal health programs. Finally, 
     critically important conscience protections on issues beyond 
     abortion have yet to be included in the bill. To take just 
     one example, the bill fails to ensure that even religious 
     institutions would retain the freedom to offer their own 
     employees health insurance coverage that conforms to the 
     institution's teaching. On these various issues the new 
     Senate bill is an enormous disappointment, creating new and 
     completely unacceptable federal policy that endangers human 
     life and rights of conscience.


                  Immigrants and Health Care Coverage

       We support the inclusion of all immigrants, regardless of 
     status, in the insurance exchange. The Senate legislation 
     forbids undocumented immigrants from purchasing health-care 
     coverage in the exchange. Undocumented immigrants should not 
     be barred from purchasing a health insurance plan with their 
     own money. Without such access, many immigrant families would 
     be unable to receive primary care and be compelled to rely on 
     emergency room care. This would harm not only immigrants and 
     their families, but also the general public health. Moreover, 
     the financial burden on the American public would be higher, 
     as Americans would pay for uncompensated medical care through 
     the federal budget or higher insurance rates.
       We also support the removal of the five-year ban on legal 
     immigrants accessing federal health benefit programs, such as 
     Medicaid, the Children's Health Insurance Program, and 
     Medicare. Legal immigrants, who work and pay taxes, should 
     have access to such programs if needed. Removing the ban 
     would help ensure that legal immigrants, who were widely 
     praised in past immigration debates for their many 
     contributions and for playing by the rules, will still have 
     access to health care.


                 Accessible and Affordable Health Care

       The Catholic bishops have advocated for decades for 
     affordable and accessible health care for all, especially the 
     poor and marginalized. The Senate bill makes great progress 
     in covering people in our nation. However, the Senate bill 
     would still leave over 24 million people in our nation 
     without health insurance. This is not acceptable.
       The bishops support the expansion of Medicaid eligibility 
     for people living at 133 percent or lower of the federal 
     poverty level. The bill does not burden states with excessive 
     Medicaid matching rates. The affordability credits will help 
     lower-income families purchase insurance coverage through the 
     Health Insurance Exchange. However, the Senate bill would 
     still leave low-income families earning between 133 and 250 
     percent of the federal poverty level financially vulnerable 
     to health care costs. Overall, the average subsidy provided 
     for in the Senate bill is $1,300 less than the average 
     subsidy in the House bill. Improvements to the bill should be 
     made so that low-income families have reasonable out of 
     pocket expense for health care.
       Immediate reforms are included in the bill that should be 
     helpful in providing relief to the uninsured and 
     underinsured. Additionally, reforms that will strengthen 
     families and protect low-income and vulnerable people such as 
     eliminating denial of coverage based on pre-existing 
     conditions including pregnancy; eliminating life time caps; 
     offering long-term disability services; and extending 
     dependent coverage to uninsured young adults--are significant 
     steps toward genuine health care reform. We urge the Senate 
     to maintain these provisions.
       These moral criteria and policy objectives are not marginal 
     issues or special interest concerns. They are the questions 
     at the heart of the health care debate: Whose lives and 
     health are to be protected and whose are not? Will the 
     federal government, for the first time in decades, require 
     people to pay for other peoples' abortions? Will immigrants 
     be worse off as a result of health care reform? At their 
     core, these health care choices are not just political, 
     technical, or economic, but also moral decisions. This 
     legislation is about life and death, who can take their 
     children to the doctor and who cannot, who can afford decent 
     health care coverage and who are left to fend for themselves.
       Our appeal for health care legislation that truly protects 
     the life, dignity, health and consciences of all reflects the 
     unique perspectives and experience of the Catholic community. 
     Our hospitals, clinics, and long-term care facilities provide 
     quality health care to millions. Our dioceses, institutions, 
     and ministries purchase health care for many thousands of 
     employees and their families. Our emergency rooms, shelters, 
     clinics, and charities pick up the pieces of a failing health 
     care system. Our Catholic moral tradition teaches that health 
     care is a basic human right, essential to protecting human 
     life and dignity.
       For many months, our Bishops' conference has been working 
     with members of Congress, the Administration and others to 
     fashion health care reform legislation that truly protects 
     the life, dignity, health and consciences of all. Our message 
     has been clear and consistent throughout. We hope and pray 
     that the Congress and the country will come together around 
     genuine reform.
           Sincerely,
     Bishop William F. Murphy,
       Diocese of Rockville Centre, Chairman, Committee on 
     Domestic Justice and Human Development.
     Cardinal Daniel DiNardo,
       Archdiocese of Galveston-Houston

[[Page 28743]]

     Chairman, Committee on Pro-life Activities.
     Bishop John Wester,
       Diocese of Salt Lake City, Chairman, Committee on 
     Migration.

  Mr. HATCH. Madam President, I yield the floor and suggest the absence 
of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. FRANKEN. Madam President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. FRANKEN. Madam President, I ask unanimous consent that the next 
hour be equally divided between the following three Senators: Franken, 
Lincoln, and Levin.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. FRANKEN. Madam President, I rise today to express my strong 
support for the Patient Protection and Affordable Care Act.
  I commend Leader Reid, Chairman Harkin, Chairman Baucus, and Senator 
Dodd for their leadership that has brought us to this critical point. 
We are on the verge of passing legislation that will do more than any 
bill in recent history to make our country healthier, our economy more 
stable, and our working families more secure.
  Make no mistake, this bill will change. There will be amendments to 
it that will make it an even better bill. There may be amendments that 
make it less to my liking and, therefore, a less good bill, to my point 
of view. But the final bill will make health care available to more 
tens of millions of Americans. It will make health insurance more 
secure for all Americans who have it and will put an end to the 
unsustainable trajectory that we are now on with the cost of health 
care, and will avert an otherwise inevitable catastrophe to our health 
care system and our economy.
  The reality right now is that we are denying millions of Americans 
their shot at the American dream because of our irrational health 
insurance system.
  Right now, if you have been sick, insurance companies can refuse to 
cover you or charge you ridiculous premiums. If you get sick, your 
insurance benefits can run out when you need them the most.
  Right now, people without insurance do not get preventive care. 
Instead, they go to the emergency room when they cannot hold out any 
longer. This is the least-efficient and most expensive way to deliver 
care, and those of us who do have insurance pay for it. It costs every 
insured family more than $1,100 a year in additional premiums to pay 
for those who don't have health insurance.
  Right now, if you are a woman who has had a C-section or if you have 
been a survivor of domestic violence, health insurance companies can 
arbitrarily decide not to cover you. That is because having had a C-
section or being a survivor of domestic violence is considered by many 
insurance companies to be a preexisting condition. That is wrong.
  What is even more egregious is that while millions of Americans 
struggle to pay for health care, insurance executives continue to make 
obscene salaries. From 2000 to 2007, a period of 8 years, Americans saw 
their premiums almost double. During that same time, we saw more than 6 
million more Americans become uninsured. During that same time, 
insurance company profits rose 428 percent--428 percent. That is all 
you need to know to understand why we have to pass this bill--428 
percent in 8 years. No wonder the insurance companies are fighting this 
bill. Of course they don't want to be subject to antitrust laws. They 
are making outrageous profits by gouging American families. Make no 
mistake, that is what this is about.
  This bill will change all that. It will fundamentally transform how 
health insurance works in this country. This bill guarantees secure 
coverage that will be there for Americans and stay there when they need 
it the most. This is not going to help just individual Americans; it is 
going to help small businesses too.
  There are urgently needed changes that will go into effect the day 
the President signs this bill into law. Effective immediately, 
preventive services, such as colonoscopies and cholesterol tests, will 
be covered by all insurance plans at no cost. This will make prevention 
a priority, not an afterthought. We will detect cancers earlier and 
stop chronic diseases, such as diabetes, in their tracks. Not only will 
this save innumerable lives, it will lower the long-term cost of health 
care for all of us. This is one of the key ways health care reform 
transforms our system of sick care into a true health care system.
  Effective immediately, any new health insurance plan will let your 
children remain on the family policy until they are 26. That is big. 
Say you are a parent whose kid has been ill in the past, maybe she had 
asthma and she just graduated, say, from the University of Minnesota. 
Your daughter is just out of school, and she wants to find a job. We 
all know this is a big enough challenge in this economy. While she 
plans for her future, the last thing she should have to worry about is 
how she is going to get health insurance.
  The good news is, after health care reform, she will have secure 
coverage until she gets on her feet. She can either stay on your plan 
until she is 26 or once the exchange is up and running, she can 
purchase an affordable plan through the exchange.
  Also, effective immediately, we will hold health insurance companies 
accountable by making them give rebates if they spend more than 20 
percent of premiums toward profits, marketing, or administration. I am 
proud to have championed this safeguard with my colleagues, Senator 
Rockefeller and Senator Whitehouse.
  The current reality is, most of us do not know where our health 
insurance premiums go. It is challenging enough to understand a billing 
statement from your health insurer, much less track where your money is 
being spent. We are going to change that.
  Thanks to Senator Jack Reed, the Senate bill also requires 
transparent reporting of how health insurance companies are spending 
your money. This transparency is especially important as we cover an 
additional 3l million Americans under this bill. We know from their 
profit margins that right now insurance companies are price gouging. 
But clear reporting will help us hold them accountable for every dollar 
we invest in health insurance.
  Based on our experience in Minnesota, I know we can do even more to 
rein in marketing, wasteful administrative costs, and profits in health 
insurance. In the coming weeks, we will debate this bill, amend it, and 
make it even better. I will be pushing to require an even higher 
percentage of your premiums go toward actual health care.
  The reason I believe we can provide higher quality care without 
excessive profits is because Minnesota already does it. We are 
distinguished by the fact that 90 percent of Minnesotans are served by 
a nonprofit health plan. These plans outperform their national peers 
and are able to put an average of 91 cents of every premium dollar 
toward actual health care services--91 cents out of every dollar.
  In other plans throughout the Nation, you may find less than 60 
percent of your premium is put toward health care. The rest is for 
overhead, marketing, and profits. By taking the profits out of the 
health insurance industry--not taking them out but lowering them to a 
reasonable level--Minnesota health plans do a better job of helping our 
residents live healthier, longer lives. As we begin debating this bill 
on the Senate floor, it is essential that health insurance companies 
get the message loudly and clearly that their top priority must be 
serving patients, not creating more and more profits, not a 428-percent 
increase in profits in 8 years.
  Under the Senate bill, we will stop insurance companies from denying 
you coverage or charging you more because of preexisting conditions. 
This will end the egregious industry practice of discriminating against 
survivors of domestic violence. Insurance companies

[[Page 28744]]

also will no longer be able to charge women more for their health 
coverage just because they happen to be a woman.
  We will ban lifetime caps and end unreasonable annual limits on your 
benefits. These insurance market reforms will help Americans, but they 
will be particularly life changing for families such as the Battersons 
who live in Bloomington, MN. Linda Batterson has three daughters. She 
owns her own business, and her husband Bud is a realtor.
  The Battersons have some relatively minor health problems--asthma, 
allergies, and back problems. But because health insurance companies 
can charge them more based on their health history, their only health 
care option in Minnesota is a high-risk pool. This year they are paying 
nearly $21,000 for health care--$21,000 for their insurance. This is 
not a Cadillac plan. Neither the Battersons' businesses nor their 
family can sustain these costs.
  But the good news is, the Battersons will get relief under our bill. 
They will be able to go to the exchange and find an affordable plan. 
Health insurance companies will not be able to charge the family more 
because of their health history. If companies are going to raise rates, 
they will have to publicly disclose and justify any increase.
  I think we can all agree that one group of Americans who suffer under 
our current system is small businesses. Across Minnesota--from Bemidji 
to Spring Valley--I have talked to small business owners who want to do 
the right thing. They want their workers to be healthy, but they cannot 
afford the current unpredictable and skyrocketing rates.
  In Minnesota, we have 92 percent of our State covered, and we have 
invested resources to create the MinnesotaCare Program to make sure 
low-income residents are covered. But even with all this success, the 
uncontrolled cost of health insurance is forcing us to tighten our 
belts and make sacrifices that no American should have to make, such as 
small businesses having to choose between laying off workers or 
dropping health insurance for everyone.
  I am pleased to tell you this bill will bring real relief to small 
businesses across our country. We will even the playing field so small 
businesses can do the right thing for workers without sacrificing their 
bottom line. This will make them competitive with large employers and 
with companies from overseas so they can attract the best and brightest 
workers.
  Right now, small businesses are often priced out of the markets. They 
may be lucky to find just one or two carriers willing to cover their 
workers. So the first important change that health care reform can 
bring is choice of plans for small businesses. They will be able to 
participate in the exchange which will offer them a choice of reliable 
plans. This coverage will be less expensive and provide better coverage 
than what is available today.
  Right now, if you are a business with, say, 15 employees and 1 of 
them gets sick or has a baby, your premiums are going to go up 
dramatically. That is because your risk pool is 15. But when you choose 
from policies on the exchange, your risk can be pooled with hundreds or 
even thousands of other businesses. That is the whole point of 
insurance, to spread the risk over the greatest number of people.
  The second key benefit for small businesses is tax credits to help 
business owners purchase coverage. Effective immediately, these credits 
will ease the burden on small business owners who offer coverage but 
are being squeezed in the current market. For business owners who have 
not been able to offer insurance, the tax credits will provide a new 
incentive to begin covering their workers, keeping the workforce 
healthy and productive.
  Today I have touched on just a few elements of the health care reform 
bill. I will be back. I have touched on insurance market reforms and 
provisions tailored to the needs of small businesses. But this just 
scratches the surface. The public option will bring much needed 
competition, and the incentives for high-quality care will make us all 
healthier. Taken together, these elements will bring our country into a 
new era in which high-quality and affordable health care is a reality 
in this country.
  Passing national health care reform this year is my top priority 
because I have listened to Minnesotans across my State. They have told 
me loudly and clearly that the current health insurance system is not 
working for them, and they have told me they want access to care. I 
have heard them.
  They want to know they can start a small business without worrying 
about the cost of health insurance because one of their kids has a 
preexisting condition. They want to know they will have health care 
when they need it the most. They want insurance companies to prioritize 
health services over profits. They are looking for us to fulfill our 
promise to pass comprehensive health care reform this year.
  I look forward to working with all of you to make this a reality.
  I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The bill clerk proceeded to call the roll.
  Mrs. LINCOLN. Madam President, I ask unanimous consent the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mrs. LINCOLN. Madam President, I have asked for this time today not 
only to address my colleagues in this body but to speak directly to my 
constituents at home in Arkansas. After many months of debate on health 
care, we are nearing yet another important step in a very deliberative 
process. Today we are voting on whether to continue to discuss how to 
improve health care in America or to stop the debate.
  I personally have carried the mantle to improve health care for 
Arkansas throughout my public service, like many of my colleagues and 
so many others as well who have worked hard on this issue. Over the 
last several decades the advance of medical technology and our Nation's 
changing demographics have placed new demands on our health care system 
that it is not designed to meet.
  Our vote later this evening is not the first step toward making the 
necessary adjustments in health care, nor will it be the last, without 
a doubt. The Finance Committee on which I serve and which is led so 
ably by my good friend from Montana, Chairman Baucus, has produced what 
I still describe as the most responsible approach to health insurance 
reform. We deliberated for more than 22 months, incorporating 
recommendations from experts all across our great Nation and proved, 
through our bill, that America can achieve unprecedented health 
insurance reforms that expand coverage, reduce cost, and provide 
stability for those with existing coverage.
  We accomplished these goals without posing long-term risk for 
taxpayers. It was not a perfect bill. We never see perfect bills around 
here, quite frankly, but I can honestly say I will fight hard so our 
final product will more closely resemble the commonsense, deficit-
reducing plan we produced in the Senate Finance Committee.
  At times like this I think it is very important for each of us to 
remember the very reasons we began this debate. Small businesses and 
working families are reaching the breaking point financially because of 
the relentless rise in health care costs. Nationally, our economic 
recovery will only be slowed by the inflationary cost of health care. 
Taxpayers and the insured are already bearing the cost of medical 
treatment for the uninsured at the most expensive point of delivery, in 
our emergency rooms. Health care in America today is a model that waits 
until people get sick rather than focusing on the wellness, prevention, 
and good management of illness that keeps people out of the hospital 
and from having the most costly care needs.
  Our current health care system wastes money and is so inefficient 
that the United States spends more than twice as much per person while 
insuring a smaller portion of our population than the average spending 
in 29 other industrialized nations. There simply are not enough health 
insurance options available to most Americans

[[Page 28745]]

today when in at least 17 States, including my home State of Arkansas, 
only one insurance company controls more than half the insurance 
market, and in at least 22 States still only two carriers control half 
or more of the market.
  Patients and doctors are routinely making treatment decisions with 
little or no objective information about which treatments are more 
effective. American capitalism is based on choice and competition 
because when these elements are present, consumers can most always find 
the best value for their money. That is not true in health care. So by 
creating health insurance exchanges through which small businesses and 
individuals can choose from a menu of private plans, we can enhance 
cost transparency, create head-to-head competition, and allow market 
forces to reduce prices.
  These are facts. These are facts, and whether we are Republicans or 
Democrats or independent, I believe we can agree on most all of them. I 
know the great majority of Arkansans believe these facts and want to 
see us accomplish these reasonable goals.
  For months now, groups from outside my State have assigned various 
motives to my deliberations on health care and tried to define the 
meaning of my vote. According to the last tally, there has been more 
than $3.3 million worth of media ads that have been purchased in my 
home State of Arkansas by groups from outside of our State--certainly 
none by me--and most with my name in the ad. Still, I have continued to 
approach this issue as I always do. These outside groups seem to think 
this is all about my reelection. I simply don't think they know me very 
well.
  I am focused on my opportunity to influence the final version of 
health care legislation in a way that most helps my State. That is why 
the people of Arkansas sent me here. They sent me here because they 
know I am going to work hard to do the best job possible and to do the 
right thing; to stand my ground on my principles.
  I have avoided the extremist claims from the left and from the right 
and tried to pull the commonsense solutions from among all the policy 
options so that we get health care reform that benefits Arkansans and 
all Americans. That is our job in this body, to represent our States in 
this unbelievably historic body, the Senate.
  The truth is, this issue is very complex. There is no easy fix, and 
it is imperative that we build on what is already working for health 
care in America and not turn away from the problems we face. We keep 
building until we can truly say one day that all American citizens will 
have access to quality and affordable health care. In order to improve 
upon and build upon what we already have, I do not support the creation 
of a so-called robust, government-administered public plan.
  I believe we should work to make sure we do not expose American 
taxpayers and the Treasury to long-term risks that could occur over 
future government bailouts of a public plan. Rather than create an 
entirely new government-run health plan to compete with private 
insurers, I support health insurance reform that focuses on changing 
the rules of our existing employer-based private health insurance 
system. I believe we should change the current rules that permit 
insurance companies to bully their customers and cherry-pick healthy 
patients, so we can force them to compete with each other.
  My first loyalties are with the people of Arkansas--not insurance 
companies, the health care industry, or my political party. In fact, I 
authored an amendment during consideration of legislation in the Senate 
Finance Committee which limits taxpayers' subsidies for health 
insurance companies that pay their top executives millions in salaries. 
Responsible health insurance reform should ensure that insurance 
executives are not receiving a personal windfall, and that companies 
they work for are not receiving excessive tax breaks while at the same 
time profiting from government requirements on consumers to buy 
insurance.
  The reason we are having this vote is because our Republican 
colleagues object to beginning debate and consideration of amendments 
on health care legislation. Although I do not agree with everything in 
this bill, I have concluded that I believe it is more important that we 
begin this debate to improve our Nation's health care system for all 
Americans rather than simply dropping the issue and walk away. That is 
not what people sent us here to do.
  Attempts by the National Republican Party and other conservative 
groups to portray this as a vote for or against this particular health 
care reform bill are untrue and deliberately misleading. The vote 
tonight will mark the beginning of consideration of this bill by the 
full Senate, not the end. Republicans have sought to revive their 
political party by opposing any real solution to our Nation's health 
care crisis. In fact, this vote for or against a procedure that allows 
us to begin debate on health care reform is nothing more and nothing 
less. Put simply, those who vote yes on this vote believe our Nation's 
health care system needs reforming, and they are ready to have an 
honest and open debate in the Senate about how to best achieve that 
reform. I am not afraid of that debate, nor am I afraid of coming 
before this body to say what I believe is the most important thing we 
can do to reform health care. I hope none of us are. Our country needs 
us too desperately now to be making good decisions and moving forward.
  I will not allow my decision on this vote to be dictated by pressure 
from my political opponents, nor the liberal interest groups from 
outside Arkansas that threaten me with their money and their political 
opposition; the multitudes of e-mails and ads we have received, 
unbelievable types of threats about what they are going to do and how 
they are going to behave. The fact is, I am serious about changing our 
health care system, as most Arkansans and most Americans are. I am not 
with those who seek to avoid the debate, nor with those who use 
political attacks to achieve their narrow goals. I will vote in support 
of cloture on the motion to proceed to this bill.
  But let me be perfectly clear. I am opposed to a new government-
administered health care plan as a part of comprehensive health 
insurance reform, and I will not vote in favor of the proposal that has 
been introduced by Leader Reid as written. I, along with others, expect 
to have legitimate opportunities to influence the health care reform 
legislation that is voted on by the Senate later this year or early 
next year. I am also aware there will be additional procedural votes to 
move this process forward that will require 60 votes prior to 
conclusion of the floor debate. I have already alerted the leader and 
my colleagues that I am prepared to vote against moving to the next 
stage of consideration as long as a government-run public option is 
included. The public option, as a part of health insurance reform, has 
attracted far more attention than it deserves. While cost projections 
show that it may reduce costs somewhat, those projections don't take 
into account who pays if it fails to live up to expectations. If, in 
fact, premiums don't cover the cost of the public plan, it is taxpayers 
in this country who are faced with the burden of bailing it out.
  Our colleagues cannot ignore the growth in the Federal Government 
since the year 2000. I can assure you that the American people have not 
ignored it. According to the American Institute for Economic Research, 
government spending grew by 55 percent under President Bush. As he was 
leaving office, government launched a massive bailout of Wall Street. 
Then it was the domestic auto manufacturing industry that needed 
taxpayer funds to survive. And finally, in order to revive a dying 
economy, it took a government economic recovery package to save or 
create hundreds of thousands of jobs. We can argue about the necessity 
of these unprecedented steps, but we need not argue about the 
impression they have made on the American people. We should be stopping 
the growth of government, not expanding it more. Without the public 
option, we could still force private insurance plans that participate 
in the exchanges to provide

[[Page 28746]]

standard benefit packages that are easy to compare and more fairly 
priced. We will be bringing millions of new customers to the exchanges 
so insurers should be motivated to lower prices and be competitive.
  I have pledged to dialog with Leader Reid regarding my concerns that 
remain about this bill. I look forward to continuing that dialog on 
improvements that I believe are necessary in order to meet the 
challenge. I will be asking my colleagues to consider these additional 
important changes I believe will improve our chances for real health 
insurance reform and that can also enjoy the support of most Arkansans 
and most Americans.
  Some of these include that the legislation remain deficit neutral, 
now and in the future, and curbs future cost, that it protects Medicare 
beneficiaries for seniors and extends solvency of the Medicare Program, 
that it improves accessibility and affordability of health insurance 
for employees and owners of small businesses and the self-employed 
through access to health insurance exchanges and tax credits, that it 
enhance choice and competition of health insurance plans for small 
businesses and individuals without the inclusion of a government-run 
public option, and that it build our Nation's health care workforce and 
ensure continued access to quality health care providers, especially in 
rural America.
  Today I know I will ultimately be held accountable by my constituents 
in Arkansas for all of my votes on health care, not the National 
Republican Senatorial Committee, not by other groups from outside my 
State that continue to engage in a conversation they have begun. I know 
my decision to support the upcoming cloture vote on the motion to 
proceed is not my last nor only chance to have an impact on health care 
reform.
  I am optimistic and encouraged about the step we are preparing to 
take in the Senate, to amend and craft a bill that will improve access 
to quality, affordable coverage options for the residents and 
businesses of my State who desperately need relief, a bill that 
improves the quality and efficiency with which we deliver health care, 
all without adding to our Nation's deficit and while lowering the cost 
of health care over the long term. I am committed to using every power 
of my office to achieve success on this issue by enacting meaningful 
reforms that will benefit the people of Arkansas and our Nation.
  I have spent the last several months in a passionate dialog with my 
constituents about health care reform. It was not only in townhall 
meetings where I heard from Arkansans. I had hundreds of conversations 
with many of them in groups and one-on-one conversations. They may not 
be in agreement about solutions, but I can assure my colleagues that 
each Arkansan I speak to expects us to roll up our sleeves and get this 
right. We can. Following the vote tonight, the bill that will be laid 
before us will not be the only possible solution. I know my decision to 
support cloture on the motion to proceed is not my last or only chance 
to have an impact on overall health care reform. My strongest hope is 
that each of us can lay political fortunes aside and make the tough, 
commonsense choices our constituents expect of us, whether you are a 
Democrat or Republican, and look at what we face and the challenges of 
our Nation. Make sure that as we are working toward an end result, that 
each of us is working as hard as we can to come up with a pragmatic 
solution that our constituents expect of us. We may not get this 
opportunity again in our lifetime.
  Today I am thinking about the Arkansas working family who can't pay 
their mortgage because of their sick child's medical bills. I am 
thinking of the Arkansas small business owner who told me that more 
than 20 percent of the cost of running his business now goes to health 
insurance for him and his workers. I am thinking about the 450,000 
Arkansans who have no health insurance. I am not thinking about my 
reelection, the legacy of a President, or whether Democrats or 
Republicans are going to claim victory in winning the debate. I hope 
all of my colleagues join me in looking forward to working with the 
leader and all of our colleagues in the days and weeks ahead as we 
strive to solve a problem whose solution is long overdue.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Michigan.
  Mr. LEVIN. Madam President, in a few hours we will take an important 
step on the road to health care reform. Our vote will come after months 
of analysis and debate and years of growing concern on the part of our 
constituents that the American health care system is in need of 
fundamental reform. Two Senate committees have approved reform 
legislation. We will vote later today on whether to open debate on a 
third one which merges the two produced by the Senate Finance and HELP 
Committees. Much time and attention has been focused on the provisions 
in this legislation which will expand the number of Americans who are 
covered by health insurance, a goal I wholeheartedly share. But a 
compelling reason for reform and a major reason to vote in favor of 
allowing the Senate to debate health care reform is the serious and 
worsening signs that for those Americans who have health insurance, our 
health care system is no longer working as it should.
  Increasingly, Americans with health insurance are at catastrophic 
financial risk, if they get sick. Increasingly, working families with 
insurance are unable to afford the escalating premiums they face to 
maintain their often inadequate coverage. Increasingly, businesses 
large and small that offer health insurance to their employees are 
buckling under the crushing weight of spiraling costs for their 
employees. Increasingly, families find that caps on their coverage 
leave them exposed to devastating medical bills. And increasingly, 
arbitrary insurance company practices that boost their own profits are 
shortchanging Americans, denying coverage because of preexisting 
conditions, and searching for ways to deny patients the treatments they 
need and have paid for through their premiums.
  Democrats are not alone in pointing out these problems. The 
Republican leader himself has said:

       Every Republican in Congress supports reform.

  That is the Republican leader who said that every Republican in 
Congress supports reform. He did not say many Republicans. He did not 
say most Republicans. Every single Republican in both Chambers of 
Congress, the Republican leader tells us, wants to reform the health 
care system.
  How will any reform happen, reform proposed by Democrats or by 
Republicans or by anybody? Only when this body can bring a bill to the 
floor of the Senate for debate and amendment, only when we work with 
our colleagues in the other Chamber to resolve differences between 
legislation approved by the Senate and that approved by the House, only 
when Congress sends the President a bill he is prepared to sign into 
law. Speeches will not reform health care. Polls and cable television 
shout fests, none of that will reform health care. We, the Members of 
the U.S. Congress, and we alone, can reform health care.
  We must listen to constituents, advocacy groups, physicians, 
insurers, health care experts, economists and anyone else with 
constructive ideas. Ultimately, it is we who must act. To do that, we 
must begin to debate here on the floor of the Senate the many complex 
issues that must be resolved. That is all today's vote will do, give 
the Members of the Senate the chance to come together in a sincere 
effort to work together, resolve our differences, and address an issue 
on which there is, we are told, even by the Republican leader, general 
agreement on the need for reform.
  Two Senate committees have already spent months seeking the proper 
ways to reform the health care system. The Senate Finance Committee has 
held over 50 meetings on health care reform legislation in the last 
year. The Health, Education, Labor and Pensions Committee spent 13 days 
marking up its legislation. So we have made progress. We are at least 
in position to

[[Page 28747]]

do what this body was designed to do and is supposed to do: deliberate 
and decide.
  The minority opposes the legislation we are trying to bring to the 
floor for debate and amendment. They say they do not like the bill. But 
why deny the Senate the opportunity to debate the subject of health 
care reform? Why prevent us from considering it? Why not offer 
amendments to the bill if you do not like it or offer a substitute 
measure for it?
  There are parts of the bill in which I would like to see changes. I 
would like to make health insurance even more affordable for working 
families, and I am willing to require that those earning more than 
$250,000 a year, for instance, pay a higher and, in my view, more fair 
and more appropriate tax rate to make that greater affordability for 
working families possible.
  Income data shows that in recent years only the wealthiest 10 percent 
of Americans have seen any real increases in income and that those 
increases are concentrated in the wealthiest 1 percent of the country, 
while the vast majority of Americans have lost ground. At the same 
time, most Americans are coping with falling income, they have been hit 
with massive increases in health insurance premiums. So I am willing to 
support an increase in upper income tax brackets to end that 
unfairness.
  Other sources of revenue, such as ending the abuse of offshore tax 
havens, can and should go toward doing other things we should be doing 
in this bill. For instance, I am concerned that the annual fee on 
insurance providers contained in the merged bill would treat nonprofit 
and for-profit insurers the same way. Millions of Michigan residents 
receive their insurance from Blue Cross Blue Shield of Michigan, a 
nonprofit company, which is the insurer of last resort in our State, 
providing coverage to residents who cannot find it elsewhere. We need 
to find ways to reform the insurance market without negatively 
impacting the not-for-profit insurance companies that are the insurers 
of last resort and that provide high levels of coverage in return for 
the premiums they collect.
  On these and other issues, I will continue to study the details of 
the legislation, discuss them with colleagues and constituents, and I 
will support improvements where needed. What I will not do is vote to 
block efforts to reform a system that simply is not working well for 
those who have health insurance, as well as for those who do not.
  The need for reform is generally acknowledged. How can we then not 
open debate? How can we not discuss, offer amendments, consider 
alternatives, make changes, and vote on reform legislation? That is the 
only path to health care reform. There is no other way. And for those 
who proclaim their belief in the need for reform to stand in the way of 
that debate is, at best, starkly inconsistent.
  A vote against even opening debate is a vote in favor of the status 
quo, which my constituents and the vast majority of Americans can no 
longer afford. They can no longer afford it because it is bankrupting 
them, in many cases literally bankrupting them. A study this year, 
published in the American Journal of Medicine, found that in 2002, 62 
percent of all individual bankruptcies in the United States involved 
medical costs.
  That is a tragedy. You should not be forced into bankruptcy because 
you get sick. But it gets worse. Three-quarters of those bankruptcies 
involved people who had health insurance when they got sick. Let me 
repeat that. In the United States, almost two-thirds of all 
bankruptcies are linked to medical costs, and three-quarters of those 
bankruptcies occurred even though the debtor had health insurance. That 
is adding absurdity to tragedy and demonstrates the inadequacy of 
health insurance for those who are covered.
  We must act to reform a health care system so broken that it crushes 
Americans under a mountain of debt. One of my constituents, a Kalamazoo 
man, had what he thought was adequate health care coverage when 3 years 
ago he needed surgery to replace two sections of his aorta. But his 
coverage left him an out-of-pocket cost of nearly $40,000. That is the 
sum that stood between this man and lifesaving surgery. Financially 
devastated by the costs, he declared personal bankruptcy. He wrote to 
me:

       No one should die because they cannot afford health care, 
     and no one should go broke because they get sick.

  He is right.
  We must act to reform a health care system so broken that it leaves 
the mother of a young Michigan State University student worried that 
her daughter will not get the care she needs. This 24-year-old student 
has insurance. Yet when she began to have unexplained seizures, her 
coverage would not pay for all the tests needed to determine their 
cause. Even after declining some prescribed tests because she could not 
afford them, the young woman's doctors eventually discovered the cause 
of her seizures: a brain tumor. This mother worries that her daughter 
will lose her insurance, will be forced to declare bankruptcy, and that 
the family will have to find some other way to cover the massive 
expense of her lifesaving care--all while coping with the other 
financial strains hitting her family and so many others. The mother 
writes:

       We will lose too many bright young people if something is 
     not done.

  She is right.
  We must reform a health care system so broken that it sent a minister 
from Jackson, MI, on a weeks-long odyssey to keep her insurance because 
she became pregnant--a joyous event for most families but apparently 
just another preexisting condition to insurance companies. When this 
expectant mother moved from a church in Massachusetts to one in 
southern Michigan, her new church immediately sought, for their new 
minister, to find her health insurance. But company after company 
declined to cover her because of her pregnancy. She and her church 
spent weeks researching the issue, changing insurance agents, providing 
document after document, pleading with insurance companies. She wrote 
me:

       I had two volunteers, myself, and two insurance agents 
     working on the situation constantly for over a month.

  And she said:

       If you have the time and energy, and some good help, and 
     are willing to spend a month hassling with the system pretty 
     much continuously . . . then you can sometimes, with a great 
     deal of luck, work the system.

  Reflecting on her experience, this minister writes:

       It is clear to me that we are desperately in need of health 
     care reform.

  She is right.
  The legislation the majority leader has brought forward will do much 
to ease the hardship on millions of Americans. It has benefits for 
those who already have insurance through their employer, with steps to 
rein in skyrocketing premiums and to reduce the risk of financial ruin 
for those who have health insurance.
  In addition to helping those with private insurance, this legislation 
provides important benefits for seniors covered by Medicare. Medicare 
beneficiaries will receive free preventive care benefits, and the bill 
will reduce the enormous costs many seniors face when they fall into 
that doughnut hole, so-called, in the Medicare Part D prescription drug 
program. Because of these important improvements in care for seniors, 
AARP has recommended that Senators vote in favor of beginning debate on 
this bill tonight.
  The legislation also contains important provisions to improve 
information technology in the health care sector, pushing for uniform 
billing practices and developing standards that will lead to the 
computer systems of health care providers being able to talk to the 
computer systems of insurance companies, reducing mountains of 
paperwork and other inefficiencies that drive up health insurance 
premiums.
  Americans who move from one employer to another will no longer face 
the risk of being denied coverage at their new job because of a 
preexisting condition.
  We must allow debate to begin. If we act, millions of those who 
already have insurance at work will benefit. If we act, millions 
without insurance will

[[Page 28748]]

get it, along with help to pay for it, so we can end the current 
wasteful situation in which emergency room care--vastly more expensive 
than primary care through a family doctor--is used for nonemergency 
purposes by those without health insurance.
  We can only accomplish these things if we vote today to begin debate 
on this legislation. We can only accomplish these things if we are 
willing to honestly and vigorously debate the best ways to achieve it. 
So I urge our colleagues not to close the doors of this Chamber to 
debate on one of the most urgent problems Americans face. I ask our 
colleagues to allow the Senate to begin deliberations on health care 
reform and not to turn away from the opportunity and the responsibility 
before us.
  Madam President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Tennessee.
  Mr. CORKER. Madam President, I know the time is slightly before the 
hour. I do not know if there are any Democrats who want to speak beyond 
the Senator from Michigan during this hour. With that, I think we are 
anxious to get going.
  Madam President, I ask unanimous consent that the Republican speakers 
be permitted to enter into a colloquy during the time controlled by the 
minority, which I understand ends at 4 o'clock today. Is that correct?
  The PRESIDING OFFICER. That is correct.
  Without objection, it is so ordered.
  Mr. CORKER. Madam President, just to make sure people who may be 
watching the Senate floor understand what is happening, Republican 
Senators took all day yesterday and today to read the bill and to 
actually go through sections of the bill to discuss it and make sure 
all of us are very familiar with the various pieces of it.
  I think all of us are united in concern about the way this bill is 
paid for. It is hard for me to believe that anybody could suggest that 
taking $464 billion out of Medicare, which is insolvent, would be a way 
to fund a new entitlement; or that pushing down an unfunded mandate to 
States, which we are going to talk about in just one moment, makes any 
sense at all--$25 billion worth; or increasing the Medicare tax, which 
would not be a tax to make Medicare more solvent, but instead go to a 
new entitlement program--we all know Medicare is going to be insolvent 
by the year 2017; and to have a bill that pays for itself over 10 years 
by having 6 years' worth of costs against 10 years worth of revenue; 
and then to have something such as the CLASS Act, which I know the 
chairman of the Budget Committee has called a Ponzi scheme, where, in 
essence, you create a program that takes in premiums over a 10-year 
period on a new entitlement for long-term care--another new 
entitlement, I might add, in addition to the one we are talking about 
today--it takes in those premiums but bars any money from going out for 
5 years. So what you have is, in essence, a collection system that 
creates $72 billion. So I think all of us are very concerned about how 
this is funded.
  But today we want to talk about our tremendous concerns with the 
Medicaid expansion that is taking place. I am joined by a number of 
Senators who have had vast experience in State government and vast 
experience in health care.
  I think the American people have now realized this bill insures, per 
the CBO, 31 million additional people. But the expansion that causes 
that to occur is that 15 million people now will be on Medicaid who are 
not on Medicaid. It is the largest expansion of Medicaid in U.S. 
history.
  What we are doing to make sure this works budgetarily is we are 
forcing States to pick up the tab. I got an e-mail last night from my 
State--and I know other States are going to be talking about that, or 
people from other States. But last night, the State sent me an e-mail 
and said this was going to cost our State almost $800 million.
  Our State has been well governed for years. The senior Senator from 
Tennessee was Governor in the middle-eighties. We have had both 
Republicans and Democrats who have governed our State very well. In our 
State, we do not expect our revenues to be back to 2008 levels until 
2013. So you can imagine that our Governor, who is on the other side of 
the aisle, is very concerned about us here in Washington saying he has 
to expand his Medicaid Program. We are going to expand it around the 
country by 15 million people, and he has to pay for it. He is more than 
upset about that particular issue.
  I know people here in Washington--the Washington establishment--
generally speaking, are upset about the fact that States actually 
balance their budgets. We don't do that here, but in order to show 
almost disrespect for the way our States, in most cases, have to 
balance their budgets, what we are saying is we are going to make it 
more difficult on them by making sure that in order to reach a goal, we 
force our States, through an unfunded mandate, to cover an additional 
15 million people under their Medicaid programs.
  Let me just mention that I thought we were actually going to do 
health care reform. I know there is probably a lot of laughter taking 
place in the halls of this building today because I thought when we 
talked about health care reform, that is what we were going to do.
  We know Medicaid is one of the worst programs that ever existed as it 
relates to health care. Let me just mention a couple stats. The Cancer 
Journal published that Medicaid recipients were two to three times more 
likely to die from the disease than people who were not on Medicaid. 
The American College of Cardiology in 2005 said Medicaid patients were 
almost 50 percent more likely to die after coronary artery bypass 
surgery than patients on Medicare or private pay. Forty percent of 
physicians in our country don't even take Medicaid. In urban areas, 50 
percent of specialists have blocked patients from entering their 
program.
  So I wish to say just this and then I will stop because I want to 
hear from other colleagues who have been around here for awhile. But 
when I was back home during August, citizen after citizen said to me: I 
know we are going to have health care reform. What I would like is just 
to have what you, Senator, have. That is what I would like to have. I 
know Senator Burr worked on a bill that would do that. It would create 
the ability for people to participate, as we do, in choice. I know 
Senator Alexander worked with Senator Wyden and others, and I worked 
with Senator Burr in the first Congress to create legislation that did 
that. As a matter of fact, Senator Wyden, from the other side of the 
aisle, created a bill that did away with Medicaid. It gave Medicaid 
recipients the same kind of choice that we in the Senate have. But it 
seems to me, Senator Reid's bill goes in exactly the opposite 
direction.
  What it does, in order to add 31 million people to the rolls, 15 
million people are being forced into Medicaid. So I would think, then, 
that in order to make sure we are treated just like our citizens, one 
of the first votes we might take is that we agree, as Senators, to be 
treated the way the majority of people in this program are being 
treated, and I assume that going on Medicaid with those same results 
for our families would be something we would embrace. I think all of us 
heard from citizens across this country that they want the same choices 
we have. But in the name of reform, we are going in the opposite way 
and, again, locking them into nonchoices, nonphysicians, bad outcomes, 
and going in exactly the wrong way we should be going and, to boot, 
making States pay for it.
  There is one class of people, though, who are not treated that way in 
this bill. I have tremendous respect for those immigrants who have come 
into our country in a legal way. Let me make sure people understand 
that. Sometimes my southern drawl confuses people. I have tremendous 
respect for people who have come into this country in a legal way. The 
Reid bill does this. He respects them too. What the Reid bill says is, 
if you are born in America and you are from 100 to 133 percent of 
poverty, then you are barred from receiving a subsidy and are forced to 
be on Medicaid, but if you come into this country as a legal immigrant, 
you actually can receive a subsidy to purchase a private insurance 
policy. I find

[[Page 28749]]

that most interesting. I don't know if some of my other colleagues--I 
know Senator Burr has spent a lot of time on this.
  I find this reform very troubling. I know the Senator has worked hard 
to give Medicaid recipients the same choice as we have. I don't know 
how you feel about the reform that is before us.
  Mr. BURR. I thank my colleague from Tennessee. I think it is 
important, throughout this education of the American people of what is 
in 2,074 pages, to remind them that for every word in here, it costs 
the American taxpayer $6.8 million; for every page, $1.2 billion.
  I think one has to look a little further at this reform aspect. Does 
this bill truly reform health care? I think as you read through the 
bill what you find are the words ``require,'' ``must,'' or ``shall'' 
4,677 times. You find the words ``tax,'' ``fee,'' or ``revenue'' 899 
times. You find the word ``agency,'' ``department,'' ``bureau,'' 
``commission,'' or ``panel'' 470 times. But we are told this bill does 
reform health care. We are told it increases competition, it provides 
more choice, it stimulates innovation. Yet we find the word ``choice'' 
40 times. We find the word ``innovation'' 25 times. We find the word 
``competition'' 13 times.
  I suspect their intent is to fix what they haven't reformed by 
allowing the Secretary of Health and Human Services, in 1,677 spots, to 
define or determine what congressional intent was. Think about that. 
This bill basically turns over a lot of the decisionmaking to the 
current or future Secretaries of Health and Human Services to decide 
what we meant in the Congress.
  Well, my good friend from Tennessee raised a lot of things on 
Medicaid, and I wish to talk about Medicaid, but I also wish to mention 
that, once again, we are paying for this by cutting $464 billion from 
our Nation's seniors. That is a trust fund. They have paid in premiums. 
Similar to the CLASS Act--it shouldn't be a surprise to us that they 
are going to steal money out of the CLASS Act that hasn't even been 
created yet because in the bill it is taking $464 billion from seniors 
who have paid into it for a lifetime, and within that group of seniors, 
11 million seniors are going to have their benefits cut because they 
chose Medicare Advantage as their preferred insurance product. It is 
not a question of whether they can keep what they have; they can't keep 
it because their benefits are going to be cut, and that affects 
America's low-income seniors the most.
  As a matter of fact, in this bill, we fix doctor payments for 1 year. 
So, in 2011, doctors' reimbursements are going to be cut 23 percent. I 
see Dr. Barrasso on the floor. So we know more doctors are going to 
stop covering Medicare beneficiaries. The pool is going to get smaller. 
We are going to affect every senior's health.
  Mr. CORKER. In essence, Medicare will become more similar to Medicaid 
because of this bill. Less physicians will be covering Medicare 
recipients because this bill, instead of using the $464 billion to make 
sure physicians are paid, will leverage a new entitlement. So my 
assumption is, this program, unless something else happens, will become 
more similar to Medicaid. Medicare will become similar to Medicaid.
  Mr. BURR. The Senator from Tennessee is 100 percent correct. Today, 
40 percent of our Nation's physicians under Medicaid will not see 
patients because the reimbursements are so low.
  Reform in health care means you have to eliminate cost shifting. As 
Dr. Barrasso knows, cost shifting means when somebody goes in for a 
service, gets health care delivered, and doesn't pay or somebody goes 
in who is underinsured, gets delivered a service, and their 
reimbursement doesn't sufficiently meet the needs of the cost of that 
service delivered. But it doesn't stop there. Medicaid reimburses at 72 
cents of every dollar of service provided. Today, for every Medicaid 
beneficiary in America, every time they receive a service from a 
doctor, a hospital, or wherever, 28 cents is shifted over to the 
private side to those who pay out of pocket, to those who have private 
insurance.
  If you are reforming health care, you can't reform health care 
without eliminating cost shifting. Yet in this plan, we increase the 
rolls of Medicaid by 15 million individuals. In essence, what that 
means is we are going to have cost shifting on steroids now. We are 
going to have more cost shifting than we had before, which means a 
higher inflation rate on private health care, that which we pay out of 
pocket or that which employers, in fact, provide for their employees.
  As a matter of fact, incorporated in this bill is a disincentive for 
small business success. I am not sure everybody has read to that point 
in the bill yet, but for a company that today can't afford, because of 
their competition to offer health care--the day they hire their 51st 
employee, the Federal Government will send them a tax bill of $38,250. 
At a time when we have 10.2 percent unemployment, 11 percent in North 
Carolina, small business is going to be the engine of job creation in 
this country, and we are saying as soon as you are successful enough 
that you hire the 51st person, if you don't offer the health care we 
tell you you have to offer, we are going to send you a tax bill of 
$38,250.
  Unfortunately, it doesn't stop there. For the Medicaid beneficiaries, 
for the Medicare beneficiaries, for everybody in America where we have 
said drugs are too high, devices are expensive, innovation costs money, 
what are we going to do? We are going to tax drug companies. We are 
going to tax medical device companies. We are going to actually raise 
the cost of our ability to detect something earlier, where our options 
are greater and, hopefully, through having those options earlier, in 
fact, we are going to be able to treat a disease or cure it much 
cheaper.
  I might add it is somewhat ironic that we are going to tax vaccines 
at a time when the industry is trying to meet the needs for vaccines 
for H1N1 across this country. This bill puts a new tax on the vaccine 
industry we have tried to revitalize in America.
  Let me suggest to my colleagues, this is not a health care bill. This 
is a layaway plan. In fact, what we have been presented is a plan where 
they are asking Americans to pay for it for a number of years--4, to be 
exact--before they get their product. We are going to pay in, in taxes; 
we are going to pay in, in Medicare shift; we are going to begin to 
increase the rolls in Medicaid, to wait 4 years down the road before we 
get the product, before we get any benefit out of it. What we are going 
to find 4 years down the road is that costs change. You see, it sold as 
a $849 billion plan today, an $849 billion health care reform package. 
Well, that is not what it is. If you look at it truly over 10 years, it 
is a $1.2 trillion plan. If you wait to start until the benefits are 
paid and look at it for a real 10 years of revenue and benefits, it is 
a $2.5 trillion plan.
  We can't even be honest enough with the American people that we tell 
them exactly what it is going to cost. But you would expect that out of 
a layaway plan, and, in fact, that is what we have in front of us.
  Let me suggest to my colleagues that if you reform health care, you 
can have coverage expansion without additional taxpayer investment. You 
can't take the things that are broken in our system and actually 
increase their use, such as Medicaid, and expect at the end of the day 
you are going to be able to save money, provide a better level of care; 
more importantly, that you are going to have a population that gets the 
benefits everybody else does: a medical home, preventive care, chronic 
disease management. It doesn't happen in Medicaid today. It will not 
happen when you increase the rolls of Medicaid. It will only happen 
when you reform health care, and this bill does not do it.
  I thank my colleague from Tennessee.
  Mr. CORKER. Our colleague from North Carolina has worked extensively 
on this issue. I think we have a couple Senators who have some business 
off the floor that is very important. I think Senator Barrasso may be 
one of those, and I think Senator Johanns is in the same boat. I know 
as a physician, the Senator actually knows something about health care.

[[Page 28750]]


  Mr. BARRASSO. Twenty-five years taking care of families and the 
people of Wyoming. I have taken care of people on Medicaid and 
Medicare. We heard from Senator Burr about North Carolina and Medicaid 
as well as Medicare and I have concerns about both. I take care of all 
patients, regardless of their ability to pay. So what we know right now 
is that the Mayo Clinic--and the Mayo Clinic in Rochester, MN, has been 
held up in the Senate by our colleagues. It has been held up by the 
President of the United States as the model for what we should try to 
get to do in America for health care. The Mayo Clinic has now told 
Medicare and Medicaid patients they are not welcome. It has put out the 
sign: No vacancies for you. It is astonishing. It is hard to believe 
the Mayo Clinic would say: No thank you, we don't want you, but they 
have done that.
  Mr. CORKER. So I guess if you had Medicaid, it is kind of like, in 
many cases, you have something that is not usable; is that correct? I 
know Senator Alexander has spoken to an analogy in the past in that 
regard, but it makes it pretty difficult if you are a Medicaid 
recipient.
  Mr. BARRASSO. As the senior Senator from Tennessee said, it is like 
having a bus ticket when no bus is coming. Others commented in the 
paper that it is like putting more people into a sinking ship.
  Why would the renowned Mayo Clinic not want to see these patients? 
They are sending out letters saying if you are from these surrounding 
States--Wyoming and others in the Midwest and the Rocky Mountain West 
send many patients there--you cannot do it. The Mayo Clinic is able to 
provide the kind of care they do because they take very few Medicaid 
patients, they take very few Medicare patients, and they take people 
who have insurance. That is why we know premiums go up when more people 
are on Medicaid. There are actually two hospitals in Rochester, MN--
Mayo Clinic, where 5 percent of their patients are on Medicaid. At the 
neighbor hospital in the same community, it is 29 percent of their 
patients.
  The hospitals in Tennessee cannot take everybody out of town. We have 
to take care of those people. When reimbursement is so low by the 
Federal Government, which is the biggest deadbeat payer in the world 
when it comes to health care--the deadbeat Federal Government pays so 
little, the Mayo Clinic wants nothing to do with them. That is why they 
came out against these proposals.
  Harvard Medical School gave these proposals a failing grade and said 
people who support these are collectively in denial, because they know 
we are looking at a health care bill that will raise the cost of care, 
to be paid for by raising taxes and cutting Medicare for seniors. Our 
seniors on Medicare cannot even get into the Mayo Clinic. It is 
fascinating. Mayo set up a branch in Arizona. They say they will no 
longer accept Medicare for patients seeking primary care at its 
facility in Arizona: We don't want them. No vacancies for you. If you 
want to come in, you have to pay additional fees--a $250 annual fee 
plus anywhere from $174 to $400 a visit if you are on Medicare.
  Mr. CORKER. I assume that by the Reid plan taking $464 billion out of 
Medicare savings and not using that money to deal with this huge doc 
fix issue--the fact that physicians are going to have a 23-percent cut 
in a year, they are not dealing with that. I know it costs about $247 
billion to keep them whole. I assume that would keep many physicians, 
such as the Senator's former colleagues from--it would cause them to 
drop Medicare recipients, is that correct?
  (Mr. LEVIN assumed the Chair.)
  Mr. BARRASSO. It will absolutely prevent new Medicare and Medicaid 
patients from getting in. The Medicare cuts will prevent doctors from 
taking new patients and may cause them to drop others. The concerns are 
so large, and the concerns aren't just for the doctors. I am concerned 
for the people in Wyoming, who depend upon Medicare for health care. I 
know the Senator is concerned for them in Tennessee. How will they get 
the care they need? More people are coming of Medicare age every day.
  This big bill, this monstrosity, will cut close to $500 billion from 
people who depend on Medicare for their care. The American people--
those watching--need this care. But this takes it away to start a whole 
new government program. It is not fixing the program that is going 
broke already.
  So the hard reality is--and I think the spokesperson for the Mayo 
Clinic said it well. She said that ``it simply is the reality of the 
health care business and how we are going to be able to continue our 
mission when these payments are so far below what it costs to provide 
the care.''
  You are not even talking about staying open, keeping the doors open, 
breaking even. The reimbursements are so far below what it even costs 
the Mayo Clinic--the model being held up by Senators on the other side 
of the aisle--so far below what it costs them to provide care. So as we 
look at this and say how can we take care of and help the people of 
America get health care, quality care, what we need to do is be aimed 
at driving down the cost of care. This means an increase of the cost of 
care and premiums. They are going to do it by raising taxes, and 
everybody will be affected. The Senator from North Carolina, a State 
with an incredible background in technology and advances in medical 
devices--anything that taxes them will be passed on to everybody, 
regardless of income level. Every patient in America will suffer. The 
Mayo Clinic--the world-renowned Mayo Clinic, where anybody in America 
would like to go for their care--I heard the Senator from Tennessee 
say, in addition to what the Senator from North Carolina said, that 
people in his State want to have the same level of care you would have. 
We would all want that. The Mayo Clinic says if you are on Medicare or 
Medicaid, like many of the other States, don't come here, because we 
cannot afford to have you, because Washington--the biggest deadbeat 
payer of all time--isn't paying enough to keep our doors open.
  Mr. CORKER. I know to the people in Tennessee this doesn't pass the 
commonsense test--a whole new entitlement when we cannot take care of 
the ones we have. I know the people in Wyoming are also that way. The 
people in Tennessee know this bill will cause the private insurance 
they now have to go up, which is exactly the opposite effect Americans 
want. We have a former Governor here, who has important business off 
the floor in a minute. He has run their Medicaid Program. He wants to 
speak to this issue. I thank the doctor, Senator Barrasso, somebody who 
actually knows about health care, for being here to talk about this 
issue.
  Mr. JOHANNS. I thank Senator Corker on behalf of not only myself but 
the folks back home in Nebraska for giving me a few minutes today, and 
I also thank Dr. Barrasso. When he talks, I want to listen. I am so 
tempted to yield my time to him because he is so knowledgeable in this 
area. I do have a few things I want to say.
  It occurs to me that after the vote tonight, what we should do is 
declare a recess for 2 weeks. We should take this bill out across our 
States and listen to the people. We should listen to the doctors, like 
Dr. Barrasso, who are on the front lines every day. We should listen to 
the nurses and hospital administrators and say: What do you think? I 
think we would get an earful.
  I did four townhall meetings during the short recess around Veterans 
Day on health care issues. I have been all over the State of Nebraska. 
Let me tell you a story--and every single Senator can tell this same 
story. I visited a small hospital in our State, the critical access 
hospital--and Dr. Barrasso is familiar with these. Under Federal law, 
these hospitals are 25 beds or under. They are in our small 
communities, not only in Nebraska but all across America. They have no 
margin for error, because all they do is hospital services. They don't 
have an exercise program or whatever. It is hospital care they provide. 
I asked the same questions to those doctors and administrators. I would 
say: Let me ask you, first, could you run this hospital and

[[Page 28751]]

keep it open on Medicaid reimbursements? It was 100 percent unanimous: 
We would go broke.
  I asked a second question: Could you keep this hospital open on 
Medicaid and Medicare reimbursements? It was 100 percent unanimous. 
They say: No, we would go broke.
  What does this bill do? It expands Medicaid. Fifteen million people 
will be added to Medicaid--the largest single expansion in Medicaid in 
the program's history. Nearly half of the reduction of the uninsured in 
this bill is due to moving people onto Medicaid, a program that if you 
had to live on those reimbursements, and you were a critical access 
hospital, you would close your doors. That is shocking to me. Who were 
they listening to when they wrote this bill? Why can't we take these 
staff people, who have been holed up in the majority leader's office 
for 6 weeks, to Nebraska or Wyoming or Oklahoma or Tennessee or Texas? 
It makes no sense to me.
  I came here saying I was going to work to solve real problems for 
real people. We say that a lot out there. Let me give you a real people 
perspective about my State. Again, every Senator can tell this story. I 
was in a beautiful little community hospital--a critical access 
hospital, with 25 beds or less--in Valentine, NE, in a beautiful part 
of our State along the northern tier. It is a beautiful area, the 
Niobrara River Valley. There are great people there. It is off the 
interstate. It is a beautiful part of our country. Pick up a Nebraska 
map, because when I say this--if you look at the map, it will bring 
home what I am talking about. Between Chadron, NE, in the northwest 
part of the State, and O'Neill, NE, closer to the north central part of 
the State, lies Valentine. That little hospital in Valentine is the 
only hospital in that northern area that is providing deliveries for 
babies.
  When you pass this bill and you expand Medicaid that they can't live 
on, and the reimbursement rates are disastrous for them--if you mess 
around with that hospital's ability to deliver babies, you have a 
crisis in the northern part of my State. You can tell that story over 
and over.
  I wanted to talk about this last thing, and I will do it quickly, 
because other colleagues want to speak. As a former Governor, I dealt 
with Medicaid to try to balance the budget. I was the Governor in 
Nebraska post-9/11, when our economy and the Nation's economy tanked. 
We had to cut budgets over and over. My State of Nebraska just finished 
a special session. They cut about $300 million from the State budget. 
Four hundred people, the Associated Press reported, will lose their 
jobs because of these very difficult budget decisions.
  Here is the point I want to make: When this is fully in effect, we 
will drop into the States--my State included--billions of dollars worth 
of unfunded mandates for Medicaid--billions of dollars in a program 
where already 35 to 40 percent of our doctors cannot afford to take 
Medicaid patients, and they are saying: We would go broke if we had to. 
We are adding insult to injury by telling our Governors they have to 
figure out that in addition to the historic problems they are having 
with their budgets, they have to deal with an unfunded mandate. In a 
moment of candor, one of my colleagues who worked on this for years 
said something when I asked: Why Medicaid? It is so problematic. Why 
all these millions on Medicaid? In a moment of candor he said to me: 
Because it makes the score look better.
  Mr. CORKER. Yes, it is the cheapest route for us and the most 
expensive way for the States. This has been mostly about moving money 
around. I have not seen a lot in here that has a lot to do with reform. 
I appreciate the comments about Medicaid and what it will do to your 
State. After having been a Governor, I know that Dr. Coburn, the 
Senator from Oklahoma, is here, and we have the Senator from Texas, who 
has been highly involved in every health care meeting we have had. 
Senator Hatch helped create SCHIP years ago. I think he knows that in 
this bill not only is there an unfunded mandate for Medicaid, not only 
are there taxes and Ponzi schemes, such as the CLASS Act, that have 
been put together, it doesn't fund an existing program such as SCHIP. 
That is another huge burden of $40 billion or $50 billion. I don't know 
if Senator Alexander wants to speak to that. I thank Senator Johanns 
for being here. I know he has a meeting off the floor.
  The PRESIDING OFFICER. The Senator from Texas is recognized.
  Mr. CORNYN. I express my gratitude to the Senator from Tennessee for 
leading this important discussion on Medicaid. If I can pull back for a 
moment, I think it is important because this is such a complex subject, 
as we can see from this 2,074-page bill. We need to define our terms. 
Medicaid, obviously, is a program for low-income people, shared by our 
State and Federal Governments. Medicare is for seniors, paid for 
entirely by the Federal trust fund, $38 trillion in unfunded federal 
liabilities to two entitlement programs, both of which are in terrible 
financial shape. Rather than make this better, this bill makes it 
worse. I will describe very quickly how in my State of Texas. I have 
watched on C-SPAN and on the floor Senators come here and say tonight 
we are having merely a procedural vote on whether to proceed to the 
debate.
  I thought we had been having a debate about health care reform for 
the last year or so. I point out that under the Senate rules, we will 
not be able to change one period, one comma, one sentence, one part of 
this bill unless we can get 60 votes to do so. So the increase in 
premiums, the taxes on small businesses and the middle class, the cuts 
in Medicare, this expansion of Medicaid--all of these are a fait 
accompli unless 60 Senators vote to change it. That is under the rules 
of the Senate.
  It is not true, in my humble opinion, that people can come in here 
and say: We are going to vote yes to proceed tonight at 8 o'clock, but 
it doesn't make any difference, the debate is just beginning. Not so.
  I again thank the Senator from Tennessee for raising this concern. 
Both of our Tennessee colleagues have been in the forefront of 
discussing this issue.
  I think this is shameful. The expansion of Medicaid in this bill to 
cover 60 million Americans is shameful. It consigns people to a health 
care gulag which they cannot get out of, where they get bad outcomes in 
terms of their health care, where they cannot find doctors who will 
treat them at the low rates paid for by Medicaid, and it bankrupts our 
States.
  The Medicaid officials in Texas have told me, after their preliminary 
review of this 2,074-page bill, it will cost Texas taxpayers, in 
addition to their Federal liability, $20 billion over the next 10 
years.
  Our friends who have been Governors have told us, as Governors and as 
State legislators, they have to make terribly hard choices. But when 
the Federal Government imposes an unfunded mandate on the States to 
pick up $20 billion over the next 10 years, what does that do to our 
ability to do other things, such as law enforcement, higher education, 
and the like? It shoves those to the side because the Federal 
Government is going to jam this down the States' throats--another 
unfunded mandate--and it disrupts those States, as the Senator says, 
that are operating on balanced budgets. They do not have the luxury of 
printing money like the Federal Government.
  Mr. CORKER. Mr. President, did the Senator from Texas see this 
weekend where college students in California were having public 
protests about the huge increase in tuition out there? Yet here we are 
getting ready to pass something that is going to drive that up even 
more because the State of California will have to cover more Medicaid 
recipients without the money being provided. So this is going to 
exacerbate that situation. I don't know if the Senator saw it this 
weekend.
  Mr. CORNYN. The Senator is correct. It is a 32-percent increase in 
fees and tuition, and that is in California alone, which is bankrupt 
already. This is the direct result of the irresponsibility coming out 
of Washington, DC, forcing more costs on them.
  I know there are other colleagues who want to talk about this topic, 
and

[[Page 28752]]

I want to have this continued conversation. I think this is a good 
format for parsing what is in this bill.
  Let me mention one anecdote in Dallas, TX. If you are a Medicaid 
recipient, or a low-income child or beneficiary in Dallas, TX, only 
38.6 percent of the doctors will see a new Medicaid patient--38.6 
percent. In other words, 61 percent will have restricted access to 
Medicaid because, as the Senator from Tennessee and the Senator from 
Wyoming pointed out, it only pays about 72 percent of what a private 
insurance policy would cover.
  Mr. President, 85 percent of Americans have private insurance, and 
they pretty much like what they have. They think it costs too much, and 
we agree. We want to help them bring down that cost. But we have these 
safety net programs which, frankly, do a lousy job. They promise 
coverage, but they deny access because of low reimbursement rates.
  Let me give an anecdote of what this means to 6-year-old Ruth Guerra 
in Dallas, TX. I took this article from the Dallas Morning News, dated 
June 3. It says:

       When Ruth Guerra, 6, tries to write, holding the pencil 
     puts just enough pressure on her left pinky to make it bleed. 
     With her condition, if she falls down while playing or a 
     classmate accidentally brushes against her, she bleeds.
       Last week [her mother] Sandra Ramirez . . . took time off 
     from her hourly job at the Dollar General after another one 
     of Ruth's bleeding episodes.

  Unfortunately, because she qualifies for Medicaid--and while people 
in Washington say: Isn't it great; we are going to give 60 million 
people Medicaid--what it means for Ruth Guerra is that she has to wait 
6 months to get an appointment with a doctor who will actually see her. 
That is what I mean when I say this bill consigns 60 million people to 
a health care gulag they cannot get out of.
  I agree with the Senator from Tennessee. We need to provide the 
American people with choices that Members of Congress have, among an 
array of choices. What this does with the mandates, with the force-
feeding Medicaid on people such as Ruth Guerra and on the States, along 
with the huge budget deficits that are going to come from it is 
shameful.
  Mr. CORKER. I thank the Senator for his contributions, being down 
here on a Saturday on a very important issue. I know Senator Coburn is 
here. Senator Alexander is here. I don't know what order they may want 
to speak. It looks like it is Dr. Coburn.
  Again, each Monday, typically in his State, he is actually seeing 
patients. He knows something about Medicaid. He knows something about 
health care. Many of the reforms he put forth would give people a 
choice, low-income citizens a choice like we have. But, instead, this 
bill confines them to Medicaid. I know he is going to talk about that.
  I thank the doctor very much for being here.
  Mr. COBURN. Mr. President, I thank Senator Corker.
  I have had the distinct pleasure of delivering over 2,500 babies for 
Medicaid insurance and taking care of their children. These are 
wonderful folks. I didn't do any differential between Medicaid and 
private insurance in my practice, but most of my colleagues did.
  The heartbreaking part about Medicaid is that when you have a sick 
child who needs a specialist, you cannot get one. You just cannot get 
one. You say: Why can't you? Do they not care? Yes, they care. But you 
know what. Because of the Medicaid reimbursement for pediatric 
subspecialities--pediatric cardiologists, pediatric oncologists, 
pediatric hematologists--there are not any.
  We only have two pediatric cardiologists in the city of Tulsa serving 
1.9 million people. Try to get an appointment for a Medicaid patient 
there. I can hardly get a regular one. How did that happen? The reason 
we have a shortage of pediatric subspecialities is directly related to 
the Medicaid system in this country because the reimbursement is so low 
that you cannot afford to have a high percentage of Medicaid patients 
in your practice and still pay your bills.
  So what consequently has happened is doctors do not go into 
pediatrics, and then they do not go into the subspecialities of 
pediatrics. So I end up having 8-month-old children seen by adult 
cardiologists or adult hematologists because there is no available 
doctor to see them because we have created a system through the 
substandard reimbursement of Medicaid that has directed people coming 
out of medical school away from that speciality.
  As a matter of fact, last year, if you take all the medical students 
who graduated from medical college, whether it is osteopaths or 
allopaths, M.D.s or D.O.s, 1 in 50 went into primary care. That is 
general internal medicine, family practice, or pediatrics, only 1 in 
50.
  We have 50 million baby boomers going to hit Medicare in the next 
7\1/2\ years, and we are not going to have the primary care doctors 
there to take care of them. The reason is because through government 
programs, we have incentivized doctors not to do primary care. 
Consequently, we don't get there.
  The other point I will tell you is that if you look at perinatal 
mortality rates in our population across the country, it is, No. 1, 
directly related more to poverty than it is to anything else. But the 
second most important factor is that if you are in Medicaid, you are 
twice as likely to have a perinatal mortality event--in other words, 
your child dies after childbirth--than if you are in private insurance. 
It doesn't matter what your culture is. If you are poor, but you have 
private insurance, the likelihood your baby is going to do better is 
greater.
  Think about that: a promise we are going to give you care, but the 
result of the care is going to be less good. We are going to give you 
care, but it is not as good care, and it is not available care. We are 
going to make you wait in line, but we are going to call it care.
  Care delayed is care denied. Let me say that again. Care delayed is 
care denied. If, in fact, you have a problem that needs attention, and 
you cannot get what you need, it does not matter what Medicaid does if 
you cannot get treatment.
  If you look at the subspecialities in Medicaid, 65 percent of them do 
not see Medicaid patients. We have about 40 percent in primary care who 
will not see a Medicaid patient. We have about 65 percent of the 
specialities, because there is such a shortage in the specialities, 
that what we are saying is we are going to have 60 million people in a 
system that says: You get care, but guess what. It is not available; 
you are on Medicaid.
  Senator Wyden did offer a plan, I say to Senator Corker, that would 
put every Medicaid patient in this country, except dual eligibles, into 
private insurance. So did we with the Patients' Choice Act, the first 
bill introduced on our side of the aisle. We take the stigma off saying 
you have a low-paying plan, and we give them the same kind of insurance 
we have right here in this body. By doing it, we save the States $1 
trillion over the next 10 years. Think about that.
  But that isn't nearly as important as we have a major increase in the 
positive outcomes for Medicaid patients. You cannot talk about Medicaid 
without talking about Indian health care because as you add up Medicaid 
to Medicare to TRICARE to VA to Indian health care, when you add all 
that up, the government is running 61 percent of our health care right 
now. No wonder we are in trouble.
  I do not deny there are big problems with the insurance industry. I 
do not deny we need a Patients' Bill of Rights that protects people's 
rights and their interests. I do not deny we need transparency in the 
insurance industry both on price and quality. I do not deny anything.
  The question we ought to ask is, if we are going to truly reform 
health care, are we going to allow everybody, when they say they have 
health care, no matter where they get it, to have an equal shot at 
getting equal care?
  You see, this bill does not do that. This bill puts Medicaid patients 
in jail and says: If you happen to be lucky enough, the lucky 60 
percent to get into the line, you will be OK. And if you need a 
subspecialty, if you happen

[[Page 28753]]

to be part of the lucky 35 percent, you will be OK. But everybody else 
is in jail. You are in monopoly jail. We are promising--the 
government--to do that.
  A final point--and then I will yield so others can talk--is the idea 
that my State--Texas is a big State. It is our southern neighbor. They 
sometimes have a better football team than we do. They certainly did 
this year. We are about one-eighth the size of Texas in terms of 
population. We cannot afford $2.8 billion over the next 10 years, I say 
to Senator Cornyn. We are going to say we are going to cover 15 million 
people and some of those will be in Oklahoma. We cannot afford it.
  What we can afford is to insure them if we make true changes in care, 
if we truly change and incentivize preventive care, management of 
chronic disease--if we truly reform health care. These bills do not 
reform health care. What they do is grow government.
  They are not going to change outcomes, other than except they are 
going to limit what you can and cannot do through cost-effective 
comparativeness.
  As we look at this bill, what we need to do is think about those we 
are going to promise something we are not going to deliver. We are 
going to call it a system, but they are not going to have it available.
  I thank Senator Corker for leading this discussion, and I yield.
  Mr. CORKER. I thank Dr. Coburn. As I listen to him, I realize we have 
a health care reform bill before us where half the money, $460 billion, 
is taken from a program that is insolvent. Instead of making it more 
solvent--a program that would take $38.6 trillion in the bank today, 
earning Treasury rates to make it solvent--it is a pretty big number--
we are taking $\1/2\ trillion out of that program to leverage a new 
entitlement. The reform we are getting out of that is we are moving 
half the folks into a program that not a person in this body would want 
to be a part of; is that correct?
  Mr. COBURN. That is correct.
  Mr. CORKER. That is not the kind of health care reform I thought we 
were going to be doing. I am shocked. As a matter of fact, as I said 
many times, I don't think there is a person on the other side of the 
aisle who would vote for this bill if you and I offered it; do you 
think that?
  Mr. COBURN. Probably not. But the Senator sparks one question. Think 
about this, and I have experienced this as a physician.
  I care for patients and they lose their job, they have a financial 
catastrophe, and all of a sudden they become dependent on Medicaid. We 
continue to see those patients. But do you know what normally happens? 
You lose your insurance, you loss your job, you come on hard times and 
go on Medicaid. You can't go back to the doctor you had before because 
they are not taking new Medicaid patients. So somebody you have been 
with for 15 years, all of a sudden you can't get back in because they 
are not going to pay enough for them to care for you. It is a 
discriminatory system that says we will send you down the line.
  That doesn't mean there are not truly caring physicians in this 
country, but it has to be said, outside of pediatrics, if you want to 
look at quality parameters, the Medicaid population ends up going to 
the less-qualified, the less-experienced, the less-good-outcome 
physicians in this country.
  Mr. CORKER. I thank the doctor. It is so good to hear from somebody 
who has dealt, year after year, with Medicaid recipients with his 
compassion.
  Senator Hatch from Utah, I don't think there is a person in this body 
on this side of the aisle who has spent more time trying to make sure 
the poor children of our country have health care. No one has done 
that. I know he is here to speak today about this huge Medicaid 
expansion. I thank the Senator for the leadership he has shown in this 
body for years, ensuring that young children in this country have 
appropriate health care.
  Mr. HATCH. I thank my colleague for leading out here, talking about 
this very important issue. You and your senior colleague from Tennessee 
are great Senators and mean a lot to all of us.
  It is funny to me that the people in this body don't listen to the 
only two doctors in the body, and both of them are excellent 
physicians. Both of them are concerned about people. Both of them make 
such cogent arguments in the field of health care. I think we have had 
a very good argument by Senator Coburn, from Oklahoma--one of our two 
doctors in the Senate.
  Senator Barrasso is an orthopedist, a specialist. He has come here to 
fight for the causes he believes to be right. He knows what is trying 
to be put off on America today is not right.
  Our States are facing a historic deficit of more than $200 billion 
right now. Yes; that is what our States are facing right now without 
this bill. One of the biggest drivers behind this is the Medicaid 
Program, which takes up an increasing share of our States' budgets 
across the country.
  The Senate bill, which is nothing more than a 2,074-page takeover by 
Washington of our health care system, calls for the biggest Medicaid 
expansion ever--133 percent of the Federal poverty level. That is 150 
percent in the House bill, if we pass that monstrosity.
  My home State of Utah only allows Medicaid coverage of up to 133 
percent of the Federal poverty level for infants, children under the 
age of 5, and pregnant women. Other categories of citizens are, 
however, covered at different levels. For example, nonworking parents 
are only covered up to 48 percent of the Federal poverty level.
  This bill will now massively expand the level of Medicaid coverage to 
133 percent for everyone. Who is going to pay for that? Our colleagues 
say the Federal Government will. What are they going to pay for it 
with? We are running the Federal Government right into bankruptcy. It 
is ultimately going to be the responsibility of the States and the 
States can't do it. Think of New York, New Jersey, California, just to 
mention three. Let's not forget that the House has already passed a 
Medicaid expansion of 150 percent of the Federal poverty level. The 
Congressional Budget Office estimates this massive entitlement 
expansion will cost States an additional $25 billion over the next 10 
years.
  You heard me right, $25 billion more. That is over the next 10 years.
  However, if history has taught us anything about the way things work 
in Washington, I believe this number is actually a huge underestimation 
and the real impact on our States will be much higher. I would like to 
read the following excerpt from a letter sent to me by Governor 
Herbert, our Governor in the great State of Utah, and what this 
Medicaid expansion would mean for my State. It is a quote. This is what 
my Governor has to say:

       As I am sure you know, Utah, like most other states, is 
     suffering from the negative impacts of nationwide recession. 
     As we prepare the state's fiscal year 2011 budget, we face 
     continued cuts to agency budgets and reduced government 
     services on top of painful reductions made last year. The 
     unfunded mandate of a forced Medicaid expansion will only 
     exacerbate an already dire situation. If required to increase 
     our Medicaid program as envisioned in Washington, Utah, and 
     most every other state, will be forced to find the money to 
     do so through other means. This will require states to either 
     raise taxes or continue to cut budgets in areas currently 
     suffering from a lack of funding, such as public and higher 
     education.

  We are seeing a real life example of this in California right now. 
Faced with a mounting State budget crises, we recently saw that the 
State-run University of California system had to hike its tuition rates 
by 32 percent--32 percent!
  I don't know about anyone else, but I will not allow this to happen 
in my home State of Utah just because Washington thinks it is a good 
idea to keep expanding government programs on the back of our States.
  Here is the reality that our States are facing:
  Unemployment rates rose in 29 States in October. A significant number 
of States are facing unemployment rates much, much higher than our 
national rate of 10.2 percent--the highest in 26 years: Michigan, 15.2 
percent; Nevada, 13 percent; Rhode Island, 12.9 percent; California, 
12.5 percent. In fact, California, Florida, Delaware and

[[Page 28754]]

Washington, DC, posted their highest unemployment rates since 1976.
  The last thing we need right now is for Washington to impose more 
liability on the states.
  This alone should be a reason enough for every Senator to stop and 
rethink their decision about letting this ``tax and spend'' bill move 
forward.
  But I have to tell you, I know what is behind all this. Ever since I 
have been here, there has been a push to have more and more people 
moved into Medicaid. Why is that? Because if they can push more and 
more people into Medicaid, then ultimately we will have a single-payer 
system--in other words, socialized medicine in this country, where the 
government will control everything. That is what is behind a lot of 
this bill.
  I have to tell you, what bothered me an awful lot about this bill is 
that even the CBO Director, whom I find to be an honorable, honest man, 
Dr. Elmendorf, he said that if we go to a government plan--which is a 
hallmark of what our friends on the other side want to do--then you 
could have almost 10 million people going into that plan. However, if 
you look at the Lewin Group study, they say if you go to a government 
plan, we could have 119.1 million people going into the new plan.
  What is it going to be, the 10 million or the 119.1 million? I 
guarantee it is going to be a lot closer to the 119.1 million than it 
will be to the 10 million.
  Our friends on the other side started criticizing the Lewin Group 
after this report. They have quoted them for years before this report. 
Now that they don't agree with our colleagues on the other side, they 
think it will only be 10 million. Don't kid yourselves. If you had to 
choose between the 10 and the 119 million, you know doggone well it 
will be closer to the 119.
  If we move millions of more people over from private insurance into 
government health care, I can't tell you the pressure that will be on 
America, the pressure that will be on the health care professionals.
  We heard from one of the great doctors in this body, whom we ought to 
listen to, that we can't get the primary care people to take care of 
people now on Medicaid, let alone adding millions more under this 
expansion.
  I thank my colleague from Tennessee for his leadership on this. I am 
happy to be here to say a few things about it because I have spent a 
lifetime working on health care issues. Before I ever got here, I 
actually tried medical liability and defense cases, defending doctors, 
nurses, hospitals, health care providers. I know what these costs are. 
They are just beginning to explode.
  If this bill passes, it is going to be an explosion of health care 
costs such as we never dreamed possible.
  I am very concerned about this. It is all driven by a desire to get, 
right here in Washington, control over all of our health care. If we do 
that, we deserve the problems we are going to have.
  I thank my colleagues for the great work they are doing.
  Mr. CORKER. I thank the Senator very much for coming. No one in this 
body knows more about what is happening in public programs than he. We 
heard for the last 55 minutes from the Senators from Texas, Oklahoma, 
Wyoming, Utah, North Carolina, Nebraska. I can't think of a better 
person to close us out this afternoon than the distinguished Senator 
from Tennessee. I am fortunate to serve with this Senator. He was a 
Governor, an education Secretary. He knows what he is talking about. I 
am proud the senior Senator from Tennessee is going to close us out on 
what I think has been an outstanding hour on the floor.
  Mr. ALEXANDER. Mr. President, for those who are watching, Republican 
Senators are reading through the bill, reading the bill in its 
entirety. It is kind of like reading the entire New Testament in Greek. 
It is better to have somebody help interpret it. We have been talking 
about page 396, title II, subtitle A, section 2001, which expands 
Medicaid. We have heard eloquent statements about how moving 15 million 
low-income Americans into a program called Medicaid, which is a medical 
ghetto, is not health care reform. We have also heard Senator after 
Senator say what right do we have to expand Medicaid and tell the 
States that you are going to pay for it. What kind of arrogance do we 
have to say that to States that are in their worst fiscal condition 
since the Depression?
  The Reid bill requires states to expand Medicaid eligibility to cover 
all persons under 133 percent of poverty, which means those earning 
about $14,000 per year for an individual and about $29,000 per year for 
a family. Individuals who are not otherwise covered by an employer-
sponsored insurance would not be eligible for tax credits. In effect, 
every American below 133 percent of poverty would be locked into 
Medicaid which is like confining them to a medical ghetto. With this 
bill we are on path to expand the largest ``public option'' we already 
have, Medicaid, and it could bankrupt the States, because they will be 
paying for it. As the former Governor of Tennessee, I do not see how 
Tennessee can pay for their part of the Medicaid expansion included in 
Senator Reid's health care bill without a new income tax, or seriously 
damaging higher education by raising tuition like California just did, 
or both.
  I am opposed to this expansion of Medicaid, which, according to the 
CBO, would cost States an additional $25 billion, and add 15 million 
people to the Medicaid Program. This would be the largest single 
expansion of Medicaid in the program's history. Why? Because nearly 
half of the reduction of the uninsured in the Reid health care bill is 
due to people moving into the government-run program that is Medicaid.
  Expanding Medicaid to cover uninsured individuals is a terrible 
vehicle for health care reform, because dumping this many more people 
into that program will increase problems for beneficiaries getting 
access to care and for maintaining quality. Plus the program is already 
riddled with fraud and abuse; this would just invite more of that. Most 
Governors are struggling with Medicaid in its current form, and they 
agree that expansion is a bad idea. This includes Democratic Governors.
  Tennessee's Medicaid Program is called TennCare. The Tennessean from 
Thursday printed an article that reports how ``People covered by 
TennCare may face new limits on their coverage and reductions in their 
benefits next year, under a plan unveiled Wednesday to help slice state 
spending.'' The article continues, ``The limits are meant to help 
TennCare, the State's Medicaid program for the poor, pregnant women and 
children, meet Govenor Phil Bredesen's goal of reducing spending by 
most State agencies by as much as 9 percent as the State deals with a 
shortfall in tax receipts that could reach as much as $1.5 billion over 
the next two fiscal years.''
  If the Reid health care bill is passed, TennCare might introduce a 
$10,000 annual cap on hospital coverage for the 1.2 million enrollees. 
Additionally, they might also eliminate coverage for occupational, 
speech and physical therapy, and limit enrollees to no more than 15 
outpatient procedures and 15 lab procedures in a year. This past 
Sunday, the Tennessean ran another story titled, ``Bredesen faces 
painful choices as TN begins budget triage'' which states ``there is no 
quarrel with the general position that Tennessee State Government faces 
a grim situation'' and the Governor anticipates that roughly $750 
million in cuts will be needed for the next fiscal year. To make 
matters worse ``state tax collections are already $101.3 million less 
than assumed when this year's budget was enacted.''
  Another article from the Tennessean reported that the State ``might 
release as many as 4,000 non-violent felons, possibly even including 
people convicted of drug dealing or robbery, under a plan outlined 
Monday by the Department of Corrections to deal with the state's budget 
crisis,'' and Tennessee is not alone in its budget crisis. Even though 
many States are going through budget crises much like Tennessee, 
Senator Reid has proposed to as even more costs onto these States. 
Earlier this month, the National Governors Association released a 
fiscal survey of the States and an accompanying release, ``The State 
Fiscal Situation: The Lost Decade.''

[[Page 28755]]

  That report said:

       The recent economic downturn started in December 2007 and 
     likely ended in August or September 2009, making it one of 
     the deepest and longest since the Great Depression.

  It went on to say:

       Medicaid spending, which is about 22 percent of state 
     budgets, averaged 7.9 percent growth in FY 2009, its highest 
     rate since the end of the last downturn six years ago. 
     Medicaid enrollment is also spiking, with projected growth of 
     6.6 percent in FY 2010 compared with 5.4 percent in 2009.

  We don't yet have an estimate from Tennessee of how much Senator 
Reid's bill will cost the state, but we expect it to be in the ballpark 
of what the Senate Finance bill would have cost, which according to 
Governor Bredesen would have cost an additional $735 million over 5 
years. Tennessee can't afford to get a $735 million bill from 
Washington. Not only is it wrong to ask states to pay for expanding 
this program, but I think it is wrong to dump low-income Americans into 
a government-run program that is failing.
  Medicaid is a program that, if given the choice, none of us would 
join. A 2002 Medicare Payment Advisory Committee survey found that 
``approximately 40 percent of physicians restricted access for Medicaid 
patients,'' meaning they won't take new Medicaid patients, because 
reimbursement rates are so low. Only about half of U.S. physicians 
accept new Medicaid patients, and yet this is how the majority leader 
proposes we cover the uninsured.
  Why is there such an access problem for people on Medicaid? It is 
because Medicaid reimbursement rates to doctors and hospitals are so 
low. Medicare pays 80 percent of what the private insurers pay and 
Medicaid pays about 72 percent of what Medicare pays. Which means if 
you are a doctor or a clinic, or a hospital, you get paid about 60 
percent for serving a Medicaid patient versus one of us who has his or 
her private health care. You can see why this spells trouble, and the 
Senate bill does nothing to fix this problem. In fact, by dumping 15 
million more people into the program it will only make things worse. 
Who would want to be one of those 15 million people?
  In addition to access problems, the quality of care for Medicaid 
patients is significantly lower than those with private insurance, and 
even those with no insurance. According to a survey by the National 
Hospital Ambulatory Medical Care, Medicaid patients visit the emergency 
room at nearly twice the rate of uninsured patients, and a 2007 study 
published in the Journal of the American Medical Association found that 
patients enrolled in Medicaid were less likely to achieve good blood 
pressure control, receive breast cancer screening, or have timely 
prenatal care than similar patients enrolled in private plans. Another 
study of cancer patient outcomes found that even after adjusting for 
patients who became eligible as a result of their cancer diagnosis, 
Medicaid patients have significantly lower survival rates than non-
Medicaid patients.
  The final example I will give today of why dumping 15 million more 
people into Medicaid is such a bad idea comes from the Government 
Accountability Office, GAO. The GAO has determined that the program is 
plagued by fraud and abuse. In 2009, the GAO labeled Medicaid as a 
``high-risk'' program, finding $32.7 billion in improper payments in 
2007 alone. That is 10 percent of the program's total spending.
  As a former Governor, I am particularly concerned about the impact 
and expansion of Medicaid would have on the State budgets and the 
resulting squeeze on higher education spending. When a governor looks 
at his budget and sees the things he has to pay for like elementary and 
secondary education, prisons, roads, and Medicaid. Then a Governor 
looks at the things they want to spend money on like higher education 
and a Governor, knowing they have to balance their budgets every year, 
can't spend money he or she doesn't have, so something has to give, and 
it's usually higher education. As I noted earlier, the New York Times 
reported Friday that the University of California Board of Regents will 
raise undergraduate fees 32 percent by next fall to make up for steep 
cuts in state funding. The article goes on to report that ``The 
University of California now receives only half as much support from 
the state, per student, as it did in 1990. Even with the higher student 
fees, the system needs a $913 million increase in state financing next 
year to avoid further [budget] cuts.''
  From 2000 to 2006, spending by State governments on Medicaid has 
risen 62.6 percent, because of that higher Medicaid spending; higher 
education has only seen an increase of 17.1 percent over the same time 
period. As a result, tuition at a public 4 year university has risen an 
average of 63.4 percent. So Congress passes a generous Medicaid 
benefit, and the governors have to pay the bills. Then the governor has 
to say to our college students: your turn, pay up. Expanding Medicaid 
is exactly the opposite of real health care reform.
  Senator Corker, you were the chief financial officer of the State of 
Tennessee. You were the mayor of Chattanooga. How would you like it if 
someone in Washington passes a program and sends you the bill?
  Mr. CORKER. I would be losing a lot of sleep right now. I know people 
all across the country who have to act responsibly, unlike us, are 
losing sleep over what we are getting ready to do to States across the 
country.
  Is the Senator finished? Is that the point?
  Mr. ALEXANDER. I think we are out of time.
  The PRESIDING OFFICER. The Senator has 25 seconds remaining.
  Mr. ALEXANDER. The Governor of Tennessee, who is a Democratic 
Governor, has estimated that the cost to our State of this bill, of 
moving 15 million Americans into this medical ghetto, is about $800 
million over 5 years. In my view, finding that much money would 
seriously damage higher education, raise tuition in Tennessee like 
California's, which just went up, or require us to enact a new State 
income tax, or all of those things at once.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from New York.
  Mr. SCHUMER. I ask unanimous consent the next hour of Democratic time 
be controlled as follows: 10 minutes under the control of Schumer, with 
the remaining 50 minutes of time available for various Democratic 
Members to engage in colloquies.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. SCHUMER. Mr. President, today we stand at a crossroad. We can 
continue to turn a blind eye to the very real, very dangerous threat 
burgeoning health care costs pose to our economic future or we can 
choose the path to restoring economic opportunity in this country by 
tackling what my dear friend, Ted Kennedy, called the ``great 
unfinished business of our society.''
  As so often is the case at any major crossroads in our history, 
embarking on what we all know is the right path is difficult. Indeed, 
this is the single most difficult undertaking I have ever seen in my 
30-year career as a legislator. But my colleagues and I know what has 
to be done. Tonight is only one step down the road. There will be more 
procedural hurdles, more disagreements, more pressure from our 
opponents, more television ads, and many amendments. But I have no 
doubt we will pass this bill.
  There have been many attempts over many decades in many Congresses to 
reform health care. This time, moral and economic necessity will guide 
us over the finish line. It is unacceptable that in this country--the 
wealthiest, greatest country in the world--there are Americans who are 
forced to choose between their health care and rent, between their 
health care and food, between their health care and an education. But 
there are. And there are too many of them, and that must change.
  Consider these facts: Health care costs are out of control. Premiums 
for New York families have doubled in the last decade. Premiums have 
risen far in excess of inflation while median income has remained 
stagnant. Costs have risen so much that more than 20 million Americans 
have skipped a doctor's visit for no reason other than cost and 23 
million Americans have premiums so high they consume $1 out of

[[Page 28756]]

every $8 earned. Health care costs now account for a staggering 16 
percent of our GDP, far more than any other industrialized country in 
the world. For every dollar a small business in the United States 
spends on health care, its foreign competitors spend a mere 63 cents. 
Yet the health care of the U.S. workforce lags behind all other 
industrialized countries. Plain and simple, our small businesses will 
no longer be able to compete unless we act to reform health care.
  Even among those Americans fortunate enough to have coverage, nearly 
88 million don't have health care they can rely on. That is half of all 
Americans age 18 to 64 and their families. And 46 million of these 
Americans have a serious preexisting condition that has made it harder 
or more expensive for them to get coverage. In addition, 37 million of 
these Americans had a gap in their coverage during the last year.
  Our health care system is holding our economy hostage. The 
entrepreneur in Binghamton who does not take a chance, who does not 
leave a job to start his own firm because he is afraid of losing his 
family's health care; the college graduate in Oswego, days away from 
losing her parents' coverage, takes a job because it provides health 
care, even though that health care eats up a quarter of her paycheck--
each of these individuals who limit their potential because they are 
concerned about their health care should inspire action among all of 
us.
  Passing this bill is an economic imperative. The broken system we 
have is not only a burden on the present, it is a tax on the future. 
Every day we do not act to fix the health care system is a day that 
handcuffs our economy. It drains it of productive workers who do not 
treat illness. It drains businesses of money they could otherwise use 
to innovate and outperform their foreign competitors, and it drains it 
of savings and wealth that every American should have in retirement as 
a reward for a lifetime of hard work.
  Inaction is not an option. The consequences of failure are simply too 
high. Premiums will climb higher, benefits will erode further, 
businesses will buckle under the cost of insurance, and Medicare will 
go bankrupt. Yet our Republican colleagues would rather see us fail. At 
every turn, they have obstructed our path with procedural delays, with 
calculated misinformation, and sometimes with outright falsehood. I am 
amazed they are against a government health care plan, but they want to 
protect Medicare. Medicare is a government health care plan. You can't 
have it both ways.
  Yet when Democrats move to protect consumers from insurance company 
abuses, Republicans fight to allow these companies to drop, deny, or 
limit coverage for the people who need it most. When Democrats tackle 
waste, fraud, and abuse in our health care system, Republicans cry foul 
to preserve the status quo. When Democrats fight to protect and 
strengthen Medicare for future generations, Republicans try to weaken 
it.
  Tonight, there is no question what path our Republicans will take. 
They will follow the map handed to them by the big insurance 
companies--protecting industry profits, defending unfair practices, and 
ignoring the threat rising health care costs pose to America's economic 
future. They will continue to speak with two tongues against government 
health care and for Medicare. You can't have it both ways.
  Our Republican colleagues will not stand in our way. The road ahead 
is not a smooth one, but the wind is now at our backs. The American 
people want reform, and we will have the votes to finally deliver it to 
them. Sure, changes will be made to improve the bill as we move 
forward, but we will pass this bill. We will finish this great, 
unfinished business.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Ms. KLOBUCHAR. I ask unanimous consent to engage in a colloquy with 
the Senators from Maryland, Delaware, Massachusetts, and others who 
will be joining us later in the hour.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Ms. KLOBUCHAR. Mr. President, as the Senator from New York has so 
eloquently stated, the time for health care reform is now. We cannot 
afford to wait any longer. We can't afford to wait, for the middle 
class.
  There are a lot of numbers that get thrown out in the debate, but I 
think we can say it pretty simply by just using three numbers. Those 
numbers are 6, 12, and 24. What do those numbers mean? Ten years ago, 
the average family in this country paid $6,000 for their health 
insurance. Now they are paying $12,000. That is an average. I know of 
one small business in northern Minnesota, a backpack company, paying 
$24,000 for a family of four. One guy started a company with five 
employees. He now has 15--a growing business. He is paying $24,000. The 
average right now is $12,000 for a family of four. Where is it headed 
if we don't bend the cost curve for middle-class families--$24,000 
average, little towns all over America, $24,000, 10 years from now. 
That is not the kind of stability the middle class needs.
  The middle class needs to know, people I know all over my State need 
to know that if their kid gets sick, they still can have health care 
coverage; that if their kid goes to college and they want to keep them 
on their policy, they can still do that. That is what we are talking 
about when we talk about stability.
  The other piece of this reform effort that is so important, coming 
from Minnesota, a State with high-quality, highly efficient care, is 
the cost issue, that we begin the long journey of reforming our 
Medicare cost so that we actually promote the kind of high-quality care 
we see in my State at places such as the Mayo Clinic and we promote the 
kind of efficient care we need to see.
  My favorite example is in Pennsylvania, the Geisinger Clinic. They 
had diabetic patients. They decided it was not going that well. The 
patients didn't feel that good about their treatment, and the quality 
they wanted was costing too much. They tried something else. For 
routine cases, they said they will see nurses and see them more often. 
The more difficult cases went to endocrinologists, and they reviewed 
the routine patients' records. Higher quality care, happier patients, 
better care, lower costs--$200 per patient per month--that is what 
happened. They got less money for that higher quality care, less money. 
That is what we are talking about. We want to use those kinds of models 
so we get higher quality care for America at a more efficient rate.
  Some of my colleagues across the aisle have been using the name of 
the Mayo Clinic in vain. This matters to me because I come from 
Minnesota. It is the home of the Mayo Clinic. The minority has 
suggested that the Mayo Clinic doesn't want any part of this bill. They 
have said the Mayo Clinic wants nothing to do with this bill. They have 
said the Mayo Clinic--and this is an exact quote from the Senator from 
Wyoming--``is no longer taking Medicare or Medicaid patients.''
  Let me set the record straight. Like anyone in this country, the Mayo 
Clinic is looking at this bill. They like some provisions, and they 
don't like others. They have specifically said they support the 
creation of accountable care organizations, bundling of payments, the 
creation of an independent commission to evaluate Medicare solvency, 
which is in the Senate bill, the MedPAC idea. They are supportive of 
these issues because right now it is becoming harder and harder for 
them to cope with the current Medicare payment system.
  This allegation that they are no longer taking these patients is 
completely incorrect. They made a decision not to take about 80 
patients a year from the State of Nebraska because they weren't getting 
paid. They are still taking all Medicare-Medicaid patients from 
Minnesota and the contiguous States. This is not a small amount. Forty 
percent of Mayo patients are on Medicare. Six percent--I wrote this on 
the back of an envelope driving in with one of their chief doctors, so 
you know it is accurate, unlike the ``facts'' we are hearing over 
there. Forty percent of their patients are on Medicare, 6 percent on 
Medicaid, 46

[[Page 28757]]

percent are on Medicare or Medicaid. Sixty percent of their business is 
from Medicare or Medicaid.
  It is just false. But what is true is that they want to see reform. 
They want to see reform of the Medicare and Medicaid system. They want 
to have it based on quality, not on quantity. That is why they support 
the quality index I sponsored, along with Senator Cantwell of 
Washington.
  Just putting your head in the sand and hiding behind the stacking of 
that bill--by the way, we had a three-page bill with the Bush TARP 
plan, that didn't work out that well when there were no accountability 
measures in that. That is not going to bring us the kind of health care 
reform the Mayo Clinic wants to see for the rest of this country.
  I heard a lot in Minnesota from small businesses. Small businesses 
are paying 20 percent more than big businesses for their health care 
right now. Why should employees of little businesses, which are really 
the entrepreneurial engine of our States and the Nation, why should 
they have to pay 20 percent more than people who work for big 
businesses? This reform effort allows them to pool their numbers, 
allows them to join together so they can buy private insurance off an 
exchange with the same kind of numbers you have at a major corporation.
  I know the Senator from Maryland has been very devoted to the idea of 
helping small businesses.
  I ask Senator Cardin about this specific issue. How does the Senator 
see this as helping small businesses in Maryland and helping the middle 
class in his State?
  Mr. CARDIN. Let me thank Senator Klobuchar for setting the record 
straight as it relates to the Mayo Clinic. It is interesting, I have 
had conversations with people at Johns Hopkins University, the 
University of Maryland Medical Center. I hear the same thing. They 
desperately want to see health care reform. The cost issues are beyond 
their ability to maintain the excellence of our health care system. We 
have to get health care costs under control.
  If I might point out, I was listening to my colleagues on the other 
side give every reason why we should not move forward with the debate, 
saying: Don't worry, things will be OK. Those were the same arguments 
they made 15 years ago, which was the last opportunity we had to debate 
comprehensive health care reform. They blocked it from being on the 
floor of the Senate 15 years ago.
  What has happened in the last 15 years, after they said: Don't worry 
about it. Everything will be OK. Just keep on with our current system 
of protecting the private insurance companies. They will do a great 
job.
  In the last 15 years, we have seen health care costs go up, $912 
billion, almost a three-time increase. We have seen the per capita cost 
of health care go from $3,400 to $8,100. We have seen that share of our 
economy in the last 15 years go from 13 percent of our economy to over 
17 percent of our economy. We need to act.
  One more number I want to give because it affects Mayo Clinic and 
affects Johns Hopkins because in many cases they are the provider of 
last resort, where no one else will give care. Also, the number of the 
uninsured has increased since 1993 from 39 million to 46 million.
  The legislation that is being brought forward by our vote later today 
will reduce the number of uninsured by 31 million. Mr. President, 98 
percent of Americans will be covered by health insurance with this 
bill. It reduces the growth rate of health care costs in America. It 
provides an affordable option for every American. This is a critically 
important bill.
  The Senator mentioned small companies. I am glad the Senator did 
because small companies are the ones that are most discriminated 
against today in our health care system. They pay 20 percent more for 
the same coverage as a larger company. They do not have options. They 
do not have a lot of choices about who they can get to insure them. Not 
only is the cost so high, the annual increases are unpredictable. How 
do you run a business, if you are a small business owner, not knowing 
whether your health care cost is going to go up by 10 percent, 20 
percent, or 40 percent in the following year? You cannot.
  As the Senator knows, we have had small businesses come before us and 
tell us they are going to have to decide to eliminate their health 
care. In one case, we had a small business owner who said: Look, I am 
going to have to give up my business and start to work for a larger 
company because I can't afford the health care.
  We are at a crisis. I do not understand my colleagues on the other 
side saying they do not even want to have a debate on this issue, they 
do not even want to vote so we can take up this issue. Instead, they 
want to protect the private insurance companies and let them continue 
to make these profits, continue to cause real problems for our 
consumers.
  I have letter after letter from people who are confronting the 
problems of private insurance today, where they are denying coverage 
based on preexisting conditions or not covering a specific drug under 
their policies. There is no effective way to challenge private 
insurance companies today. This bill will give the consumers of America 
a chance against our private insurance companies.
  Ms. KLOBUCHAR. Mr. President, if the Senator would yield, I see the 
Senator from Delaware is in the Chamber. Both the Senator from Maryland 
and the Senator from Delaware serve on the Judiciary Committee, and we 
have had several hearings in that committee about an issue people do 
not always think about that hurts the middle class, and that is the 
money that is being sucked down the fraud tube. Medicare fraud is $60 
billion a year, I think.
  Mr. KAUFMAN. It is up to $220 billion.
  Ms. KLOBUCHAR. Mr. President, $220 billion. This bill will give us 
the tools. I know I wish to add even more to it on this subject, to go 
after that money, so that money can go back to help the middle class 
afford health care.
  I yield to the Senator from Delaware.
  Mr. KAUFMAN. That is absolutely right. What we are going to do is 
increase the number of whistleblowers, people who will see health care 
fraud and report it. We are going to get more prosecutors. We are going 
to get more FBI people. We are going to get more people to make sure we 
bring this health care fraud down. That is part of this bill.
  But I do not understand--to follow up on what the Senator from 
Maryland said--how can you say you do not want to debate the bill, when 
you look at the fact that the alternative is our present health care 
system, which is totally, completely broke? How can you say you do not 
want to do it? You say you are fiscally responsible. How can you say 
you are fiscally responsible when you are not going to do anything 
about Medicare and Medicaid health costs and the cost of health 
benefits in this country?
  As we have said many times before on the floor, my State is one of 
the worst cases; that is, in 2016, a family of four making $50,000 a 
year would be paying $29,000 in health care premiums. They cannot 
afford $29,000 in health care premiums. So what is going to happen? 
They are going to have the equivalent of half what they have today. If 
they can afford $12,000 or $13,000, they are going to have half the 
program.
  I heard my colleagues on the other side talking about rationing. What 
is going to happen to these people when they are getting half as much 
health care from these health care companies? And the health care 
companies are the ones that decide what procedures you can have, when 
you can have them, and those kinds of decisions. When people have their 
health care insurance cut by this amount, you have to worry about 
whether they are going to be able to get the things they need.
  Of course, Medicare and Medicaid prices are going through the roof. 
It is going to bankrupt the country. In 6 or 7 years, Medicare and 
Medicaid costs will cost more than everything else in the Federal 
Government. So how you can talk about----
  Mr. CARDIN. Will my colleague yield?

[[Page 28758]]


  Mr. KAUFMAN. Absolutely.
  Mr. CARDIN. On the Medicare issue, during the last hour we heard all 
these people, who for a long time have been trying to privatize 
Medicare and reduce the program, now saying that Medicare is going to 
be in jeopardy if this bill moves forward. It is very interesting. The 
AARP gets it right when it says:

       The new Senate bill makes improvements to the Medicare 
     program by creating a new annual wellness benefit, providing 
     free preventive benefits, and--most notably for AARP 
     members--reducing drug costs for seniors who fall into the 
     dreaded Medicare doughnut hole, a costly gap in prescription 
     drug coverage.

  This bill strengthens our health care system, strengthens Medicare 
for the future, and that is what is going to be critically important to 
our seniors.
  I thank my colleague.
  Mr. KAUFMAN. I think that is absolutely right. Right now, medical 
bankruptcies are 60 percent of U.S. personal bankruptcies--a rate 1\1/
2\ times what it was 6 years ago--because of medical bills. The thing 
that is striking about this is, 75 percent of the families entering 
bankruptcy because of medical bills actually have health insurance. 
Two-thirds of all Americans filing for bankruptcy because of medical 
bills already have health insurance. We cannot stop that unless we 
change the system and give people more insurance and give them better 
insurance and make sure you cannot be denied for preexisting conditions 
and make sure--the killer--once you get sick--it is bizarre. You get 
sick, and then the health insurance company comes in and cuts off your 
health insurance. No wonder so many people are going into bankruptcy.
  Ms. KLOBUCHAR. If the Senator would yield, I see the Senator from 
Massachusetts is in the Chamber, who I think has firsthand knowledge of 
the importance of this bill, having taken the seat once held by our 
dear friend Senator Kennedy, who worked so hard to get this bill done, 
to get health care to the people of his State.
  I say to the Senator, maybe he would want to talk about what this 
would mean to the people of Massachusetts.
  Mr. KIRK. I thank the Senator.
  I thank Senator Klobuchar for her leadership, as we approach the 
important moment on voting on a motion to proceed with this debate.
  I was appointed by the Governor of the Commonwealth basically in 
conformity with Senator Kennedy's wishes. He knew how divided this body 
was over the important health care legislation and the importance of 60 
votes so we could proceed to debate the merits of this bill. I am 
honored and humbled to be standing at his desk, to be one voice and one 
vote from Massachusetts.
  It is a historic moment, and it is a poignant moment. As I reflect on 
my experience on his staff, as Senator Kaufman was on Senator Biden's 
staff at that time, my experience began 40 years ago under the 
leadership of Senator Kennedy. That was the time he first spoke about 
the need for national health insurance that would be affordable and 
accessible to every single American--in hearing after hearing, in 
speeches on the Senate floor, and in field hearings throughout America, 
prodding, listening, leading.
  I can only reflect on how proud he would be of his colleagues and the 
leadership of Senator Reid and Senator Dodd, Senator Harkin, Senator 
Baucus, all his colleagues who are now uniting in this moment of 
history to do for the American people what they have waited for for 
several decades, even since the first utterance of this important 
health insurance coverage by former President Harry Truman.
  Having read through this bill and knowing how proud Senator Kennedy 
would be of this legislation, I will tell you why he would be. If you 
look through the bill, what does it do? It saves money. It controls 
costs. It reduces the Nation's deficit. It stimulates competition. It 
expands coverage. It strengthens Medicare. It attacks fraud, waste, and 
abuse. It increases transparency. It eliminates patient discrimination. 
It promotes flexibility and innovation. It rewards quality and value--
not quantity and volume--of health care. It provides affordable, 
quality health care choices for individuals, families, and small 
businesses across America.
  It introduces, through Senator Kennedy's leadership, a provision 
which provides long-term services for the elderly and the disabled.
  Mr. CARDIN. Mr. President, will the Senator yield for one moment?
  Mr. KIRK. Before I do, I say to the Senator from Maryland, there is 
one large, major question. If this bill promises to do all these 
things, for the life of me, I cannot understand how 1 of the 100 of us 
could go home for Thanksgiving and be able to explain to middle-class 
families, who are stretched and looking for health security and 
financial stability, that he or she would not vote even to debate the 
merits of this legislation.
  Mr. CARDIN. I was going to comment, listening to the Senator, at the 
desk that was Senator Kennedy's desk, how proud he would be of the 
statements the Senator is making here this evening. Senator Kennedy was 
our champion for middle-income families in America. He understood they 
needed a voice in the Senate, and he was their strong, passionate 
voice.
  This bill speaks to middle-income families. It is what Senator 
Kennedy fought his whole career for here in the Senate, to do something 
that would help middle-income families.
  As the Senator points out, we need to bring down the cost of health 
care. Health care costs are rising three times faster than wages. 
Senator Kennedy understood better than any of us that Americans are 
falling farther and farther behind because of the health care issues, 
because of health care costs. Private insurance companies can make lots 
of money if health care costs go up. They are not losing. It is the 
middle-income families who are getting hurt by the system.
  He understood that small businesses could not survive unless we 
figured out a way to deal with the health care issues. And as to people 
on Medicare--most people on Medicare are from middle-income families. 
We need to protect Medicare for the future. That is why, again, I get 
very concerned when I hear what we have heard over the last hour in the 
discussions, because one of the principal reasons we need to bring this 
bill forward on the floor of the Senate tonight is to strengthen 
Medicare, to make sure it is there for the future, to make sure it 
stays strong, and to make sure we expand benefits, as we do under this 
bill.
  I thank the Senator because those of us who have heard Senator 
Kennedy speak on the floor of the Senate know how sorely missed he is 
here, and we are proud you are representing that vote here on the floor 
of the Senate tonight.
  Mr. KIRK. Mr. President, I thank the Senator from Maryland very much.
  Ms. KLOBUCHAR. Mr. President, if the Senator would yield, I also see 
the Senator from Rhode Island in the Chamber. Rhode Island is a State 
that has one of the highest unemployment rates right now in the 
country, and it certainly is a State that would welcome this kind of 
reform. And also on the issue we have been talking about, Medicare, the 
Senator from Rhode Island has long fought for seniors.
  As to Medicare, as has been pointed out, if we do nothing, it is 
going to go in the red by 2017. The seniors I know who are 65 want to 
live to be 95 and still have Medicare. People who are in their fifties 
want to make sure Medicare is there for them when they are 65. That is 
why it is so important we make these smart reforms, to raise the 
quality of the care, and to make sure we preserve and save Medicare. 
And that is what this bill is about.
  I yield to the Senator from Rhode Island.
  Mr. REED. Mr. President, I thank the Senator from Minnesota. I want 
to add my comments to that of the Senator from Maryland and the Senator 
from Delaware to commend the new Senator from Massachusetts. He not 
only carries on the great work of Ted Kennedy, but he does it with the 
same passion and eloquence.
  What struck me in this legislation--and reminiscent of Senator 
Kennedy--is that this legislation will provide real help to real 
people. It is about solutions, not slogans.

[[Page 28759]]

  Let me illuminate, if I may. Premium relief. What is troubling so 
many middle-class families? They are too wealthy to qualify for direct 
public assistance in terms of the Medicaid Program, but they are not 
wealthy enough to pay for insurance.
  This legislation will cap family outlays on medical insurance 
premiums. Families making under $88,000 will pay no more than 10 
percent of their income on premiums. They will be given direct 
assistance through the tax system. There will be a rebate. So people 
now, rather than staring at 20 percent, 15 percent, 18 percent 
increases, will at least know there is a cap. And perhaps if we do our 
work well enough, the whole system will begin to reduce below the 10-
percent mark, and everyone will benefit.
  It is also notable that real families worry about many things. They 
worry about educating their children. They want them to be educated, 
but they also recognize as full-time students in higher education, they 
can stay on the family health care plan. It is interesting to note that 
decisions made about education are tied into health care, and also, in 
fact, as to where you work, if you should keep your job you do not like 
because you have health care or go on, whether you strike out to start 
a new business because you have this brilliant idea or stay in your 
current position because there is health care there. But what this bill 
does, again, is provide real help for real people and allows families 
to keep their children on their health care plan until they are 26 
years old.
  It also reforms dramatically the insurance system. Again, we listen 
to many of the complaints: Oh, we don't want a government-run health 
care system; we don't want bureaucrats telling us what to do. The 
irony, of course, as you mentioned, and Senator Schumer did, too, is 
that one of the most popular health care programs in this country is 
Medicare, which is government run. One of the other most popular health 
care programs in this country is run through the Veterans' 
Administration, which is a government agency. The least popular 
programs are private health insurance, where everyone has complaints--
doctors, patients, providers. This legislation will prevent lifetime 
limits that insurance companies dictate. It will also do many other 
things.
  So let me conclude because I appreciate very much--and if the time 
allows, I have a question for the Senator from Massachusetts. But this 
is a bill that when you move past all of the rhetorical smokescreens--
because, frankly, most of our colleagues on the other side don't want 
to do anything. They didn't want to do it in 1993 and 1994; they didn't 
want to do it in 1933 and 1935; and they still don't want to do it--
this legislation helps real people with solutions not slogans about 
nationalization and bureaucrats.
  Ms. KLOBUCHAR. The Senator from Delaware.
  Mr. KAUFMAN. I was presiding yesterday for I don't know how many 
hours. When you listen to what is said on the Senate floor by the other 
side, they are talking about a model where there is no competition. Any 
tax on an insurance company is going to be passed on to the consumer. 
What kind of a business--I don't know anybody in business who, if they 
get an increase in cost, they just pass it on to the consumer. Right? I 
mean, we have a law of supply and demand the last time I checked. But 
every single one got up and talked about the cost and said this is 
going to hurt the consumer. It is not going to hurt the insurance 
companies because they are just going to pass it on to us. The reason 
they are going to pass it on to us is kind of obvious.
  Here is a list, a small list, that lists all the States in America 
and how much of their insurance is tied up in two or less companies. Do 
you know what you have to do? You have to get down to No. 40, Oregon, 
because the first 39 States on this list, two insurance companies make 
up over 50 percent of the market in their State. How can you have 
competition when you have so much of the business tied up in just one 
entity?
  The way you can tell there is not competition? You don't have to have 
an advanced degree in economics to figure out there is no competition. 
How do you know there is no competition? Every January, my premiums go 
up. The only other thing I know that I get that goes up every January 
is my cable bill, right? There is no competition in cable. You either 
take cable or you don't. They say there is competition. So every year, 
whether it is January, February, or March my cable bill goes up. And 
every year, just like clockwork, my health insurance premiums go up. So 
clearly, there is not competition.
  That is why a public option is so important. We have to have a public 
option so there is competition not only in the top 39 States where one 
firm has over 50 percent--two firms have over 50 percent of the 
business--but in all 50 States.
  That is what this bill does. It is amazing to think on the other 
side, the support they have for competition, and I believe they do and 
I know them and I respect them and they all are concerned about 
competition--except every once in a while they kind of turn a blind eye 
to the fact of how powerful competition is. Competition is valuable and 
powerful in keeping costs down and increasing benefits and quality of 
care--only when there is actually competition. So we are going to have 
to have competition. This bill will actually do it.
  Ms. KLOBUCHAR. If the Senator will yield, I think we have been joined 
by the Senator from North Carolina, who is a member of the HELP 
Committee and I know has a background in business and understands a 
little bit about competition.
  So how does she see this as being a problem? I know in the State of 
the Senator from Maryland there is limited competition, and in a number 
of our States one or two providers--Minnesota is an exception, but one 
or two providers dominate the market, jacking up the prices.
  The Senator from North Carolina.
  Mrs. HAGAN. I think one of the key points is the fact that this bill 
is going to eliminate discrimination based on gender and preexisting 
conditions. I have two children right now who are in their midtwenties. 
My daughter is paying more per month for health insurance than her 
brother. Yet it is the exact same policy. The same with preexisting 
conditions. How many people do we know who have a condition such as 
diabetes or asthma, or a woman who has had a C-section who is, 
therefore, denied from getting health insurance? We have to be sure we 
correct this, and that is what this bill does.
  Let me give a couple of examples. So many people in North Carolina I 
have heard from have some of these situations. Recently, I got an e-
mail from a family in Greensboro. It is a working family. The husband 
has Graves disease, which is a treatable condition, but he can't obtain 
health insurance because of this condition. Without health insurance, 
his life is gravely in danger. He repeatedly uses the emergency room 
for care.
  To make matters worse, he has a 2-year-old son who has hemophilia and 
has to be taken to the emergency room every time he bumps his head, 
which sometimes can cost, for a 2-day supply of medicine, $4,600. The 
family makes too much money to qualify for Medicaid and, obviously, 
with these preexisting conditions, health insurance is way out of reach 
for them. It is heartbreaking for this family. What the father has 
decided to do is to purchase life insurance instead of trying to get 
health insurance, and he is 29 years old.
  Ms. KLOBUCHAR. If the Senator will yield, I think what the people 
will be shocked to find out is that I think in eight States domestic 
abuse is actually a preexisting condition. You talk about gender 
discrimination. If a woman is a victim of domestic abuse, she will 
basically not be able to get certain insurance policies. Is that right?
  Mrs. HAGAN. That is right. In all but 12 States, insurance companies 
are currently permitted to charge women more than men for the exact 
same policies.
  Mr. CARDIN. If the Senator will yield for a moment, as Senator 
Klobuchar pointed out, if you don't have

[[Page 28760]]

competition--and Senator Kaufman said the same thing--if you don't have 
competition, what is your choice? You are going to have to pay the 
premium.
  There was a Washington Post article written about a street in 
Gaithersburg. Gaithersburg is a growing suburban community not far from 
here, certainly middle-class families. They think they are doing fairly 
well. It talked about one street in Gaithersburg, and they gave half a 
dozen stories about people--real stories--about people having problems 
with our current system. They talk about Patty, who has private 
insurance and thought she was in good shape. She talks about having to 
search a book in order to find out what doctor she could go to to stay 
in the network because it is too expensive to go out of network, and 
then she hits her deductible and finds that her fees and copayments 
come in fast and strange, making it unaffordable for her with her 
current insurance coverage. She has no other choice. That is the only 
insurance she can get.
  Two doors down the road is Chuck who needs oxygen, needs certain 
medicines. He had to fight with his insurance company to get the 
prescription drug covered. He got the prescription drug covered, only 
to find out the nurse who administered the drug was not covered, and it 
cost $400--another problem with a private insurance company.
  Across the courtyard, Will and Sarah, they have insurance today. They 
are going to lose it because he just lost his job, and he has no 
prospect for being able to afford insurance.
  The last one is Martha. This is a very interesting one. Martha went 
to the emergency room for delivery of her child. She needed an 
epidural. She made sure she went to a hospital that was in-network 
because she wanted to make sure it was covered. Guess what. That 
anesthesiologist she had no control over was not in-network and she had 
to pay all that extra money. Again, no choice. She had no choice in the 
system. There is no competition.
  I know we have Senator Kirk here who is our newest Member. Perhaps 
the Senator could tell us what he is hearing from Massachusetts. He is 
a new Member here. I don't know whether he is getting the same stories 
of what is happening in his State.
  Mr. KIRK. Well, it is exactly the same story, with one exception, I 
would say to the Senator from Maryland, which is that 3 years ago, 
Massachusetts adopted its own health reform. Now, 97 percent of the 
people in Massachusetts are covered with health insurance.
  As you have said and as the Senator from Rhode Island has said, the 
best illustrations of the need for health reform are the individuals, 
the real people. So I will tell my colleagues a story about a young 
lady. She is a waitress, a 24-year-old girl. Her name is Jessica 
Wheeler from Somerville, MA. She is a waitress and works part time as 
an intern. She had dreams of graduate school, but she was concerned 
about health insurance. We have an exchange in Massachusetts not 
dissimilar to what is being offered in this legislation where there is 
increased competition from private insurers and others. She applied to 
the exchange and was found eligible and enrolled and took out an 
insurance plan.
  Shortly after, she was stricken gravely ill with organ failure and 
was hospitalized for an extended period of time. She was made well. She 
has to take a pill every day in order to keep up with her condition, 
but her coverage was complete. She has applied now to graduate school, 
and although she probably has her tuition issues stretching her means 
and so forth, she is free of the concern and need of expensive health 
care bills; otherwise, she would have been without. So it is just 
another illustration.
  Just one other point on competition that keeps coming back and back, 
I ask myself: Why do middle-class families save their hard-earned money 
to buy health insurance? Obviously, the answer is so that they will 
have coverage if they get sick. Without competition, I will tell you 
what is going on. Insurance companies--now get this--are denying 
coverage because people are sick or they say: Well, you reached a 
certain limit, and we didn't realize you were going to get that sick, 
so we dropped the coverage.
  Ms. KLOBUCHAR. If the Senator could yield, I have exactly the same 
kind of example where someone wants to buy coverage, they are willing 
to pay for some coverage, but they can't. They basically are cut out 
because they are sick.
  This is one of the saddest letters. We just got this from Cheryl from 
Bemidji, MN. She says:

       I am writing to you because I just got off the phone with 
     my daughter Mickey. At first I couldn't understand her 
     because she was sobbing so hard. Her husband had just been 
     told by his boss that they wouldn't be carrying health 
     insurance on their employees any longer. They are a small 
     company in northern Minnesota and it was costing them $13,000 
     a month. For her, for my daughter, this is a matter of life 
     and death. She has cystic fibrosis. Because it is a 
     preexisting condition, the insurance companies won't touch 
     her unless it is under a group plan such as the one her 
     husband just lost.

  She says:

       You need to stand and be my voice, be Mickey's voice. 
     Mickey is a fighter, but she can't keep fighting a system 
     that is so against her. Mickey has already lived longer than 
     any of the doctors expected. I want her to live to see her 5-
     year-old son become President one day.

  That is from a mom in Bemidji, MN.
  So I will just ask my colleagues, how can we continue to go down this 
path where hardworking families--a man who has a job, who is working 
for a small business, gets cut off from his insurance, and because his 
wife has cystic fibrosis, they aren't going to be able to afford 
insurance.
  The Senator from Delaware.
  Mr. KAUFMAN. I think the reason we use these examples so much is 
because certain words kind of roll off your lips; words such as 
``preexisting condition.''
  Here is an example involving Angela in Dover, and she is a bartender, 
not a waitress. Her income is from tips. She has no health insurance 
through her employer. She became pregnant. She tried to find private 
health insurance, but she was declined coverage because pregnancy was 
considered a preexisting condition.
  Now, just do a visual for a minute. This woman has been living off of 
tips. She is about to have a baby, and there is nowhere she can go to 
get health insurance. She applied for Medicaid to find prenatal care 
for herself and her baby, was denied coverage because she earned $200 
more than the monthly income limit. I mean, just picture this now, if 
you were in this situation. She called organizations and clinics and 
was unable to find a payment plan she could afford.
  Midway through her pregnancy, Angela decided to cut back her work 
hours so she could qualify for Medicaid. She worked all 9 months of her 
pregnancy and delivered the baby on May 27. The Medicaid coverage she 
got was especially crucial because she had complications with 
hyperthyroidism and was able to get the necessary prescriptions to 
control her condition.
  OK. Do we have the picture? How would we like to see ourselves with 
our spouses or our kids with this kind of a decision? The sad part of 
the story, as if it is not sad enough, is that Angela was so anxious to 
ensure that everything possible was done for a healthy baby and the 
system threw up roadblocks. Pregnancy should not be considered a 
preexisting condition.
  People in this country who are pregnant should not have to worry, in 
addition to going through the trauma of being pregnant for 9 months and 
the baby being healthy and all the fears you have and on top of that 
fear they may go into bankruptcy because they cannot afford to pay for 
the doctor bills for their baby. This is real stark to me.
  We are going to vote tonight on cloture so we can move to a bill that 
will, once and for all, make sure Angela Austin and all the women 
similar to her who have the ``preexisting condition'' of pregnancy will 
only have to worry about their baby and what is going to happen to her 
and not worry about what she is going to do when the child is 2 and she 
is in bankruptcy, because so many people are going into bankruptcy.

[[Page 28761]]


  Ms. KLOBUCHAR. Maybe the Senators can answer this. In these thousands 
of letters and calls we get from these people, they are asking us to be 
their voice. They don't want to say we are not going to debate this 
bill at all, that we are going to put it in a drawer and pretend it 
didn't exist.
  Mr. CARDIN. That is the interesting point. These are all real 
stories, people who are being denied health care today because of 
arbitrary practices from private insurance companies or the way our 
system is currently organized.
  The vote tonight is a pretty simple vote. If you think the current 
system is what you want, OK, I understand why you are voting against 
cloture. I understand that you say the status quo is fine; we don't 
even want to debate the issue; we don't care about the people who have 
been affected by the arbitrary actions of private insurance companies 
and saying that pregnancy and childbirth is a ``preexisting condition'' 
or when you are using over-the-counter drugs to keep your cholesterol 
under control and the insurance company says that was a preexisting 
condition.
  All we are saying tonight is: Is this worthy of debate on the floor 
of the Senate--a clear vote? Those who vote for cloture say this is 
worthy. The people who have written us these letters are entitled to 
have the Senate take up this issue. That is why we point out that there 
are numerous groups, including the American Medical Association, that 
say vote for cloture, let's have this debate before the American 
people.
  Ms. KLOBUCHAR. Along those lines, before I yield to the Senator from 
Massachusetts, I started out talking about the cost issue. I wanted to 
put in the Record the statement of November 5, 2009, from the Mayo 
Clinic. There have been things said about their position. My friends on 
the other side have said they ``don't want any part of this bill'' and 
they ``want nothing to do with it.'' Those are exact quotes. They said 
they ``are not taking Medicare and Medicaid patients anymore.''
  Those are exact quotes. They are all incorrect. I will put this in 
the Record. It is dated November 5, 2009. ``Points of Agreement and 
Divergence.'' They say:

       We are encouraged by much--including provisions to pay for 
     value in health care, an insurance exchange, individual 
     mandate, subsidies for people to achieve coverage, and pilot 
     projects on accountable care organizations and bundling of 
     payments.

  To be fair, they also say they are ``concerned about other areas 
including a public option that is based on Medicare rates. . . .''
  As you know, the options in the House and Senate bills are not based 
on Medicare rates but negotiated rates. They are concerned about the 
long timeline for implementation of value provisions, as I am. They are 
concerned about across-the-board cuts for providers. They neither 
endorse nor support the bill. To say they don't want any part of the 
bill is false.
  I ask unanimous consent that this material be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

     A Perspective on Current Health Reform Issues From Mayo Clinic


            Reform Bills: Points of Agreement and Divergence

       As the House and Senate prepare to bring their final bills 
     to their respective floors, Mayo Clinic would like to 
     highlight the areas of agreement and divergence in the bills 
     and our positions on health care reform. We are encouraged by 
     much--including provisions to pay for value in health care, 
     an insurance exchange, individual mandate, subsidies for 
     people to achieve coverage, and pilot projects on accountable 
     care organizations and bundling of payments.
       At this juncture, Mayo Clinic will neither endorse nor 
     oppose entire bills in the House or Senate, but will continue 
     to point out provisions that we think move the country toward 
     patient-centered health care and areas where we have 
     concerns.
       While many provisions in the bill are aligned with our 
     recommendations, Mayo Clinic remains concerned about other 
     areas including a public option that is based on Medicare 
     rates, the long timeline for implementation of pay for value 
     provisions and across the board cuts to providers.
       It is critically important that we accelerate the timeline 
     to adjust the Medicare payment system to pay for value in 
     order to truly bend the cost curve--especially in light of 
     the growing number of baby boomers reaching retirement age.
       These payment reform provisions should not lag behind 
     expanding coverage to more Americans. In any event, we must 
     focus on ensuring the financial viability of health care for 
     the long term to ensure that patients have access to quality 
     care across the country.


  Support House IOM Study of High Value Care and Geographic Variation

       Mayo Clinic supports the provision that was added to the 
     House bill that will charge the Institute of Medicine to 
     study and design new payment methodologies to build value and 
     address geographic variation into the Medicare payment 
     system. The proposal is consistent with Mayo Clinic's focus 
     on creating a mechanism to better define value, measure it, 
     and create new payment methodologies that reward it.
       Most of us, as patients or family members, don't stop to 
     think that our doctors and hospitals are generally paid more 
     for doing more tests and procedures--whether or not we need 
     it. Take for example, the story of a patient eventually seen 
     here at Mayo Clinic:
       An older gentleman went to an emergency room because he 
     fainted. A CT scan of the heart was done and showed 
     calcification. Urgent heart catheterization was recommended 
     and then bypass surgery was performed. Later, when a stress 
     test was done, an abnormality was found and a second heart 
     catheterization showed a complication--one bypass was 
     blocked. Stents were placed in the heart artery where the 
     bypass was blocked. However, the fainting spells continued. 
     With his issue unresolved, the patient came to Mayo Clinic, 
     where we conducted a lengthy assessment by a team of 
     physicians. It was determined that all he needed was an 
     adjustment of his medications. In the end, the tests, stents, 
     and surgery performed at the other facility were not needed, 
     did nothing to help the patient, but were paid for by 
     Medicare. On the other side, the additional office time spent 
     at Mayo to fully assess patient's situation and ensure proper 
     diagnosis and treatment was not covered by Medicare.
       Doctors and hospitals are usually paid more for doing more 
     tests, visits, hospital admissions, and surgeries rather than 
     spending time with the patient and assessing their individual 
     needs. What if instead, the system rewarded doctors and 
     hospitals for spending time with patients, for doing a 
     procedure successfully, for the fact that you leave the 
     hospital without a fall or infection, and for providing 
     excellent service to you while you were under their care.


      Support Cantwell Amendment to Incentivize Value in Medicare

       We support a similar provision in the Senate Finance 
     Committee bill introduced by Sen. Cantwell that will help 
     move Medicare in the direction of paying for value by 
     creating a value modifier for physician payments that will 
     create incentives around value in the Medicare physician 
     payment formula.


               Insurance Reform that Gives Access to All

       We believe coverage can be achieved without creating or 
     expanding a government-run, price-controlled, Medicare-like 
     insurance model. A public option that employs a true 
     negotiated rate process is better than a system based on 
     Medicare rates. However, we are concerned that the exchange 
     could be opened to large employers, which could result in a 
     large shift from private to public insurance plans.
       We support reforms to the current insurance system that 
     eliminate pre-existing condition exclusions, and create an 
     individual mandate where individuals can purchase private 
     insurance in various ways:
       Through employers,
       On the individual market,
       Through co-operatives, or
       Through an exchange model like the Federal Employees Health 
     Benefit Plan (FEHBP).
       We also believe that the government should help people 
     afford the insurance through sliding scale subsidies as 
     needed.


       Encouraged by Accountable Care Organization Pilot Project

       Mayo Clinic is encouraged by provisions in the House and 
     Senate bills that allow groups of providers who voluntarily 
     meet certain statutory criteria, including quality 
     measurements, to be recognized as Accountable Care 
     Organizations (ACOs) and to be eligible to share in the cost-
     savings they achieve for the Medicare program. Both houses 
     propose to start an ACO pilot program January 1, 2012.
       Mayo Clinic believes that under this approach, a group of 
     physicians would be responsible for quality and overall 
     annual Medicare spending for their patients. Different 
     payment models could be tested. For example, physicians would 
     be paid FFS rates, less a withhold, and then receive bonuses 
     for meeting resources use and quality targets over the course 
     of a year. Options should include creating virtual 
     accountable care organizations based on physician-hospital 
     referral relationships. Such an approach would create 
     incentives for physicians and hospitals to work together to 
     provide better value care.


                Bundling Payments Can Help Contain Costs

       Both the House and Senate bills have provisions to test a 
     system of bundling payments for Medicare Parts A and B. We 
     are

[[Page 28762]]

     pleased with the pilot projects on Medicare payment bundling. 
     However, we would like to see a more aggressive 
     implementation timetable--not one that starts in 2014 or 
     later, but finishes by 2014--so that we can see more 
     immediate financial results for the Medicare system.
       To realize cost savings quickly, Mayo Clinic believes 
     Medicare should start bundled payments for high-cost hospital 
     episodes such as total knee replacement, heart attack, and 
     lumbar disc herniation. Over time, bundled payments could be 
     considered for some chronic conditions as well. The bundled 
     payment should include hospitalization (Part A), physician 
     (Part B) and post-acute care (nursing home, home health care, 
     etc.) services. The outcome would be defined as reasonably 
     attainable improvement in health status in the safest, most 
     cost-effective way and would cover the entire episode of care 
     through the patient's return to function.
       The goal is to reduce practice variation and focus on an 
     outcome-based goal. Such a reformed payment model would 
     encourage improved coordination of care among physicians, 
     hospitals and nursing homes, and it would encourage 
     utilization of nursing and other non-physician caregivers.


    CMS Innovation Center to Enhance Quality, Improve Patient Safety

       Mayo Clinic also supports the proposal in the Senate 
     Finance Committee bill that calls for the HHS Secretary to 
     create an Innovation Center within the CMS. The Innovation 
     Center will be authorized to test, evaluate, and expand 
     different payment structures and methodologies which aim to 
     foster patient-centered care, improve quality, and slow the 
     rate of Medicare cost growth. The provision calls for 
     promoting improved quality and reduced cost by developing a 
     collaborative of high-quality, low-cost health care 
     institutions. The collaborative would develop best practices 
     and proven care methods in improved quality and efficiency, 
     as well as assist other health care institutions on how best 
     to employ such best practices and proven care methods.


           Independent Commission to Extend Medicare Solvency

       The Senate Finance Committee proposal includes a provision 
     to establish a 15-member Independent Medicare Commission to 
     develop and submit proposals to Congress aimed at extending 
     the Medicare program's solvency and improving its quality. 
     Each year, beginning in 2013, the Medicare Actuary's Office 
     would make projections about whether Medicare's per-capita 
     spending growth rate in two years will exceed a targeted 
     rate. In years when Medicare costs are projected to be 
     unsustainable, the Commission's proposals will take effect 
     unless Congress passes an alternative measure.
       Mayo Clinic believes that this commission can insulate many 
     health care decisions from direct political influence in 
     Congress while still being accountable to Congress. We also 
     believe that the commission should have the authority to 
     change the health care payment system with the goal to move 
     away from fee-for-service medicine and toward paying for 
     team-based, coordinated care.
       In addition to payment reform, the commission could serve 
     as a trusted national data aggregator, making performance and 
     pricing information publically available so that stakeholders 
     can identify best practices and high performers.
       This perspective is written by Jeffrey O. Korsmo, Executive 
     Director, Mayo Clinic Health Policy Center; and Bruce Kelly, 
     Director of Government Relations, Mayo Clinic.

  Mr. KIRK. I know time is running short. I want to say one thing about 
this. We have heard talk about the status quo. Make no mistake, this is 
a situation with respect to--we assume when we hear the words ``status 
quo'' that things will remain as they are.
  In the area of health care and health insurance, things are not going 
to remain where they are. The status quo is not the status quo. We 
either move forward or we fall back. If we don't address or at least 
debate the merits of the bill and don't move it forward, we all know 
what is going to happen. The figures are there. The average family 
premium, which is now over $13,000, in 2016 will double to $24,000. 
That is not the status quo. That is falling back. Similarly, the number 
of uninsured will rise from 47 million today to 54 million in 2014. 
That is not the status quo. That is falling back. Fourteen-thousand 
people will continue to be dropped from coverage each day. That is not 
the status quo. That is falling back. I could go on.
  There is a reason this bill needs to be debated. It is because the 
average middle-class working family deserves and needs health care 
security and financial stability. This bill will bring them that. At 
least I hope that the Members of the Senate--all 100--would say that, 
on the merits, this bill and this need should be debated.
  Ms. KLOBUCHAR. I thank the Senator from Massachusetts. The Senator 
from North Carolina is here. I know the people of North Carolina and 
the people in the South have concerns about the current state of 
affairs in health care as well.
  Mrs. HAGAN. Yes. A lot of what we have been talking about are people 
who don't have health insurance and who want it enhanced because of 
preexisting conditions. We have people who are sick and stuck with 
health insurance.
  I received an e-mail from a young North Carolinian who works for 
AmeriCorps. She was the valedictorian of her high school class. She 
suffers from a brain abscess. Her illness has put her into debt for the 
rest of her life. She has health insurance, but it ran out when she hit 
a $50,000 cap. Her bills far exceed the cap. It is sinking her entire 
family into debt. She is sick and stuck.
  How many people do we know who have a spouse or themselves who have 
health insurance, and they are working, but they cannot switch jobs 
because they would lose their health insurance? I have a good friend 
whose husband has cancer. She wants to change jobs, but she cannot do 
it because of the condition of her husband. Once again, people are sick 
and they are stuck. We have to be sure we can have a debate, that we 
can move forward on health care reform so we can help people.
  Mr. KAUFMAN. We are all concerned about the economy. Even with health 
care reform, I think for every Senator I talk to on both sides of the 
aisle, their biggest problem is getting people back to work again and 
getting the economy moving. It is truly tragic when you think so many 
people are losing their jobs. Under our present system, the way it is 
structured, when you lose your job, you not only lose the money coming 
in to you, you lose your health insurance. You lose your self-respect 
because we are all judged on where we work. That is how people judge 
us.
  As has been said, the longest walk is the walk home to tell your 
spouse and your kids that you lost your job. The irony of ironies and 
the thing that makes this so incredible is that you don't just lose 
your job and self-respect, you lose your health care insurance.
  We have a system, and we have to change the system so these people 
out their right now can maintain their health care insurance and care 
for their children and their families, as they and everybody in their 
families go through this very traumatic experience.
  Mr. CARDIN. We are running out of time, with only a few more minutes 
left. I want the people in Maryland and of the Nation to understand 
what this vote means. We are going to bring an amendment to the floor 
of the Senate for debate. Any Senator will be able to offer an 
amendment to how we should advance health care. The Senator from 
Massachusetts is absolutely correct. We are either going to continue to 
see our health care system with more people being denied coverage, with 
the costs escalating much faster than our economic growth, with 
businesses having to decide to terminate plans--that is what is going 
to happen--or we can take up health care reform and try to rein in the 
practices of private insurance companies and provide a way where every 
American can get access to affordable health care. That is why the 
American Cancer Society Cancer Action Network says:

       The American Cancer Society Cancer Action Network urges all 
     Senators to vote in favor of allowing critical health care 
     legislation introduced by Senator Harry Reid this week to be 
     debated on the Senate floor. With thousands of cancer 
     patients being denied coverage, charged excessive premiums, 
     and facing exorbitant out-of-pocket costs, it is urgent that 
     the Senate take action now, not later, to protect and extend 
     health coverage to millions of Americans in need.

  Last week, Cynthia and Eric Cathcart were here in the Senate. They 
are two people who are self-employed. They cannot even get an insurance 
policy to cover their family. They have to have two separate policies, 
with two

[[Page 28763]]

deductibles and two premiums, and they cannot afford it. We must take 
up this issue for the Cathcarts and the millions of Americans who 
cannot make it under this current system. Middle-income families are 
depending upon us tonight.
  Ms. KLOBUCHAR. There is a lot of talk about Medicare and our seniors 
and what this bill does. Think of the woman I talked about who is a 
fighter, as her mom says, but she cannot keep fighting a system that is 
so against her. As you pointed out, the advantage of this bill is, it 
gives our seniors a better playing field with the drug companies paying 
for their drugs in the doughnut hole. Also, it is my understanding that 
AARP wants to advance the bill. Certainly, AARP has stood up for 
seniors for years and years and years. They know we need to preserve 
Medicare and keep it safe.
  Can the Senator comment on AARP?
  Mr. CARDIN. AARP not only wants us to advance the bill; they support 
the bill. They believe this bill will improve the Medicare system, make 
it stronger, and provide additional benefits, particularly in reducing 
the dread Medicare doughnut hole. They want the Members of the Senate 
to vote to allow this bill to come to the floor.
  Ms. KLOBUCHAR. Maybe we should end with the Senator from 
Massachusetts, the home State of Ted Kennedy, having the last word of 
this very interesting colloquy, in which we heard from the Senators 
from North Carolina, Rhode Island, and Maryland.
  Mr. KIRK. I thank the Senator. I am honored to be a Senator in this 
body. Back home, they think I am the 60th vote. I would like to believe 
we would have a more enlightened full body and that 60 would be a 
number we would pass through.
  The American people are looking forward to debate on this issue. I 
think they believe they deserve many of the aspects that are contained 
in the bill. On behalf of my constituents in Massachusetts and those 
who, for so many years, revered and loved and elected and reelected 
Senator Kennedy--I think they all, as we do, have him in our minds and 
hearts tonight, and we hope we can advance this bill to the American 
people, knowing his spirit and years of work are a reminder of our 
obligation.
  I hope we will have a successful vote this evening. That will provide 
an opportunity for the American people to hear a debate and perhaps 
allow corrections by whatever amendments may be needed, so we proceed, 
keeping in mind, as is true in all legislation, we cannot let the 
perfect be the enemy of the good. The good is something our people have 
been waiting for, for decades. The time is now. Let the debate begin.
  I thank the Chair and yield the floor.
  Ms. KLOBUCHAR. I thank the Senator. I believe our hour has ended. We 
yield the floor.
  The PRESIDING OFFICER. The Senator from Utah is recognized.
  Mr. BENNETT. I ask unanimous consent that during the next hour, those 
Senators who come to the floor may be allowed to proceed in a colloquy.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BENNETT. I came to the floor early so I could listen to what my 
Democratic friends have had to say. I found it quite enlightening, and 
I have a few comments with respect to it.
  They have been debating vigorously against the status quo. They have 
been giving us examples, heart-tugging, real-life examples of people 
who are finding difficult problems in the situation as it now exists--
as if the debate were between the status quo and doing something.
  The debate is between the solution that has been offered by the 
majority leader and other solutions, which people on this side of the 
aisle have been trying to bring forward through the entire time and 
have not been allowed to come forward.
  We recognize that things need to be done to fix problems with respect 
to the health care situation. We realize the legislation we have been 
living with for all these years needs to be amended. We have been 
unable to get any of our ideas to come forward. Now we are told there 
is such urgency to deal with the status quo that we must pass this 
bill, and we must pass it virtually without amendment.
  I would like to point out, as I have done before, if there is such 
urgency with respect to the challenges we have in health care, why do 
we wait until 2014 to have those changes come? We have heard all these 
examples coming on the Democratic side of the aisle of people who have 
terrible problems under their health care plan. We must act, we must 
act immediately, and the act will be to say to all of these people: We 
will solve your problem in 2014. We will delay all of these reforms we 
are talking about until 2014.
  I made that point the other day, and the Senator from Maryland said, 
no, some parts of this bill will begin immediately. And he is exactly 
right. The parts of the bill that would begin immediately are the 
taxes. We will start taking in money in 2010 if this bill passes. The 
annual pharmaceutical manufacturers fee would drive up the price of 
everybody's drugs, an annual nondeductible $2.3 billion fee. That will 
begin in 2010. The medical device manufacturers fee, another $2 
billion, will begin in 2010. The medical insurance provider fee, that 
will begin in 2010. The cosmetic surgery fee, that will begin in 2010. 
In 2011, there will be a limit on contributions and in 2013 a high-cost 
insurance excise tax. All the taxes are front-loaded, but all of the 
reforms they promise this bill will bring to all of the people whose 
stories they told us will not take place until 2014. The status for 
them will remain quo. For all of these attacks on the status quo, the 
one change we will get is they will start charging the taxes but they 
will not start delivering any kind of health care reform until 2014.
  Why are we delaying until 2014? Not because they do not think people 
need it but because they realize that if they start spending at the 
same time they start taxing, the score they will get out of the 
Congressional Budget Office will point out the true cost of this bill. 
And it is the true cost of this bill that is the kind of thing we need 
to be debating and talking about rather than listing story after story. 
My State is full of them, and I am just as sympathetic as anybody of 
people who have problems with the present health care system. That is a 
false debate.
  We all realize, all 100 of us realize that something has to be done 
to make the health care system better. This is not, should we do 
nothing; this is a debate about what should be done. The proposal we 
have from the majority leader is not the answer to the problems we 
face.
  Mr. KYL. Mr. President, I wonder if I may interrupt to ask, when the 
Senator said this is not the approach, the approach taken by the 
Democratic leader, among other things, because of the cost of it--my 
colleague from Arizona is here, and I think no one takes second place 
in this body to him in carefully looking at the cost of every bill we 
have on this floor. He frequently proposes amendments to reduce the 
cost of the bills.
  I wonder if my colleague from Arizona agrees with my colleague from 
Utah and is aware of the respected columnist David Broder who wrote in 
today's Washington Post--actually, it is for publication tomorrow--a 
column, the title of which is ``A Budget Buster in the Making.''
  Mr. McCAIN. Mr. President, I say to my colleague, not only is David 
Broder's column this morning important, but he is probably the most 
respected columnist in America. He talks about it in far more eloquent 
terms than I can.
  I ask my friend from Arizona--a very unusual event happened today. 
The majority leader, I guess proceeding on the concept, the age-old 
tried tactic of ``shoot the messenger,'' came to the floor of the 
Senate and excoriated David Broder, of all people, probably the most 
respected columnist. I might say, Mr. Broder from time to time has 
written an article or two or more that has been critical of me, but he 
always had my respect. For the majority leader, who cannot rebut the 
facts in David Broder's column, to come to the floor and excoriate one 
of the most respected columnists in America is remarkable.

[[Page 28764]]

  One of the things, I say to my friend from Utah, is that I do not 
think Americans really understand the scam that is going on here of 
beginning to collect taxes. Tax increases and Medicare cuts of 
approximately $1 trillion begin 40 days from now. In other words, on 
the first of January, according to this plan, Americans will begin 
experiencing cuts in Medicare and increases in taxes, 40 days from now. 
But then it will be 208 weeks and 1,460 days before any benefits from 
the legislation come about.
  Tell me, isn't that like a couple goes to buy a house and they say: 
OK, you can have the house for X amount. And by the way, you have to 
start making the payments now and for the next 4 years before you can 
move into the house. Is there anybody who would agree that is nothing 
but a scam on the American people? I do not think the American people 
truly understand the reason why--and why would they do that? To 
disguise the real cost of this $2.5 trillion bill. That is why they do 
it. I think Bernie Madoff went to jail for this kind of behavior.
  Mr. BENNETT. I say to my friend from Arizona, he reminds me of a 
real-life experience of a husband who at Christmastime came back to his 
wife and presented her with a brilliant Christmas present that she had 
not been expecting. She said to her husband: How could we afford this 
because the only amount we had in our Christmas budget was--pick a 
number--$200, and this is obviously worth more than $200.
  He said: Oh, don't worry about it. I paid $200 for it.
  She said: How in the world did you get $200?
  He said: The department store agreed to take the other $1,000 in 
payments later on.
  That is exactly what is happening here. We are making a downpayment 
and telling ourselves that the total cost is covered as outlined by the 
Congressional Budget Office.
  Mr. McCAIN. Again, it is so important that we read this hernia-
inducing bill, that we understand the details of it. Specifically in 
these cuts, which are going to take place in 40 days--40 days from now; 
Happy New Year, America--in 40 days, it will cut $135 billion from 
hospitals, it will cut $120 billion from 11 million seniors on Medicare 
Advantage.
  I would like to pause there for a moment. Senator Kyl and I represent 
the State of Arizona. We have thousands and thousands--and I am going 
to get the number before this debate is over--of seniors who are on 
Medicare Advantage. They are going to cut out the Medicare Advantage 
Program and tell the American people that if you like your insurance 
policy you have, you can keep it? How does that work? Then there is $15 
billion going to be cut from nursing homes, $40 billion from home 
health agencies, and $8 billion is going to be cut from hospice care--
my God, hospice care, $8 billion.
  Here we are telling the American people that we are going to fix 
health care in America, and the way we are going to pay for the massive 
government takeover of health care is through cuts. It is terrible on 
its face, but does anybody really believe these cuts are going to take 
place? Does anybody really believe the doctors are going to be cut $247 
billion in the next 10 years? Does anybody believe we are going to cut 
$247 billion--or whatever it is--from Medicare? We are not. Why are we 
not? Because we are a loving, caring nation. We are not going to tell 
our seniors that they are not going to receive a high quality of 
Medicare.
  Of course, this latest mammogram incident where a board, not unlike 
the one that is envisioned in this bill, said that women over 40 should 
not have mammograms--by the way, I have a close friend, Carly Fiorina, 
who has just recovered from chemotherapy. What would her situation be 
today if she had not had a mammogram? Women all over America are rising 
up about it. If you think that is bad, wait until you get this 
legislation.
  By the way, while my friends are standing, I would like to say please 
sit down, I have shocking news. The three Senators we were worried 
about--the Senator from Louisiana, the Senator from Arkansas, and the 
Senator from Nebraska--shocking news. They are going to vote for this 
bill to move forward. That was an issue of tremendous speculation with 
the media. I certainly did not know that with all the protestations we 
had from those three Senators that, by golly, they were thinking long 
and hard. Guess what. So, OK.
  Mr. BENNETT. I say to my friend from Arizona, and then I will yield 
to my friend from Tennessee, Senator McCain just asked a question: Does 
anybody really believe these cuts will take place?
  I share with him an experience I had driving home from the Senate 
just this week. I was listening to the radio, and the first story on 
the radio was this vote coming up. The Senate is going to vote at 8 
o'clock on Saturday. The second story was that the House of 
Representatives just passed a doc fix of $200 billion. So we already 
have action by the House of Representatives proving that the comment by 
Senator McCain is exactly right. Before this bill even gets passed, 
they are reversing the cuts over in the House of Representatives. 
Senator Reid tried to do it here before we got to this bill, and we 
voted him down. So the House is going to take care of it, and they will 
ping-pong the bill over here.
  There is no question that these cuts will not take place.
  My friend from Tennessee wishes to comment.
  Mr. ALEXANDER. Mr. President, I see the Republican leadership in the 
Chamber. It seems as if every other word we hear coming from the other 
side is that this vote tonight is historic. I agree, it is historic. 
But I think my view of why it is historic is a little different from 
their view.
  I wonder if my colleagues would not agree with me that this bill is 
historic in its arrogance? It is historic in its arrogance to think 
that we in Congress are wise enough to take this entire complex health 
care system, that serves 300 million Americans and is 16 percent of our 
economy, and think we can write a 2,074-page bill and be wise enough to 
change it all at once. It is historic in its arrogance by dumping 15 
million low-income Americans into a medical ghetto called Medicaid, 
which none of us or any of our families would ever want to be a part of 
for our health care. It is historic in its arrogance by sending the 
States, that are going broke, a big chunk of the bill for what we have 
just done. It is historic in its arrogance because it tells Americans 
that the bill costs $849 billion and then thinks we are not smart 
enough to read the print and figure out that the real cost is $2.5 
trillion when it actually is implemented. It is historic in its 
arrogance by telling us that paying for reimbursement for physicians is 
not an important part of a health care bill. It is historic in its 
arrogance because it cuts and taxes grandma's Medicare, which according 
to the trustees will be broke by 2015 to 2017, and then spends it on 
somebody else other than grandma. The bill is arrogant because its 
telling us it will reduce premiums for most Americans, when, in fact, 
it increases premiums for most Americans.
  So People say: Where is the Republican health care bill? My answer to 
that is, don't expect Senator McConnell to come rolling in here with a 
wheelbarrow with a 2,074-page budget-busting, debt-ridden, arrogant 
piece of legislation because that is not what we believe in.
  What we need to do as a Congress is re-earn the trust of the American 
people by setting a clear goal of reducing health care costs, showing 
some humility, and starting to move step by step in that direction. I 
hope during this hour that we have a chance to talk about the specific 
steps to reduce health care costs that we Republicans have offered day 
after day to no avail.
  Mr. KYL. Mr. President, if I can interrupt my colleague and 
compliment him on the phrase ``arrogance.'' Maybe ``hubris'' is another 
word. To think we are smart enough in Washington to figure out what is 
best for 300 million Americans is truly arrogant.
  A question posed by my colleague from Arizona a moment ago: Do they 
really think they can whiz this by the American people with regard to 
it not adding to the deficit, for example? Good question.

[[Page 28765]]

  I want to get back to that Broder piece my colleague from Arizona 
quoted. There is actually a survey that answers that question. It turns 
out the American people are pretty smart about this. The question in 
this Quinnipiac poll read:

       President Obama has pledged that health insurance reform 
     will not add to our Federal budget deficit over the next 
     decade. Do you think that President Obama will be able to 
     keep his promise? Or do you think that any health care plan 
     that Congress passes and President Obama signs will add to 
     the Federal budget deficit?
       Answer: Less than one-fifth of the voters, 19 percent to be 
     exact, think he will keep his word. Nine out of 10 
     Republicans, 8 out of 10 independents said that whatever 
     passes will add to the torrent of red ink and by a margin of 
     4 to 3 even Democrats agreed that this is likely.

  That is why, Broder says at the end:

       By a 16 point margin the majority of this poll said that 
     they oppose the legislation moving through Congress.

  So while it is true they are rather arrogantly trying to contend 
there will not be any big budget deficit from this, the reality is the 
American people have broken the code they will. One of two things will 
happen. My colleague from Arizona put his finger right on it. Either we 
will make cuts in Medicare, for example, that we have never had the 
political ability to make in the past, in which case our seniors will 
be hurt, or else, as David Broder said, this bill will truly be a 
budget buster.
  Neither of those results are very sanguine outcomes to an attempt to 
transform or reform our health care.
  Mr. McCONNELL. Will the Senator from Arizona yield for an 
observation?
  Mr. KYL. Absolutely.
  Mr. McCONNELL. I certainly share the views of Senator McCain that 
letting these cuts stand is not likely. On the other hand, the 
President of the United States said he would veto any measure seeking 
to reverse these cuts. So we have a Hobson's choice: Either the cuts 
will occur in which case seniors will be devastated or they will not 
occur, as the Senator from Arizona has pointed out, and the deficit 
will balloon further.
  Mr. McCAIN. Did the majority leader happen to notice that the AARP 
has now endorsed this bill? It has endorsed a bill that will cut 
people, 300,000 of them in my State, from their Medicare Advantage 
Program, that would cut $15 billion from nursing homes, that would cut 
$8 billion from hospices, and that AARP, which, by the way, I 
understand gets some $60-some million out of this deal--I say to the 
senior citizens in my State: Take your AARP membership card, cut it in 
half, and send it back to AARP because they have betrayed you.
  Mr. BENNETT. If I could make the comment, Mr. President, among the 
people who do not believe these changes would not occur is CBO itself. 
CBO itself agrees this is smoke and mirrors. They do it in very polite 
language, but let me share with you the language. They say:

       These longer-term calculations assume that the provisions 
     are enacted and remain unchanged throughout the next 2 
     decades, which is often not the case for major legislation.

  That is about as gentle a way as CBO can put it. They don't believe 
this thing is going to stand without these kinds of changes. Yes, they 
have come forward because their computers say: You put the numbers in 
this way, this is the result you get. But human beings are saying that 
is not what is going to happen over the next two decades.
  Mr. KYL. If my colleague will yield, Broder, in his column as to this 
estimate of budget deficit, he says it depends upon two big gambles.

       Will future Congresses actually impose the assumed $420 
     billion cuts to Medicare, Medicaid and other Federal health 
     care programs? They never have.

  Mr. McCAIN. Also, I would like to follow up on what the Senator from 
Tennessee has said because, particularly from some quarters on the 
other side of the aisle, we have been attacked: Where is the Republican 
plan?
  A very important article was written by Robert Samuelson in the 
Washington Post on November 16--again, one of the most respected 
economists in America.
  I don't lay off these opinions of my own on them, but the fact is, 
when you have highly respected people like Robert Samuelson, one of the 
most respected economists in America, I quote from his column--the 
title is ``Obama Care, Buy Now, Pay Later.'' That is the title of it. 
He says--which I think is directly in consonance with what the Senator 
from Tennessee said:

       [A] prudent society would embark on long-term policies to 
     control health costs, reduce government spending and curb 
     massive future deficits.

  Then he goes on to say:

       So what do they do? Just the opposite. Their far-reaching 
     overhaul of the health care system--which Congress is halfway 
     toward enacting--would almost certainly make matters worse. 
     It would create new, open-ended medical entitlements that 
     threaten higher deficits and do little to suppress surging 
     health costs. The disconnect between what President Obama 
     says and what he's doing is so glaring that most people could 
     not abide it.

  That is strong language from an economist. I think what the Senator 
from Tennessee is saying, and what we are trying to say is, let's go 
forward. Let's have malpractice reform. That is nowhere in this 
monstrosity. Why don't we encourage health savings accounts and expand 
them? Why don't we let people go across State lines to get health 
insurance policies of their choice? Why don't we reward wellness and 
fitness? There is a long list of amendments, of fixes to the long-term 
costs of health care that we could control, that we could enact 
tomorrow on a bipartisan basis. They do not add to the deficit. In 
fact, what they do is control health care costs, which is what is wrong 
with health care in America.
  The quality of health care in America is outstanding. It is the cost. 
We could be working together step by step, as the Senator from 
Tennessee says, with a long list. I am sure he will add to them the 
ones I just gave out to control health care costs in America. We stand 
willing to do it.
  After this bill fails, because the American people overwhelmingly are 
beginning--it may pass the Senate. It may pass the House. It will not 
pass.
  Then why don't we sit down together for a change, Republicans and 
Democrats, and move step by step to fix the health care problems in 
America?
  Mr. ALEXANDER. The Senator from Arizona is exactly right.
  There is no Senator in the Chamber who has a better record of working 
across party lines on bipartisan steps in the right direction than the 
Senator from Arizona. But going to Mr. Samuelson's comment--I was 
talking to a businessman this morning.
  I said: If you had a problem in your company, would the first thing 
you would do is to tear the whole company down and start over again? Or 
if the football team had lost two or three games, would you blow up the 
stadium and run everybody off? No, that is not the way you do it.
  The person I was talking to said: What I would do, I would identify 
the problem, I would test the solution, I would phase it in, and I 
would make sure we can afford it.
  The American people know that. I think they are sitting up there 
looking at us saying: What are these guys doing? Two-hundred-fifty 
million of us have health care policies, 85 percent. We would like for 
the rest of America to have that opportunity too. But we know we can't 
afford that until we get the costs down.
  Why don't we do as the Senator from Arizona suggested, let's move 
step by step in the right direction to re-earn the trust of the 
American people by reducing costs?
  He said: Why haven't we done that? One of those steps is to allow 
small businesses to pool their resources and purchase a health plan, 
which the Congressional Budget Office has said would allow nearly 1 
million more employees of small businesses to be covered. Their rates 
would be lower than they are paying today. It would save $1.4 million 
of Medicaid. This is what the Congressional Budget Office said. So it 
would reduce costs, increase insurance coverage, and lower premiums. 
The reason we are not considering it is because when we brought it up, 
the Democrats said no. They filibustered it. They didn't come across 
the aisle and say

[[Page 28766]]

that is a pretty good idea; let's put that together with two or three 
of ours, and we will reduce costs.
  I say to Senator Bennett of Utah, you have founded a company. You 
have run a company. If you were having a problem with the cost of a 
product or some other fundamental problem, is the first thing you would 
do, is to think you were wise enough to tear the whole thing down and 
start over again? Or if you called in a consultant and he recommended 
that to you, what would you say to him?
  Mr. BENNETT. Obviously, I would not respond in the way the folks 
across the aisle have responded to this health care crisis. The example 
the Senator has given is a valid one. That is not how you deal with it.
  The other point I would make is that if I had a serious problem that 
was causing difficulty for the survival of the company, I would not put 
the solution off for 4 years while I raised prices on the existing 
products to try to pay for it. I would try to do what I could to get 
the fix upfront as soon as possible.
  As both Senators have pointed out, we Republicans have fixes that 
could start now and don't have to wait until 2014 in order to get a 
good CBO score.
  Mr. McCAIN. Along those lines, again, about this Madoff-type 
budgetary procedure, I am not that good at math. I am sure the Senator 
from Tennessee is. Help me out.
  We have $1 trillion that they want to make in offsets, right, in this 
10-year plan. If you started the program at the same time that you 
enacted the savings, that would be $1 trillion, right? That would be 
$2.5 trillion. So the deficit, if you used correct accounting 
procedures--in other words, you bring in the benefits at the same time 
you start paying for it--you would end up with a $1.5 trillion deficit 
to the budget? Does that make sense?
  Mr. ALEXANDER. It sounds right to me. It is another part of the 
arrogance of this bill, which is to say we are not smart enough to 
figure it out. The majority is saying the 10-year cost of the bill is 
$849 billion, but it doesn't start counting until the fifth year, and 
Senator Reid thinks the American people are not smart enough to figure 
that out. That is part of the arrogance of the bill.
  Mr. McCAIN. If the benefits kicked in at the same time the taxes did, 
you would be talking about a $2.5 trillion cost.
  Mr. ALEXANDER. That is $2.5 trillion, right?
  Mr. BENNETT. I point out the CBO makes the same point at these 10 
years. Again, quoting the CBO letter, talking about the 10 years 
following, when you have the full 10 years of expenditures instead of 
just 5 or 6 years of expenditure, it says:

       Under the legislation federal outlays for health care would 
     increase during the 2010-2019 period, as would the federal 
     budgetary commitment to health care.

  So those who are saying this is going to be a saving to the 
government and you are going to turn the cost of health care--turn the 
cost curve with respect to health care down, the CBO has said: No, that 
is not the case. The Federal commitment would go up in those years.
  Again, by delaying the implementation of the expenditure while 
implementing immediately the implementation of the revenue, they are 
creating the kind of financial chicanery that, as Senator McCain has 
said, put Bernie Madoff in jail.
  Mr. McCAIN. Could I bring up another issue to the Senator from 
Tennessee and the Senator from Arizona and Utah. A New York Times 
article this week stated: ``Drug Makers Raise Prices in Face of Health 
Care Reform.''

       Even as drugmakers promise to support Washington's health 
     care overhaul by shaving $8 billion a year off the Nation's 
     drug costs after the legislation takes effect, the industry 
     has been raising its prices at the fastest rate in years.
       In the last year, the industry has raised the wholesale 
     price of brand-name prescription drugs by about 9 percent, 
     according to industry analysts. That would add more than $10 
     billion to the nation's drug bill, which is on track to 
     exceed $300 billion this year. By at least one analysis, it 
     is the highest annual rate of inflation for drug prices since 
     1992.

  So the moral of the story is, you lie down with dogs and you get 
fleas. So they cut a deal with the administration to cut drug costs, 
and guess what. With inflation zero, no inflation, they have decided to 
raise costs by more than 8 percent. Oh, the Consumer Price Index has 
fallen by 1.3 percent. The Consumer Price Index has fallen by 1.3 
percent, and the prescription drugs have increased in cost by 9 
percent.
  What does this do to seniors? Seniors are not going to get a COLA in 
Social Security this year because the consumer price index has fallen--
which is the indicator as to whether cost of living adjustments are 
given to Social Security recipients. So what does the drug industry do? 
Without inflation, they raise the cost of prescription drugs by some 9 
percent at a time when Americans are hurting more than ever. Shame on 
the drug industry. Shame on those people, and shame on the 
administration for cutting a deal with them.
  Mr. KYL. Mr. President, I see our other colleague from Utah here. I 
know that during Finance Committee deliberations, he was directly 
involved in one of the conversations about the drug costs and also has 
been working on his own ideas for alternative approaches to some of 
these problems. I will ask a question and then if my colleague from 
Utah, Senator Hatch, may like to comment further, we would invite that.
  Is it the case that the Joint Committee on Taxation, which reported 
to the Finance Committee, and the Congressional Budget Office both said 
that not only would the increased taxes on the pharmaceutical industry, 
the medical device industry, and the insurance industry be passed on to 
consumers in the form of higher premiums but that overall under the 
legislation that is before us, for the average family as compared to 
what prices are today, insurance premiums would actually go up and this 
was one of the two major reasons, the other being mandated benefits?
  Mr. HATCH. The Senator is absolutely right. They even said the 
premiums of the so-called government plan would be higher than private 
sector insurance premiums. It is incredible.
  I have enjoyed the comments by the distinguished Senators from 
Arizona, Utah, and Tennessee. If you look at what they are trying to 
do, they are going to throw out a system that 85 percent of the 
American people feel is basically OK, because they have not taken care 
of the 15 percent who don't have insurance. But when you deduct the 6 
million people who work for companies that provide insurance but they 
don't take it--they would rather have the money--and you take out the 
11 million people who basically qualify for Medicaid or SCHIP but are 
not enrolled, and you deduct those who earn over $75,000 a year and can 
afford their own insurance, and then you take the illegal aliens, the 
documented workers and undocumented workers, you basically come down to 
17 million people who need and deserve our help. We are going to throw 
the whole system out for 85 percent of the people when we could, 
through subsidization, help those who deserve help.
  It doesn't make sense. What are they thinking over there? I hope it 
is not that they want to take us to socialism or to Europeanize us, 
when Europe is trying to get away from Europeanization.
  We are rapidly approaching one of the most important votes for all of 
us in the Senate. This is bigger than any of us, our parties or our 
ideologies. This is about the future of the greatest Nation in the 
history of the world. It is about your children and my children. It is 
about your grandchildren, my grandchildren. Elaine and I have three 
great-grandchildren and two more on the way. It is about giving the 
future generation the same opportunities and same sense of pride. It is 
about every American's way of life.
  Every American business will be subject to this. Look at that thing, 
a 2,074-page edict from Washington. I am going to spend my time before 
this historic vote to highlight some very important numbers. Every 
Member of this Chamber should understand what they are voting to 
advance. Make no mistake, our actions today will not be

[[Page 28767]]

without consequences. History and future generations will judge us by 
what we do here today.
  Zero is the number of provisions prohibiting the rationing of health 
care, not one word prohibiting the rationing of health care. All you 
have to do is look at some of the things that happened this week and 
you start to worry about it. How about this? Zero is the number of 
government-run entitlement programs that are financially sound over the 
long term. Consider these important numbers: 10.2 percent national 
unemployment rate, the highest in 26 years; 70, the total number of 
government programs authorized by this bill, 70 new programs at a time 
when we are going into fiscal insolvency; 1,697 times the Secretary of 
Health and Human Services is given authority to determine or define 
provisions in this bill. We are turning the whole thing over to the 
bureaucrats here in Washington. More numbers: 2,074 total pages of this 
bill--look at that--2010, the year Americans start paying higher taxes 
to support this bill. My colleague from Utah and my colleagues from 
Arizona and Tennessee have brought that out in no uncertain terms. The 
year when this bill actually starts is 2014, most of the major 
provisions of this bill. Some of them don't even begin until 2015. The 
number $6.8 million is the cost to taxpayers per word in this bill; $8 
billion is the total amount of new taxes on Americans who do not buy 
Washington-defined health care; $465 billion in cuts in Medicare at a 
time when Medicare faces a $38 trillion unfunded liability to finance 
more government spending; $494 billion is the total amount of new taxes 
in this bill.
  If you think that is all, I think you have something coming here. 
According to the Budget Committee, using CBO figures, $2.5 trillion is 
the real cost of this bill over a 10-year period. Our total national 
debt will be $12 trillion. These numbers are facts and they are 
indisputable.
  Let me finish by reading an excerpt from a fellow Utahn from Provo 
who is worried about what this bill will do to our country.

       I am writing out of deep concern over the increasing 
     expansion of government. I moved here from Germany 20 years 
     ago. I love America because it is free--free-er than Germany 
     in that I have the freedom to choose among other things how I 
     want to insure my family (we have six children). I'm all for 
     affordable health insurance which requires affordable health 
     care. I am self employed and have been hit hard by the 
     economy. There is a good chance that we would actually 
     benefit from [this bill]. Business has been so bad that we 
     would qualify for free school lunches if we asked for it. But 
     I don't want more government handouts. I don't want the 
     government telling me what kind of insurance I need to have. 
     I don't want the government telling me what services I can 
     receive when I need them. I don't want them taking an ever 
     greater part of my income to help finance government programs 
     such as the ``public option'' and the army of government 
     employees it will take to administer such a program. I do not 
     want more government. I want less. A lot less.
  These people from Germany have been living in our country as citizens 
for 20 years. They know what it was like to have their type of a 
system. I think we ought to pay attention to that humble person who, in 
spite of the travails they have, don't want this big, massive 
government program to become law.
  Mr. McCAIN. Mr. President, I thank both Senators from Utah for their 
thoughtful comments and significant involvement. I wish to return to 
the issue of what we need to do. I say that because criticism has been 
leveled at this side of the aisle that we have no plan; therefore, 
since we have no plan, we should embrace this. The fact is, we have had 
plans. We have had proposals. We have tried to get them listened to. 
They range from medical malpractice reform to other free market cost 
reduction measures that add competition and quality to the health care 
system. Our objective is affordability and availability.
  I want to talk with the Senator from Tennessee about the issue of 
medical malpractice reform. Here is a huge piece of legislation. Yet I 
ask my friend from Tennessee, is there any measure in this bill we have 
been able to detect so far--we have been able to detect $100 million in 
additional Medicaid benefits for the State of Louisiana, but we haven't 
been able to determine all of the aspects of this bill. On the issue of 
medical malpractice reform, physician after physician in America says 
they have to practice defensive medicine for fear of finding themselves 
in court. Why is it that we have literally no addressing of an issue 
that could significantly reduce cost?
  As I recall, the CBO said that medical malpractice reform could 
reduce direct medical costs by some $54 billion over 10 years. There 
are other estimates that say if we added in the cost of the practice of 
defensive medicine over prescription medicines and drugs because of 
fear of finding themselves in court, this could be as much as $200 
billion. Yet there is not one significant addressing of the issue of 
medical malpractice in this legislation. I think that is a testimony to 
the influence of the American trial lawyers association.
  Mr. ALEXANDER. Mr. President, I would say to the Senator from 
Arizona, that is a part of the problem. But I think of it a little 
different way. There has been a lot of talk this week about medical 
care availability for women in America. In Tennessee, in 45 of our 95 
counties, there are no OB/GYN doctors. So pregnant women in Tennessee 
in those counties have to drive 50, 60, 70 or 80 miles for prenatal 
health care. They might have to check into a hotel for a few days in a 
big city in order to have their baby.
  Mr. McCAIN. Could I add, the mirror opposite of that is the State of 
Texas which was hemorrhaging medical doctors and care providers and 
then, after they enacted a very modest malpractice reform, there was a 
flood of physicians returning to the State of Texas. Isn't that the 
case?
  Mr. ALEXANDER. That is exactly right. In fact, a number of us have 
offered to the Senate, as a part of the way we would go about reducing 
health care costs, basically adopting the same kind of provisions they 
did in Texas which still leaves anyone who is hurt, a complete right to 
recover from that injury, but makes a major change in the availability 
of doctors to that patient. And in the case of Tennessee, we were 
talking about OB/GYN doctors to women who are about to have babies. The 
Senator from Arizona said that would save at least $54 billion over 10 
years. No one doubts that reform of medical malpractice, junk lawsuits 
against doctors, would reduce costs. The point we are trying to make 
here is, instead of that historically arrogant 2,074-page bill that 
presumes we know enough to change every aspect of health care in 
America, why don't we re-earn the trust of the American people, who 
have lost a lot of confidence in those of us in Washington, and start 
taking steps in the right direction to reduce cost? We could do it by 
adopting our legislation to reduce unwarranted medical malpractice 
suits. That would be one step.
  Mr. McCAIN. Could I revisit with the Senator an issue we talked about 
a little earlier and with my friend from Utah as well. This is the 
recent spate of publicity concerning a recommendation that women wait 
until 50 years of age before--I see our physician Dr. Barrasso is here 
also--getting routine mammograms. That ignited a firestorm throughout 
America and story after story of women who have experienced breast 
cancer who state categorically that if they hadn't gotten the mammogram 
when they did, it is possible they would not be alive today.
  Now that is a nice academic discussion. But I would ask--maybe Dr. 
Barrasso would answer it--isn't that the kind of advisory board this 
legislation could put into law; that those kinds of mandates could come 
down, which could literally jeopardize the health and lives of 
Americans?
  Mr. BARRASSO. Mr. President, I would say to my colleague and friend 
from Arizona, this type of legislation would have cost my wife her 
life. She is a breast cancer survivor, diagnosed by a routine screening 
mammogram. She was in her forties when that mammogram was performed. 
She went through the testing and had the operation. In that age, in her 
forties, she already had the breast cancer spread from her breast to 
one of the lymph nodes. It was a screening mammogram that

[[Page 28768]]

saved her life. She has had three operations, two bouts of 
chemotherapy. As a result, she is a survivor--6 years later.
  But this piece of legislation says: No, no, do not worry about it. 
There is not going to be any denial of care. There is not going to be 
anything like that. But if you turn to page 1,150, it talks 
specifically about this preventative task force, specifically saying 
when they make their recommendations there is going to be money that 
taxpayers are going to pay to tell people what those recommendations 
are. Then, if you go to page 1,190, it says that if it is not approved, 
they will deny payment for that service--deny payment. It does not say 
they might.
  Mr. McCAIN. I say to the Senator, you would not describe that as a 
``penal panel''?
  Mr. BARRASSO. Some people might.
  Mr. KYL. Mr. President, I went back to my office and got the exact 
pages our doctor colleague has just been talking about--page 1,189 and 
page 1,190 of the actual bill. My colleague from Arizona asked the 
question--this entity, this U.S. Preventive Services Task Force; the 
entity that made the recommendations with regard to mammograms is it 
possible their recommendations could be used to deny coverage or reduce 
payments or deny payments?
  Well, here is the exact language, if my colleagues would like to hear 
it. The Secretary of HHS is, of course, the person who implements this. 
It is not the task force. The task force makes the recommendations, and 
then the Secretary of HHS issues the regulations. Quoting:

       Notwithstanding any other provision of this title, 
     effective beginning on January 1, 2010,--

  That is just a couple months from now--

       if the Secretary determines appropriate, the Secretary 
     may--
       (1) modify--
       (A) the coverage of any preventive service described . . . 
     to the extent that such modification is consistent with the 
     recommendations of the United States Preventive Services Task 
     Force. . . .

  So there you have modifying the coverage. Then, secondly, as my 
colleague was just reading:

       (2) provide that no payment shall be made under this title 
     for a preventive service described in subparagraph (A) of 
     such section that has not received a grade of A, B, C, or I 
     by such Task Force.

  In other words, they make the recommendation, and they say this does 
not meet our standards, so she can say, therefore, we are not going to 
pay for it.
  That is taking the recommendations of this task force and translating 
it into the rationing of health care. This is how rationing begins.
  Mr. BENNETT. Mr. President, if I could share with Senators this 
statistic. We hear a lot of talk about everybody has to be covered. We 
talk about the United Kingdom, where they have a plan where everybody 
is covered. The cancer survivor rate for women with breast cancer in 
the United Kingdom, after diagnosis, is 57 percent. The cancer survivor 
rate in the United States, where we have people who are not covered, is 
67 percent. I do not think we want to move in the direction of bringing 
that rate down.
  Mr. BARRASSO. The reasons for that are they are not doing early 
enough screening, and even once they are able to find the cancer in 
Great Britain, how long do they have to wait in line until they 
actually receive the surgery? The delay of care is the denial of care, 
and that is what is going to happen under this bill.
  I see my colleague from Idaho standing as well because he is familiar 
with this situation. But I look at this and see the numbers. They said: 
Well, we don't want to cover this service because it would only save 1 
life out of 1,900 women in their forties. Well, in my case, that 1 life 
out of 1,900 was my wife Bobbi.
  I know the Senator from Idaho wants to get involved in this 
discussion.
  Senator Risch.
  Mr. RISCH. Mr. President, as you read these pages, most of it is 
incomprehensible. But, interestingly enough, the point made by the good 
Senator from Arizona about the ability of the U.S. Government to cut 
off health care to people is stated so clearly on page 1,189 of the 
bill. The title of the provision is ``Authority to Modify or Eliminate 
Coverage of Certain Preventive Services.'' How much clearer can it be? 
This bill gives authority to the group that was identified to modify or 
eliminate coverage of certain preventive services.
  Had this bill been in effect in the last week when the 
recommendations came out on mammograms, American women would be denied 
coverage for mammograms in the time period that was identified by this 
group. This is absolutely clear on this. This is just the beginning of 
the kind of health care rationing you are going to see under this bill. 
Americans are frightened, and they should be. Health care rationing is 
coming to America if this bill is passed.
  Mr. BENNETT. Mr. President, I would like to share another statistic 
in this whole circumstance that I think we need to focus on because, 
back to the Broder column Senator McCain talked about, we are talking 
about the amount of expenditures and the creation of a new entitlement.
  Let's go back to the debate on the budget. We got the numbers that 
said the projected revenue for fiscal year 2009 was $2.2 trillion. The 
entitlement spending for 2009 was $2.2 trillion. That means everything 
we have done in government--our embassies overseas, our military, the 
national parks, education, whatever it is--absolutely everything in 
2009, other than entitlement spending, had to be borrowed money.
  What are we doing with this bill? We are going to increase 
entitlement spending. We are going to increase the role of government 
that this Congress or future Congresses have no direct control over 
through the appropriations process. I have been chairman of an 
appropriations subcommittee. The amount we have control over in the Ag 
Subcommittee is about $17 billion. The total bill was $80 billion. The 
rest of that $80 billion was off-limits to the Appropriations 
Subcommittee because it was on autopilot as entitlement spending.
  The entitlement spending for farm subsidies is small potatoes, to use 
a farm subsidy word, compared to the entitlement spending for health 
care. So facing the kinds of deficits we are facing, facing the runaway 
entitlement spending we have, the largest portion of which is 
entitlement spending for health care, what are we being told to do? 
Increase the entitlement spending for health care and put future 
Congresses in an even deeper financial bind by taking even more of the 
total portion of the Federal budget that is outside the appropriations 
process and putting it on autopilot. That is the issue we must keep in 
mind as we look at this whole circumstance.
  Mr. McCAIN. Mr. President, I thank the Senator.
  Could I go back, again, and reemphasize with my colleagues and the 
American people what is very odious about the bill that is before us; 
that is, the Madoff-style budget gimmickry associated with this 
legislation. In 40 days--in 40 days--tax increases and Medicare cuts of 
approximately $1 trillion will begin--in 40 days. That is 6 weeks from 
now. But any benefits that would accrue from this legislation would 
begin in 208 weeks--1,460 days.
  So why in the world would we approve--and, obviously, we know why it 
is done. It is to make the budget look better, when it is deception 
being perpetrated on the American people because we are not telling 
them the true cost. We are not telling the truth because, if the 
benefits started at the same time the taxes started, it would be a $2.5 
trillion deficit over 10 years.
  It is unfair to the American people, who are going to have to foot 
the bill for this massive piece of legislation--it is unfair to them to 
tell them they are going to have to start paying the taxes and footing 
the bill for it and only 4 years later would any benefits come to them. 
I think that is a really wrong thing to do to the American people.
  Do you know what. The American people are beginning to figure it out. 
Mr. President, 51 to 35, the American people do not want this. The 
American

[[Page 28769]]

people do not want an increase in the deficit. They want the spending 
stopped, and they are figuring it out. I am afraid my friends on the 
other side of the aisle may have underestimated the intelligence of the 
American people.
  Mr. ALEXANDER. Mr. President, I would like to thank the Senators from 
Arizona, Utah, and Idaho. Reading that big bill is very hard to do. So 
for those who are watching, what we have been trying to do--as Senator 
McCain and Senator Kyl just did--is take specific provisions and 
discuss them and interpret them.
  We have done that with the higher premiums. We have done that with 
the higher taxes that the bill will require. We have done that with the 
Medicare cuts. Earlier today we had an hour discussion, led by Senator 
Corker, that discussed how the bill would send the costs for Medicaid 
expansion to States.
  We have talked now about what we would do if this bill were to fail, 
which we hope it does. We think this bill is historic in its 
arrogance--arrogance that we could turn over this whole system, that we 
think the American people cannot figure out that the bill costs $2.5 
trillion, instead of the $849 billion, as advertised.
  What we propose is, we move step by step in the direction of cutting 
health care costs for individuals and for our government. We have 
proposed legislation that would reduce junk lawsuits, combat waste, 
fraud, and abuse, allow small businesses to pool resources to purchase 
insurance, allow Americans to purchase health insurance across State 
lines, expand health savings accounts, and promote wellness and 
prevention.
  Mr. BENNETT. Mr. President, I wish to make the point, again, 
following up on what the Senator from Tennessee has had to say, that 
the argument we are hearing from the other side is a false argument 
when they say it is either this bill or the status quo and the 
Republicans have nothing to offer.
  We have been offering proposals all along. I have been immersed in 
this for 3\1/2\ years, cosponsoring, with my Democratic friends, ideas 
on the way to go forward. Those proposals were not even allowed to be 
considered in committee. The 2,000 pages we see before us were written 
without a single Republican knowing where the room was, let alone being 
in the room. Then we are told: But you stand for the status quo, and 
the status quo is unacceptable.
  I repeat what I said earlier: The way this bill is constructed, the 
status will remain quo until 2014, as far as benefits are concerned, 
but the taxes will start immediately. But we all know the revenue that 
comes from those taxes will not be held in trust to pay for the 
benefits in 2014. They will go for other things, to pay for the $1.4 
trillion deficit we have this year. Then, in 2014, when the expenses 
start, the money will all have been spent that had been brought in, in 
the 4 years previously, and, as the CBO says, there will be change.
  I yield the floor.
  The PRESIDING OFFICER. The time reserved for the Republicans is 
expired.
  Under the previous order, the time until 6:30 p.m. will be controlled 
by the majority.
  The Senator from Michigan.
  Ms. STABENOW. Mr. President, it is my pleasure and honor this evening 
to be here to strongly support this motion, this historic motion to 
proceed to a historic debate about whether we, as America, the greatest 
country in the world, are going to make sure all Americans have access 
to affordable health care insurance. This is something that has been 
debated for 100 years. Now we have the opportunity, with the House 
having passed their version, to move forward to this debate where we 
will have lots of opportunity to offer amendments and to debate honest 
differences in policy. But in the end, I believe confidently that we 
will come together to move forward to pass legislation that will save 
lives, that will save money for the American people, that will protect 
Medicare, and that will stop insurance abuses happening for families 
every single day.
  I have come to the floor so many times to talk about health insurance 
reform, as has the distinguished Presiding Officer from Rhode Island. I 
wish to take just a moment to say thank you to a few people because, as 
the Presiding Officer knows, we would literally not have this 
opportunity today if it were not for Senator Harry Reid, our 
distinguished majority leader. He is a quiet, smart, determined, 
focused leader who has listened to everyone, who has looked at the work 
products from the Finance Committee and the HELP Committee and brought 
together a combined bill that is the best of both. He is going to give 
us the opportunity to continue to debate and improve it on the floor 
before final passage. So I thank Senator Reid. I know he is passionate 
about his State of Nevada, and that is his No. 1 love after family, but 
I think No. 2 is the Senate and the ability to lead and get things 
done, and I thank him.
  I thank Senator Baucus for his incredible leadership on the Finance 
Committee; Senator Dodd for his leadership and stewardship in bringing 
the HELP Committee through with their legislation; Senator Harkin, 
Senator Wyden, and Senator Bennett, who is on the floor. We are not 
agreeing on the movement forward on this bill, but there have been 2 
years of working on health care that I appreciate, and their efforts 
together to work on health care.
  I thank Senator Snowe. I don't know if she is going to be with us 
this evening, but her courageous vote on the Finance Committee is 
something we desperately appreciate. I know she is going to continue to 
provide input, and I am hopeful she will be with us on the final vote 
because her input and her knowledge have been extremely important in 
this process.
  I also thank the memory of a very important Senator named Ted 
Kennedy, who I know is here in spirit, for 40 years of dedication to 
this cause.
  Finally, I thank President Obama. If not for his vision, we would not 
be here today. For 8 years under a former President, we did not have 
the opportunity to get here to this place. We did not have the 
opportunity to be able to end insurance abuses and truly protect 
Medicare for the future, to put forward health care reform, to save 
lives, and to save money. I also thank President Obama for 
understanding that health care is also about jobs and that we have too 
many people in this country today who are losing their job, and with 
that they are losing their health insurance. So it is impossible to 
talk about health care reform without also talking about jobs because 
for most families they are connected and one and the same.
  I have spoken on the floor so many times on health care cost and 
access. Frankly, health care is something that brought me to public 
service 30 years ago; when I was 5, I just want to say that for the 
record. I led an effort in our community to keep a nursing home open in 
Okemos, MI, and ever since then have been fighting to get to this 
debate, to get to this point in terms of affordable health insurance 
for all Americans.
  So tonight, after this vote, we start the real debate. This bill 
provides a framework for every American to find affordable insurance. 
Is it everything I would do if I was writing it by myself? Of course 
not. Every Member can say the same thing. But the Democratic process is 
coming together with the best ideas and negotiating and doing the best 
we can to be able to solve as much as we can in the best way possible. 
I am going to continue to work to make health care truly affordable and 
will be sponsoring and cosponsoring amendments as we move forward to 
improve on what I believe is a very good bill. I am confident that at 
the end, again, we will pass legislation that saves lives, that saves 
money, that protects Medicare, and that stops insurance abuses.
  When we first started this effort, I set up the Health Care People's 
Lobby on my Web site so that people could share their stories, how they 
felt about what we should be doing. Should we move forward and act? 
What should happen? What were their experiences with their health 
insurance and the companies that cover them now? I have heard so many 
stories. I wish to thank

[[Page 28770]]

everyone--thousands of people--who has shared their story. I want to 
put a face on this debate and vote tonight by sharing just a couple 
with you.
  When we say saving lives, this is not just a slogan. We are talking 
about saving lives. Forty-five thousand people have the ultimate 
rationing every year because they can't find affordable insurance. As a 
consequence, they lose their lives--45,000 people in the greatest 
country in the world. We can do better than that, and that is what this 
bill is about.
  I wish to share just one story of a young man, Joe, from Okemos, MI. 
He is a recent graduate of dental school. He worked very hard, was very 
bright. He was just between jobs after completing his residency, and we 
know how long and hard that is, to get to that point. He suddenly fell 
ill. This was only a few months ago. He called his mom. She urged him 
to go to the doctor, but because Joe didn't have insurance, he was 
worried about going to the doctor, so he didn't. He continued to feel 
worse. His family finally got him to agree to go to the hospital, but 
by then it was too late. Joe died at age 27 of an aneurism--27 years 
old--because in America, he didn't have insurance and was afraid he 
couldn't afford it if he went to a doctor.
  This is about saving lives. This is about saving money for businesses 
that are trying to keep the doors open, that may provide insurance now 
but are at a point where either the jobs go or they have to stop 
providing insurance. So people come in, and the owner says: I want to 
keep you working, but we are not going to be able to have health care 
for you anymore.
  This is about the fact that our country is spending twice as much as 
any other country on health care and yet sometimes having outcomes that 
are far worse than we would like to see as it relates to other 
countries. We are 29th in the world in the number of babies who make it 
through the first year of life. Of all of the insurance companies a 
woman can choose from if she goes into the private individual insurance 
market--59 percent don't provide maternity care, basic care, prenatal 
care, care for mom and baby during the first year. So that is going to 
change because of the values we bring to this.
  We are going to protect Medicare. Folks don't have to believe us. 
There is a lot of debate about what is happening in Medicare. I am very 
proud to say we have received a very strong letter from the AARP 
supporting a ``yes'' vote this evening to move forward on this debate, 
and that is critically important for us.
  Let me share from the Web site of AARP what they say--the champions 
for seniors in this country; what they say, not what we say--about what 
is being done in health care reform.
  On their Web site:

       Myth: Health care reform will hurt Medicare.
       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.
       Fact: Health care reform will lower prescription drug costs 
     for people in the Medicare Part D coverage gap or doughnut 
     hole so they can better afford the drugs they need.
       Fact: Rather than weaken Medicare, health care reform will 
     strengthen the financial status of the Medicare program.

  That is why AARP has written a letter urging us all to vote yes on 
the motion this evening we will be voting on, because we are 
strengthening Medicare for the future.
  Then let me speak to the question of insurance reforms because the 
reality is that the majority of people have insurance. The majority of 
us so far have insurance through our employer, and we hope that as we 
bring down the costs and save money, that, in fact, we will be able to 
make sure people are going to be able to continue to have the coverage 
they are paying for today. So we are talking about insurance abuses and 
stopping those insurance abuses.
  I wish to share a couple of stories from individuals who have found 
themselves in a very difficult situation. I realize my time has come to 
an end, so I will be brief, but I do want to share just a couple of 
stories in conclusion.
  From the newspaper recently: Benjamin French, a young boy in 
Michigan, was born with his right arm missing below the elbow. In his 
12 years, he has been fitted with seven prostheses. His most recent 
replacement will cost nearly $30,000, and his doctor says he will soon 
grow out of it. He is a 12-year-old who is growing up, so as he gets an 
artificial arm, it has to be replaced periodically to be able to grow 
with him. But according to his insurance company, the boy is ineligible 
for future coverage of prosthetic devices because he has already spent 
his lifetime maximum benefit. That is going to stop. We are going to 
eliminate those lifetime caps that get in the way of a 12-year-old 
being able to have the artificial arm he needs as he grows up so he can 
lead a normal life.
  I wish to share one other story, and that is from Glen from Sterling 
Heights. He is 62 years old. He got laid off in December. It doesn't 
look as if he will be called back. He writes:

       I am too young for Medicare. I have preexisting conditions, 
     so nobody wants to insure me. If I get sick before I can get 
     Medicare, my savings and everything else will be wiped out. 
     This is not the way I pictured retirement was going to be. I 
     raised four children, got them through school, and married; 
     paid taxes and did what I thought was the right and moral 
     thing to do. I didn't create this mess, but I am sure paying 
     for it.

  He did the right and moral thing, and that is what we are being asked 
to do on behalf of the American people.
  Vote to move forward tonight. Vote for the debate. Doing nothing is 
not an option when we are losing jobs, people are losing lives; when we 
are losing the capacity of the country to be able to provide the health 
care for our families that we need to provide. It is our turn tonight 
to vote yes on proceeding to a debate that I believe, working together, 
will result in legislation on health care that will save lives, save 
money, protect Medicare, and stop insurance abuses.
  Thank you, Mr. President. I yield the floor.
  The PRESIDING OFFICER. The Senator from New Jersey is recognized.
  Mr. MENENDEZ. Mr. President, for many months the voices of opposition 
to any health care reform have been loud and clear. They have been 
shouting at townhall meetings and heard in debates in this Chamber. All 
too often, we have heard shrill voices raised in anger from those who 
are either misinformed or who would choose the status quo that benefits 
insurers at the expense of families. For too long those voices have 
gone unanswered.
  The Patient Protection and Affordable Care Act we are about to 
consider is our answer. It is loud and it is clear. It is thoughtful 
and historic. Once again, like so many other pieces of landmark 
legislation in the last century, it is a product of this side of the 
aisle.
  Those who have chosen to block any attempt at health care reform this 
year are on the wrong side of history, just as those who came before 
them had one response to every landmark piece of legislation for the 
last 80 years. Their response has been a resounding ``no.'' They told 
us that it is not good for business, that it is socialism, that it 
stifles free market forces, and that it is too much and it goes too 
far.
  We have heard the same fear mongering and innuendo since the New 
Deal. There are those who raised the specter of socialism then and said 
no to Social Security. They said no to unemployment insurance when 
President Roosevelt proposed it as part of the Social Security Act. 
They said no when John Kennedy and Lyndon Johnson fought for Medicare. 
They said no to the Civil Rights Act. They said no to the Voting Rights 
Act. They said no to the Clean Air and Clean Water Acts. They said no 
to jobs programs. They said no to increasing unemployment insurance, 
when people needed it the most. They said no to government oversight of 
polluters who poison our land with toxic waste, and then they said no 
to cleaning it up. They have been on the wrong side of history for 
almost a century on every major piece of legislation that has leveled 
the playing field for average Americans. They are on the wrong side of 
history once again.

[[Page 28771]]

  All we hear from the other side of the aisle is the dim echo of the 
past, with no plan for the future. Americans are tired of the 
naysayers, tired of the shrill voices of no, when so much is at stake. 
It is time to say yes, time to say yes to stopping greedy insurance 
companies from standing between doctor and patients, time to say yes to 
ending medical decisions based on risk management and the bottom line 
rather than on saving people's lives.
  This historic legislation, like so many other pieces of legislation 
debated on this floor, is about people--their lives, their hopes, their 
health, and their dreams for a better life for themselves and their 
families. We can be proud of this legislation. I know that when the 
dust settles and the provisions of this bill become clear, America will 
be proud of it as well.
  This landmark reform legislation includes State-based exchanges 
creating a fair, open, and competitive marketplace for affordable 
health care coverage. It includes an amendment I proposed for long-
overdue consumer protections for emergency services without having to 
call your health care provider and get a prior authorization. It 
requires insurance plans to provide behavioral health treatments, such 
as those for children who face the challenges of autism, as part of the 
minimum benefit standards. It encourages investments in youth therapies 
to prevent, diagnose, and treat acute and chronic disease. There is a 
tax credit for innovative biotechnology research. It ensures that minor 
children qualify as exchange-eligible and provides for the availability 
of child-only health insurance coverage in the exchanges. It stops 
insurance companies from denying coverage for some preexisting 
condition, some preexisting health status, or gender. It ends the 
medical benefits shell game that insurers have played with people's 
lives.
  As soon as this bill passes and the President signs it into law, 1.3 
million seniors in New Jersey will receive free preventive care, such 
as colonoscopies or any other recommended preventive service; 227,000 
New Jersey seniors will have their brand-name drug costs in Medicare 
Part D cut in half; 854,000 New Jerseyans will qualify for tax credits 
to help them buy health insurance and ease the burden of premiums, 
deductibles, and copayments; 107,000 small businesses in New Jersey 
could get a small business tax credit--up to 50 percent of premium. 
Health care reform will end the hidden tax that gets passed along with 
the $1.1 billion spent on uncompensated care in New Jersey. It will 
provide portability, security, and choice through the health insurance 
exchange for 1.5 million New Jersey residents who don't have health 
insurance at all.
  The bottom line is that Senator Reid's merged bill helps New Jersey 
and America. It is fair, balanced, and fixes a badly broken system. It 
is truly a historic piece of legislation and will be remembered as 
such. Yet there are all those who will stand against all of it, those 
who will stand firmly on the wrong side of history once again, those 
who will use every legislative tactic to stop this legislation as they 
tried to stop Social Security and Medicare. I am afraid history is 
about to repeat itself.
  We have seen that the truth has been a victim on the Senate floor 
today. We listened to some of the most dire predictions, some of the 
most incredible statements, with figures thrown out there that are 
astronomical, simply not true, and in defiance of what the nonpartisan 
CBO said, which we all depend on--Democrats and Republicans. They said 
this bill actually cuts the deficit by $130 billion in the first 10 
years and $650 billion in the second 10 years.
  In the face of a health care system that seems to work only for 
health insurers--certainly not for average Americans--one must ask 
what, if any, health care reform are my friends on the other side for. 
What were their predecessors for when Americans were standing in bread 
lines and needed unemployment insurance? What were they for when they 
voted against Medicare? What are our Republican colleagues for now? 
They seem to be for one thing only: protecting the status quo, leaving 
health care just the way it is, letting insurers make medical 
decisions, letting insurers collect premiums and then find creative 
ways to deny coverage.
  On the other hand, this bill represents the change America voted for. 
But as we have seen, change does not come easily. You have to work for 
it. You have to fight for it. Sometimes, in the face of the naysayers 
and fear mongers, you need more than the truth, common sense, and even 
a good plan; you need to fight for what you know is the right thing to 
do for every American, not the few, not the powerful and the well-
connected but everyone.
  At the heart of it, this vote we will cast tonight is about change. 
We can see how hard real, honest, commonsense change is. We must ask 
ourselves: Do we continue to be the agents of change or do we stand 
with the status quo that discriminates against hard-working Americans 
who are denied health coverage because of preexisting conditions? Do we 
continue to be agents of change or do we stand with the status quo and 
deny coverage to women when they are pregnant? Do we continue to be 
agents of change, however hard it may be, or do we continue to deny 
millions of Americans access to quality, affordable care?
  History calls on us to stand on rare occasions for what is fair and 
just and right for the American people. This is one of those occasions. 
It requires more than parliamentary maneuvers to slow the process. It 
requires more than voices raised under the banner of free market values 
at the expense of fundamental human values. It requires doing what is 
right for the American people. Only then will we find ourselves on the 
right side of history. That is what this vote is about.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa is recognized.
  Mr. HARKIN. Mr. President, I thank the Senator from New Jersey for 
his very strong and poignant statement. I listened to it all. I think 
he really summed it all up.
  Let me add to that by saying we are at a momentous crossroads right 
now in the history of our country. We are at a time that likens itself 
to 1935, when this Congress passed the Social Security Act. It is like 
the time in 1965 when Congress passed Medicare. Both of them were giant 
steps forward in the health and economic security of the American 
people. But as much as they are part and parcel of our American life 
today, both Social Security and Medicare were bitterly opposed in this 
Senate by conservatives who did not want to change. In fact, one 
conservative Republican Senator said that passing Social Security would 
put an ``end to the progress of our great country.'' They attacked 
Medicare as socialized medicine. As Senator Robert Taft said at that 
time, ``It is going to Sovietize America if we have Medicare. It is 
going to be a government takeover.'' Well, here they go again. They are 
unduly frightening people in this country. We saw it earlier with the 
death panels--all bogus. It was to instill fear in people.
  It is hard to change, but the people of America voted last November 
overwhelmingly for Barack Obama and for Democrats in the House and 
Senate because they wanted to change the system. They knew we had to 
change.
  People don't fear change. They know it is tough, but they don't fear 
it. They don't fear change in our health care system either. What 
people fear is keeping the present system. That is what I hear. They 
fear being denied coverage because they have a preexisting condition or 
one of their children has a preexisting condition and they will not be 
able to get health care coverage. That is what people fear. They fear 
they will be dropped from their policy because they have come down with 
cancer or heart disease or some other chronic illness. They fear that 
if they have a serious illness, they will have to go into bankruptcy to 
pay the bills. Sixty-two percent of all the bankruptcies in this 
country are because of medical causes. Eighty percent of those are 
people who already had coverage. That is what people really fear.

[[Page 28772]]

  Another reason I think conservative forces will fail this time is 
because they believe people who have good health insurance really lack 
compassion and they don't care about the 46 million other Americans who 
don't have it. I disagree. People care deeply about those 46 million 
Americans who don't have insurance. It is a national shame when 
children don't have access to a doctor.
  It is unfortunate that our Republican friends are determined to 
prevent us from even debating and amending the bill. That is what the 
vote tonight is about. Republicans and the health insurance industry 
are joined at the hip, using the same talking points, same distortions, 
same cooked-up scare tactics.
  All I can say is, since the Republicans' goal is to obstruct, 
obstruct, and obstruct, the people of this country are looking to us, 
to the Democrats, as they did in Social Security and as they did in 
Medicare, they are looking to us to move this country forward. So this 
is a call to arms for our caucus. I hate to put it in those kinds of 
partisan terms, but what can I do when every single Republican says 
they want to obstruct and stop this bill? It is now on us, the 
Democratic caucus, all 60 Members, to come here and stand strong for 
the American people. Now is not the time to go wobbly in the knees, I 
say to my friends in the Democratic caucus. Now is the time to stand 
strong, the time to come to the well at 8 o'clock tonight and move this 
country forward. It is time to say yes to the American people and no to 
these fears and unfounded allegations you will hear from the other 
side. Now is the time to take the next step forward in the real 
progress of this country.
  The PRESIDING OFFICER. Under the previous order, the time until 7:15 
p.m. will now be controlled by the Republicans.
  The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, I wish to be notified when I have spoken 
20 minutes, please.
  The PRESIDING OFFICER. The Chair will gladly do that.
  Mr. GRASSLEY. Mr. President, on November 10, former President Clinton 
visited the Democratic Senate caucus. It has been widely reported that 
his message to Senate Democrats was that on health care reform, the 
worst thing to do is to do nothing.
  With all due respect to the former President, that is simply wrong. 
Mr. Clinton, the worst thing we can do is pass this bill. This is not 
something I say lightly because there are serious problems with our 
health care system. There are important steps we need to take to fix 
the problems in our system. But the excesses of this bill appear 
willfully ignorant of what is going on outside health care. Those 
things deal with our economy. Those excesses make this bill far worse 
than doing nothing.
  We are a nation facing challenging economic times. We have seen the 
auto industry go into bankruptcy. We have seen banks shutter their 
doors.
  I want to refer to a chart of our national debt. The Federal debt has 
increased by $1.4 trillion since inauguration. This chart shows the 
growing amount of debt the Federal Government is taking on. The amount 
of increased debt added since the inauguration is $11,535 per 
household. The national debt now exceeds $12 trillion for the first 
time in history.
  I wish to show a chart on Federal health spending. As this chart 
illustrates, this bill bends the Federal spending curve further upward 
by $160 billion over the next decade. The red area of this chart is 
that net additional Federal health spending, not according to this 
Senator but according to the nonpartisan Congressional Budget Office. 
Americans have rightly lost faith when in the face of the current 
economic crisis Congress thinks this $2.5 trillion restructuring of the 
health care system happens to be a good idea.
  Perhaps one of the biggest warning signs that this bill will saddle 
taxpayers with more spending and debt is the fact that the budget fail-
safe mechanism was dropped from the bill behind closed doors in the 
Capitol where this bill was written--and I emphasize ``closed doors.'' 
The Grassley budget fail-safe mechanism was cut from the bill and lots 
of budget gimmicks were added.
  Former Congressional Budget Office Director Douglas Holtz-Eakin wrote 
in yesterday's Wall Street Journal that this bill is ``fiscally 
dishonest'' and that it uses ``every budget gimmick and trick in the 
book . . . leave out inconvenient spending, back-load spending to 
disguise the true scale, front-load tax revenue, let inflation push up 
tax revenues, promise spending cuts to doctors and hospitals that have 
no record of materializing,'' and so on.
  This bill is simply irresponsible. It is worse than doing nothing.
  Let's talk about some of the excesses in the bill. It increases the 
size of government by a staggering $2.5 trillion when fully 
implemented. It imposes $\1/2\ trillion in new fees and taxes. Imposing 
these new fees and taxes as the economy is struggling to recover is 
worse than doing nothing. This $\1/2\ trillion in new taxes will hurt 
small businesses and destroy job creation. It breaks President Obama's 
campaign promise by increasing taxes on individuals and families making 
less than $250,000 per year. Adding insult to injury, these fees and 
taxes will also cause health care premiums to go up beginning next 
year.
  But I don't want you to take my word for it. Both the nonpartisan 
Committee on Taxation and the Congressional Budget Office have 
confirmed these taxes and fees will be passed through to the consumers 
in the form of higher health insurance premiums, and these taxes and 
fees will start increasing premiums 4 years before most of the reforms 
in this bill take effect in 2014.
  Let's take a look at what happens to Medicare and Medicaid in this 
bill. Both of these health care entitlement programs are already on 
perilous financial footing. Both are facing a financial meltdown. This 
bill adds to that burden.
  First of all, the Medicare trust fund started going broke last year. 
In the year 2008, the Medicare Program began spending more out of the 
trust fund than was coming in. The Medicare trustees have been warning 
all of us for years that the trust fund is going broke. They now 
predict it will go broke right around the corner, about 2017. But 
rather than work to bridge Medicare's $37 trillion in unfunded 
liabilities, this bill cuts $\1/2\ trillion from that Medicare Program 
to fund yet another unsustainable health care entitlement program.
  Medicare has a major problem with physician payments that will cost 
more than $250 billion to fix. But this bill ignores that problem by 
pretending the problem does not exist. This bill would leave future 
Congresses virtually no way to restructure Medicare to do the doctors 
fix.
  By diverting Medicare resources elsewhere and ignoring major problems 
such as that one, this bill does worse than nothing.
  Then there is Medicaid. The Medicaid Program serves 59 million low-
income children and families. It is our health care safety net and it, 
too, is on very shaky financial ground. The Government Accountability 
Office has reported to Congress that States are reaching a financial 
and budgetary crisis with Medicaid. Like Medicare, Medicaid is 
essentially going broke. The Government Accountability Office models 
predict that State spending on Medicaid will grow faster than State 
revenues for at least the next 10 years.
  Here is what the Government Accountability Office has said about this 
situation:

       Since most State and local governments are required to 
     balance their operating budgets, the declining fiscal 
     conditions shown in our simulation suggest that, without 
     intervention, these governments would need to make 
     substantial policy changes to avoid growing fiscal 
     imbalances.

  But this bill does not fix this problem either. Here again, this bill 
makes the problem worse. This bill adds another $374 billion in 
spending to the Medicaid Program. It adds 15 million people to the 
rolls of the worst delivery system in health care. It increases State 
spending by $25 billion, and that happens to be a hidden tax increase 
because States will be forced to raise

[[Page 28773]]

taxes to pay for this increased cost--another unfunded mandate. By 
dropping the equivalent of a 10,000-pound weight through to our frayed 
Medicaid safety net, this bill does worse than nothing. This bill also 
compounds these long-term entitlement spending problems by creating yet 
another new entitlement program called the CLASS Act. This one is a 
voluntary Federal program for long-term care insurance.
  I devoted several years of effort to improving long-term care 
support, particularly for the disabled and the elderly.
  I understand the issues that supporters of the CLASS Act want to 
address. But the CLASS Act is simply not viable in its current form.
  The CLASS Act is almost certain to attract people who are most likely 
to need it. This is known as adverse selection. That will cause 
premiums to increase and healthier people to drop out of the program. 
It is a classic insurance death spiral.
  On November 13, the administration's own chief actuary confirmed 
this. The chief actuary issued a dire warning in a report on the CLASS 
Act in the House bill, which is virtually identical to the Senate 
version. Quoting the chief actuary:

       There is a significant risk the problem of adverse 
     selection would make the CLASS program unsustainable.

  For the first 10 years, the CLASS Act saves money. It saves money at 
the beginning because it collects premiums before benefits start 
getting paid out. But some time afterwards, it starts to lose money. We 
all know what happens from there. It will become the taxpayers' 
responsibility to rescue the program as it fails. Look at financial 
struggles of Social Security. Look at Medicare. Look at Medicaid. Now 
go home and look at your children and grandchildren.
  Creating an unsustainable CLASS Act is not a responsible thing to do 
for our children and grandchildren. By adding the ticking time bomb of 
yet another unfunded liability to our children and grandchildren 
through the CLASS Act, this bill, again, does worse than nothing.
  Health care is one-sixth of the economy. The American people do not 
want a bill that makes the economy worse. The nonpartisan Congressional 
Budget Office, the Committee on Taxation, and even the Office of the 
Actuary of the U.S. Department of Health and Human Services have told 
us what the American people already knew: These massive partisan health 
care reform bills are going to make the problem worse when it comes to 
the cost of health insurance.
  According to a September 22 letter from the Congressional Budget 
Office to Chairman Baucus about the Finance Committee bill, CBO wrote:

       Premiums in new insurance exchanges would tend to be higher 
     than the average premiums in the current law individual 
     market.

  So according to CBO, after these bills spend $1 trillion, many of the 
people struggling to afford their premiums today will actually end up 
paying more if this bill moves forward and is enacted. By increasing 
costs when people desperately need Congress to lower costs, this bill 
does worse than nothing.
  It does not have to be this way. When the debate began last year, 
interested legislators of both parties set forth benchmarks that were 
no-brainers. Health care reform should lower the cost of premiums. It 
should make health care more affordable. It should do so without 
Medicare cuts that jeopardize access to care for seniors. It should do 
so without overloading the Medicaid safety net until it rips. It should 
do so without adding to the already unsustainable, unfunded liabilities 
by creating yet another unsustainable entitlement program. It should 
have done all those things. That is what we intended to do when we 
started out.
  Instead, this bill threatens the economic recovery. It is $\1/2\ 
trillion of new taxes hurting small business and destroying job 
creation. It calls for an even bigger and more unsustainable Federal 
budget. It adds to that burden with a massive new government-run health 
plan. It makes health care more unaffordable and lowers quality.
  I know some people believe we should get on to the bill and try to 
fix it by amendment. But this 2,000-page bill has many more problems 
than can be fixed by amendment on the Senate floor.
  If you want to improve it, it should be stopped right now and get 
back together where we were at one time. Democratic leaders and the 
White House have put together one extreme health care plan after 
another. After the bailouts for Wall Street and Detroit, a stimulus 
bill that led to the highest unemployment in 26 years, and the Fed 
shoveling money out the door without any accountability, this health 
care reform bill is the straw that broke the camel's back.
  What Senate Republicans are trying to say tonight, with tonight's 
vote, is we don't support reform just for the sake of reform. Changes 
to the health care system must be responsible and not break the backs 
of the taxpayers and the job-creating engine in America, small 
business.
  It doesn't make any sense to make major new unsustainable commitments 
to entitlement spending. Already, Medicare's solvency is in jeopardy 
and the Reid bill would make things worse for Medicare. Seniors are in 
a tough situation today with the way the economy has hit their 
retirement savings. We have to step back and remember it is not our 
money, it is their money. It is the taxpayers' money we are talking 
about--$2\1/2\ trillion of taxpayers' dollars over the decade when this 
bill is fully implemented.
  Generations of hard-working Americans will be forced to pay the 
costly price for this bill if it moves forward. It is irresponsible for 
Democratic leaders to use their filibuster-proof majority in the Senate 
and their control of the House and the White House to push through such 
massive legislation, reshaping one-sixth of the American economy. The 
unintended consequences of this legislation could have a destabilizing 
effect at just the wrong time as America's economy struggles to recover 
and working families are doing everything in their power just to hold 
on.
  The late Senator Moynihan often warned about the perils of a majority 
party pushing through major bills and changes in a partisan way. It is 
a well-founded warning that Democratic leadership has not heeded--this 
time, at least. If a bill like this one cannot get support more 
broadly, then something is wrong with it.
  Moreover, grassroots America has spoken out against this legislation. 
It is alarming how those voices have been disregarded by congressional 
leaders. President Andrew Jackson made it clear that our duty is to 
tune in to the common sense of the American people who sent us here. I 
quote President Jackson:

       Our Government is founded upon the intelligence of the 
     people. I, for one, do not despair of the republic. I have 
     great confidence in the virtue of the great majority of the 
     people, and I cannot fear the result.

  Listen to what President Jackson said. Listen to the concerns of the 
people. They are telling us to reconsider this massive, complicated 
legislation and take a path that leads to less spending, less taxes, 
and less debt. Instead of continuing to mortgage the future of our 
children and grandchildren, we need to get back to basics. Congress 
should pass commonsense medical malpractice reform to stop wasting so 
much money on defensive medicine. Congress should empower consumers to 
shop around for health care and lower costs with competition just like 
with other services the consumers buy. Congress should make market 
reforms that help small businesses and the self-employed have greater 
access to health insurance at an affordable rate.
  These issues can be addressed without upending the entire health care 
system with the result of higher taxes, higher insurance premiums, and 
deficits and debts that will get in the way of the opportunity that 
results from the ingenuity and industry of the American people.
  If we were sitting around a coffee shop in Springfield, IL, or Little 
Rock, AR, and we were discussing health care reform and I told them we 
are talking about a bill that is going to raise taxes,

[[Page 28774]]

cut Medicare, raise premiums, and not do anything about costs, they 
would say that is not health care reform.
  I encourage my colleagues to listen to the American people and to 
send this bill back to the drawing board.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Kohl). The Senator from Wyoming is 
recognized.
  Mr. ENZI. Mr. President, as morning broke over our Nation today, 
millions of Americans woke to a typical, crisp fall day. It seemed 
ordinary as shop-owners opened their local grocery stores; children 
filled soccer fields and families made preparations for Thanksgiving 
holiday. It seemed ordinary. But today is anything but ordinary in the 
life of our Nation.
  We have all heard the phrase and repeated it so many times, that we 
have almost grown numb to it--America is facing the worst economic 
crisis since the Great Depression. Think about that for a minute. What 
that really means is that for every single legislator in this Senate, 
we are in unchartered territory.
  We have never been here before and recent signs of a slow, unsteady 
and jobless recovery are troubling. And, the American people know it. 
In a survey from this past week, 82 percent of Americans said that our 
Nation's economic conditions are poor.
  Consider the news reports from just yesterday that 14 percent of all 
mortgage loans--meaning 7.4 million households--were delinquent or in 
foreclosure in the last quarter. That is the highest number since the 
mortgage bankers industry began this survey in 1972.
  Consider the unemployment rate--it reached a 26-year high of 10.2 
percent in October. We lost 190,000 jobs in just the month of October 
alone. And, according to the Department of Labor's broadest measure, 
some 17.5 percent of Americans are without a job entirely or 
underemployed. We have shed 3.5 million jobs since January of this year 
and the average work-week is now down to 33 hours for the American 
worker.
  It is against this backdrop that the Senate majority leader has 
chosen to bring up this health care bill. Health reform is a huge 
undertaking.
  Every one of the 2,074 pages in this bill will have a dramatic impact 
on the health care of every American. I have to tell you, that is a 
bridge. This is a bigger problem than anyone can imagine because it 
will affect every single American. This bill represents a massive 
government intrusion into the medical care of every American.
  Under this bill, the government will review every employer health 
insurance plan in the Nation to determine if it satisfies all of the 
government mandated benefit requirements. If it does not, the 
government will then tax many of those employers.
  The government will also now determine whether it believes your 
health insurance costs too much. It will decide what benefits should be 
covered and what preventive services you should receive.
  Earlier this week, the U.S. Preventive Services Task Force 
recommended that women under age 50 should not receive annual 
mammograms. Anyone who was concerned about this decision needs to 
understand that this bill empowers a task force just like that to 
determine which preventive services should be covered by every health 
plan in America.
  As one of the only Members of the Senate to sit on both committees of 
health care jurisdiction, I understand the complexities at work in 
comprehensive health care legislation. And I understand that this bill 
gets it wrong.
  Instead of taking a step-by-step approach to health reform, 
identifying consensus reforms where we can fix what is broken and leave 
what works, the majority leader has chosen a different approach. 
Without Republican support and without the approval of a growing 
majority of the American people, Senator Reid has chosen to shake 
nearly 20 percent of our economy in its foundation in attempting to jam 
through a strictly partisan bill.
  This bill will increase our health care costs, do nothing to improve 
the quality of our care, it will increase our Nation's debt and deficit 
and it will harm our Nation's tenuous job market.
  There is no credible study and there will be no serious, unbiased 
economist who will say that this bill will create jobs or strengthen 
our economy. And that is what the people in the most recent election 
said was mot important.
  Recently, in an op-ed in the Wall Street Journal, the dean of Harvard 
Medical School Dr. Jeffrey Flier gave the current health reforms a 
``failing grade.'' Dean Flier wrote about the reform bills being 
debated in Congress, that ``there are no provisions to substantively 
control the growth of costs or raise the quality of care. So the 
overall effort will fail to qualify as reform.''
  Dean Flier went on to write:

       In discussions with dozens of health care leaders and 
     economists, I find near unanimity of opinion that, whatever 
     its shape, the final legislation that will emerge from 
     Congress will markedly accelerate national health-care 
     spending rather than restrain it. Likewise, nearly all agree 
     that the legislation would do little or nothing to improve 
     quality or change health-care's dysfunctional delivery 
     system.

  I ask unanimous consent that this editorial be printed in its 
entirety in the Record at the conclusion of my statement.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  [See exhibit 1.]
  Mr. ENZI. With ratings of failed reform like the dean of the Harvard 
Medical School, why are we talking about taking the time to tweak a 
failure of ideas so we can say we did something. We are not fooling the 
American people. The voices of August are still echoing and coming from 
a vast majority.
  Other experts have weighed in on the provisions in the Reid bill and 
their potential impact on jobs. One such provision is the job-killing 
tax of $28 billion that will disproportionately fall on the backs of 
small business employers in the form of a mandate on employers to 
provide Washington government-approved insurance.
  This job-killing tax has been studied by the non-partisan score 
keepers at the Congressional Budget Office as well as nationally 
recognized economists and health experts. These experts have said that 
the costs of this new tax will ultimately be paid by the American 
working men and women.
  Businesses that cannot afford to provide health insurance will pass 
the costs of these new penalties on to their workers in the form of 
lower wages, reduced hours and jobs cut. Yes, this so-called health 
reform bill will threaten your jobs and if this vote is successful we 
will spend weeks debating this bill. And just like committee work so 
far, the majority will reject real solutions just like they have 
through the two amendment processes that have been merged to make this 
flawed bill.
  According to one recent study by the Heritage Foundation, this new 
job-killing tax in the Reid bill will place more than 5 million low-
income workers at risk of losing their jobs or having their hours 
reduced and an additional 10 million workers could see lower wages and 
reduced benefits. At a time of unprecedented economic peril, the 
majority has chosen to bring a bill to the Senate that will threaten 
our Nation's jobs and our economic growth.
  This bill will also increase our Nation's growing debt and deficit. 
Currently, our Nation's debt is greater than $112 trillion and our 
deficit for fiscal year 2009 was greater than $1.4 trillion. As a 
percentage of the economy, our deficit is 10 percent of GDP--the 
highest it has been since the Second World War. Once again, we are not 
debating this bill in a vacuum. Rather, we are debating this bill at a 
time when our credit card is maxed out.
  I worry about the country that I am leaving for my children and 
grandchildren. Our Nation is being buried under a mountain of debt, 
which poses a deadly threat to the future of our Nation.
  The Federal Government will spend $1.4 trillion more than it receives 
in revenue this year. The government will make up that deficit by 
borrowing more money, mostly from China and other foreign governments.
  These levels of debt are not sustainable and, our foreign creditors 
are beginning to recognize this fact. As our

[[Page 28775]]

creditors grow more concerned about our ability to pay our debt 
obligations, the interest rates we pay will grow. That means that it 
will soon cost us considerably more to allow Washington to continue to 
borrow the money it needs to fund its current spending binge.
  With our current and growing debt, Congress should be concerned. 
Think about it--our most fundamental duty as Members of Congress is to 
wisely manage the power of the purse for our Nation. The Framers wisely 
put in place a process of appropriations that would be annually checked 
by the representatives of the American people here in Washington.
  In this bill we create yet another stream of mandatory spending in 
perpetuity--or until it runs out--that is not reviewed by Congress on 
an annual basis.
  I remind my colleagues that our Federal deficit is nearly nine times 
the size of the deficit just 2 years ago. During the same 2-year 
period, our Nation lost 8 million private sector jobs. Our total 
Federal debt is now around 85 percent of GDP. According to David 
Walker, the former head of the Government Accountability Office, at the 
end of the fiscal year 2000, the Federal Government had about $20.4 
trillion in total liabilities and commitments and unfunded promises for 
just Social Security and Medicare. That number rose to $56.4 trillion 
at the end of fiscal year 2008. That is a 176-percent increase in only 
8 years. By the end of this year, that number is expected to rise to 
$63 trillion. With these staggering statistics, it is astonishing we 
are even debating the creation of a new entitlement obligation forever.
  A couple days ago, Majority Leader Reid stated that this bill will be 
deficit neutral, but you have to understand what that means. First, the 
true cost of this bill is hidden by implementing the massive middle-
class tax increases and Medicare cuts in the first year and pushing the 
massive costs in health care subsidies out to the fifth year. 
Republican Leader McConnell referred to this gimmick as being akin to 
paying a mortgage for 4 years before actually moving into the house. I 
wish to emphasize that a little bit. It is a gimmick. You collect the 
money to begin with, but you don't provide the benefits until further 
down the road. Then you say: We covered all those costs. But when you 
extend it on out, it will not continue to cover those costs. So 
disaster.
  As the only accountant in the Senate, I am shocked to see that what 
would constitute as fraud in the accounting world seems to be reason to 
hold a press conference to do a hollow boast. The gimmicks in this bill 
are stunning, whether it comes to implementation of the tax on so-
called Cadillac health plans or the increased taxes or the $464 billion 
in Medicare cuts--Medicare cuts. We are already having a problem with 
Medicare solvency. It is going to go broke. We are going to take $464 
billion from Medicare. Then we are going to form a special commission 
and this commission will be able to tell us, on an annual basis, where 
we can make cuts in Medicare so it doesn't go broke. But let's see, 
there is a deal with the hospitals that they are not going to be 
touched. There is a deal with the doctors that they will not be 
touched; in fact, theirs is going to be increased. There is a deal with 
PhRMA where they will not be touched. Who does that leave? That means 
cutting benefits for seniors. They and home health care and nursing 
homes are the only places you can cut it, if you let those other people 
off the hook. That is what the bill does.
  When it comes to the long-term care provisions in this bill that 
Budget Committee Chairman Conrad has referred to as a Ponzi scheme, you 
have to be a little bit worried. If Washington accounting had to come 
under the same laws as private business, the administration and 
Congress would be in jail. To attempt to claim the mantle of fiscal 
responsibility, the majority leader has jammed 10 pounds of entitlement 
spending into a 5-pound sack. Again, entitlement means the payments 
automatically go on forever with no further review or constraint. That 
is not fiscal responsibility and the American people are not buying it. 
They know, evidently better than we do, what we are talking about.
  A large majority of Americans believe their prescription drug costs 
will go up under this bill and that the cost of their premiums will go 
up. They are right. What the CBO score doesn't provide us with and 
can't provide us with is the cost of this bill to each and every one of 
us. But we know that cost will be great. The CBO evaluation says it is 
going to be paid for. Paid for? That is an evaluation of whether it is 
going to cost the government anything. It is not an evaluation of 
whether it is going to cost the people anything. The only place to get 
that money is from the people or, in this case, also stealing it from 
Medicare. In order for this bill to reduce the deficit, the majority 
leader has to assume that the Medicare payments to physicians will be 
cut by 21 percent next year. He also has to assume these payments will 
be annually cut another 5 percent for the next 9 years.
  In order for this bill to reduce the deficit, the majority leader 
also has to assume that more and more middle-class Americans will pay 
this new tax on high-cost health insurance plans. According to the 
Congressional Budget Office, 84 percent of the revenue collected by 
this new tax will come from Americans earning less than $200,000 in 
2019. This reminds me of another tax which was originally intended to 
target just 155 individuals who made more than $200,000 and did not pay 
any income tax. Today the alternative minimum tax now hits millions of 
middle-class Americans, and every year Congress has to enact 
legislation to prevent it from hitting millions more. This bill is 
drafted that same way. It will creep up there and catch everybody in 
increased taxes.
  In order to believe that this bill will reduce the deficit, its 
sponsors must believe that future Congresses will allow millions of 
middle-class Americans to be subject to these new taxes. While the 
majority leader claims all these things will happen, the American 
public isn't fooled.
  In this morning's Washington Post, the dean of Washington 
journalists, David Broder, not a politically conservative columnist and 
someone often cited by the other side, pointed out that a recent survey 
found that less than one-fifth of the American people believe that 
health care reform will be deficit neutral over the next 10 years. By a 
16-point margin, the majority in this poll said they opposed the 
legislation moving through Congress. Mr. Broder called this legislation 
a ``budget-buster in the making.''
  It is difficult to quantify the scope of this bill. I have heard some 
of my colleagues talk about how many years would elapse in 2\1/2\ 
trillion seconds. I heard some of my colleagues talk about how many 
cars $2.5 trillion would buy or how many school districts it would fund 
or how many decades it would fund State budgets across America. I don't 
think people are understanding how comprehensive this bill is that 
entails 100 percent of the people. That is the difficulty we in the 
Gang of 6 had coming to any conclusion because it is so big that as we 
get into one area and scratch the surface and find out what we don't 
know, it takes a lot of research time to get there to be able to make 
basic decisions. But it was easy to cram into a bill and say: This 
solves it, solves it for $1 trillion. We should never say $1 trillion 
because that sounds like one, and one is not a very big number.
  It is $1,000 billion. We don't know what 1 billion is either, but 1 
billion is 1,000 million. So we are talking about a lot of money here.
  Perhaps the best way to quantify this bill is, it keeps me up nights 
and, more importantly, these issues we are debating keep our 
constituents up at night. I am sure everybody has been hearing from 
their constituents. We worry immensely about the cost and the 
obligations we are passing on to our children and grandchildren. Where 
is this bill taking our country, and will we have the courage in our 
time to preserve and protect our Nation's great strengths for future 
generations? These are the questions that keep me up at night,

[[Page 28776]]

and I know these concerns are shared on the other side of the aisle. I 
sense it in conversations I have had with the senior Senator from 
Delaware and the senior Senator from Nebraska. I sensed it in my work 
over the summer with the chairman of the Budget Committee. I know they 
share these concerns on the other side. That is why I believe 
passionately that we must defeat the motion to proceed on this bill.
  I am sometimes an optimist, and I still hope we can start over and 
get to work on a bipartisan bill that has the trust and support of the 
American people. Any major piece of legislation that has gone through 
this body has done so in a bipartisan way. It has been necessary to get 
the confidence of the American people. They don't have confidence in 
Congress right now. This bill is not helping.
  We say we are spending our children and grandchildren's money. 
Actually, we are doing that plus spending seniors' money. When you take 
that Medicare money, that is what you are doing. The seniors have 
figured it out. That is why it was so raucous in August and ever since. 
They have been concerned about their future and the promises made to 
them. We have a system that is going broke, and then we are going to 
take money from it. We ought to back up and make sure Medicare money 
goes to Medicare. I know part of that is listed as fraud and abuse. I 
am always fascinated when government talks about fraud and abuse 
because we talk about it, but if we have known that these billions of 
dollars of fraud and abuse were out there, why haven't we been 
collecting that money? Once we turn it over to the government to do 
that, it is no longer needed. Well, it is needed to pay the bills, but 
it is no longer that much of a care because the paid-for has already 
been taken care of.
  There ought to at least be a separate account set up that you have to 
actually collect the fraud and abuse money before you can spend it, but 
we are not going to do that.
  Every senior can tell you some instances of fraud and abuse that they 
think are happening, and we have passed those on. I see some effort to 
collect that but not a lot.
  As many of my colleagues know, before I came to the Senate, I was a 
small business owner. My wife and I owned three small shoestores in 
Wyoming and Montana. When I was showing someone a shoe and he or she 
said they didn't like it or couldn't afford it, I didn't try to give 
them a sales pitch. I knew it was time to try to find another shoe, one 
they liked and could afford. There is a lesson from this in this health 
care bill. The people of America are complaining, and we are showing 
them the shoe we want to show them. They don't want to see that shoe. 
They said: We thought you were going to lower my costs. Every person 
out there thought they were going to have the benefit of reduced costs, 
and they are not seeing it in this bill. They wanted to help out other 
people, and some of that is in here, to a limited extent. But that 
isn't the main thing that they expected to have happen from this. Small 
businesses out there are particularly hurting, and this will react on 
small businesses, those shoestores all over the United States, the 
grocery stores, the dry cleaners. This is even going to affect doctors. 
They are small businesses, for the most part.
  So there is a lesson in this story when it comes to reforming health 
care. It is time to listen to the customers and find the alternative 
they expected, that they wanted, and they can afford.
  Probably the biggest help to me in legislating has been the 
experience of working in a shoestore. The people tell you what they 
want, and they have told us what they want. We haven't listened. If you 
want to make the sale, you better listen. You better see how your 
inventory matches what they want. We haven't checked the inventory or 
we have said: We don't have anything in here that you need, but we have 
some things to take care of other people. That is not going to sell.
  We have a big decision to make tonight. It will have a lasting effect 
on our country, a lasting effect in that if the motion to proceed 
passes, we are going to debate it for a long time. A bill this size 
deserves a lot of time. It is necessary. And it is more comprehensive 
than we are going to be able to get into, no matter how long we debate 
it.
  So the American people are going to be surprised at the time we waste 
when we could be solving jobs and the economy, which is their biggest 
concern at the present time.
  Mr. President, I yield the floor.

                               Exhibit 1

                 Health ``Reform'' Gets a Failing Grade

                         (By Jeffrey S. Flier)

       As the dean of Harvard Medical School I am frequently asked 
     to comment on the health-reform debate. I'd give it a failing 
     grade.
       Instead of forthrightly dealing with the fundamental 
     problems, discussion is dominated by rival factions 
     struggling to enact or defeat President Barack Obama's 
     agenda. The rhetoric on both sides is exaggerated and often 
     deceptive. Those of us for whom the central issue is health--
     not politics--have been left in the lurch. And as controversy 
     heads toward a conclusion in Washington, it appears that the 
     people who favor the legislation are engaged in collective 
     denial.
       Our health-care system suffers from problems of cost, 
     access and quality, and needs major reform. Tax policy drives 
     employment-based insurance; this begets overinsurance and 
     drives costs upward while creating inequities for the 
     unemployed and self-employed. A regulatory morass limits 
     innovation. And deep flaws in Medicare and Medicaid drive 
     spending without optimizing care.
       Speeches and news reports can lead you to believe that 
     proposed congressional legislation would tackle the problems 
     of cost, access and quality. But that's not true. The various 
     bills do deal with access by expanding Medicaid and mandating 
     subsidized insurance at substantial cost--and thus addresses 
     an important social goal. However, there are no provisions to 
     substantively control the growth of costs or raise the 
     quality of care. So the overall effort will fail to qualify 
     as reform.
       In discussions with dozens of health-care leaders and 
     economists, I find near unanimity of opinion that, whatever 
     its shape, the final legislation that will emerge from 
     Congress will markedly accelerate national health-care 
     spending rather than restrain it. Likewise, nearly all agree 
     that the legislation would do little or nothing to improve 
     quality or change health-care's dysfunctional delivery 
     system. The system we have now promotes fragmented care and 
     makes it more difficult than it should be to assess outcomes 
     and patient satisfaction. The true costs of health care are 
     disguised, competition based on price and quality are almost 
     impossible, and patients lose their ability to be the 
     ultimate judges of value.
       Worse, currently proposed federal legislation would 
     undermine any potential for real innovation in insurance and 
     the provision of care. It would do so by overregulating the 
     health-care system in the service of special interests such 
     as insurance companies, hospitals, professional organizations 
     and pharmaceutical companies, rather than the patients who 
     should be our primary concern.
       In effect, while the legislation would enhance access to 
     insurance, the trade-off would be an accelerated crisis of 
     health-care costs and perpetuation of the current 
     dysfunctional system--now with many more participants. This 
     will make an eventual solution even more difficult. 
     Ultimately, our capacity to innovate and develop new 
     therapies would suffer most of all.
       There are important lessons to be learned from recent 
     experience with reform in Massachusetts. Here, insurance 
     mandates similar to those proposed in the federal legislation 
     succeeded in expanding coverage but--despite initial 
     predictions--increased total spending.
       A ``Special Commission on the Health Care Payment System'' 
     recently declared that the Massachusetts healthcare payment 
     system must be changed over the next five years, most likely 
     to one involving ``capitated'' payments instead of the 
     traditional fee-for-service system. Capitation means that 
     newly created organizations of physicians and other health-
     care providers will be given limited dollars per patient for 
     all of their care, allowing for shared savings if spending is 
     below the targets. Unfortunately, the details of this massive 
     change--necessitated by skyrocketing costs and a desire to 
     improve quality--are completely unspecified by the 
     commission, although a new Massachusetts state bureaucracy 
     clearly will be required.
       Yet it's entirely unclear how such unspecified changes 
     would impact physician practices and compensation, hospital 
     organizations and their capacity to invest, and the ability 
     of patients to receive the kind and quality of care they 
     desire. Similar challenges would eventually confront the 
     entire country on a more explosive scale if the current 
     legislation becomes law.
       Selling an uncertain and potentially unwelcome outcome such 
     as this to the public

[[Page 28777]]

     would be a challenging task. It is easier to assert, 
     confidently but disingenuously, that decreased costs and 
     enhanced quality would result from the current legislation.
       So the majority of our representatives may congratulate 
     themselves on reducing the number of uninsured, while quietly 
     understanding this can only be the first step of a multiyear 
     process to more drastically change the organization and 
     funding of health care in America. I have met many people for 
     whom this strategy is conscious and explicit.
       We should not be making public policy in such a crucial 
     area by keeping the electorate ignorant of the actual road 
     ahead.

  Mr. GRAHAM. Mr. President, the bill we have before us today is a 
2,074-page, multi-trillion-dollar bill written in the dark of night. 
This process brings back the worst of Washington. The substance of the 
bill raises taxes during a recession, compromises individual health 
care choices, cuts Medicare to pay for the uninsured and will 
eventually explode the deficit--the combination of which will 
jeopardize the finest health care system in the world without lowering 
costs. Today we are voting on the motion to proceed to the bill and I 
will vote no because this bill is broken beyond repair. Instead of 
proceeding to a flawed bill, we should stop and start over.
  Despite President Obama's repeated statements that Democrats would 
legislate in an open and transparent manner, this bill was drafted in 
secret and Republicans were excluded. As a candidate and now as 
President Obama, he even went so far as to tell the American people 
that the negotiations would be broadcast live on C-SPAN. Instead of the 
change Americans thought they voted for, we have gotten more of the 
same.
  The bill we are moving to consider will cost $2.5 trillion once fully 
implemented; nearly three times the official CBO score of $848 billion. 
The Democrats are playing a shell game to hide the true cost of this 
legislation. With this bill we get 10 years of taxes and only 6 years 
of programs. While some may claim that the bill is deficit neutral, the 
Federal Government's financial commitment to health care under this 
bill actually grows. Health care costs are not contained or reduced, 
they are simply offset by reductions and tax increases elsewhere in the 
Federal ledger.
  A central premise of this legislation is that Congress will allow 
nearly half a trillion dollars in Medicare cuts to go into effect. 
Congress has not had the political will to allow these types of cuts to 
stand in the past, so why should we believe that future Congresses will 
not follow suit. Case in point, the ``doc fix.'' When we passed the 
Balanced Budget Act in 1997, we included a formula to limit the cost 
growth in physician spending in Medicare. Congress allowed that formula 
to reduce payments to physicians only once and has not done so again. 
We leave the flawed formula in place and each year we act to block the 
scheduled cuts to physician payments instead of fixing the problem. 
This bill increases doctor payments by half a percent in 2010 and then 
assumes a 23-percent cut in 2011, budget gimmickry at its finest.
  Medicare is currently $36 trillion in the hole, but as we have seen, 
Congress doesn't have the will to cut Medicare by fifty cents, much 
less $500 billion. When we tried to rein in Medicare costs in the 
budget in 2007, we proposed $33 billion in savings and only got two 
dozen votes.
  In a nod to Congress' traditional actions, or lack thereof, Democrats 
even included an Independent Medicare Advisory Board that can cut 
Medicare provider payments if Congress fails to act. Cutting an already 
cash-strapped program is not the way to finance health care for the 
uninsured.
  In addition to the nearly half trillion dollars in cuts contained in 
this bill, we get a half trillion dollars in new and increased taxes. 
The bill would tax Americans who choose higher cost insurance plans, it 
would tax employers for not providing health coverage, it would tax 
Americans for not buying health coverage, and it would increase the 
Medicare payroll tax on some Americans to fund a new health care 
entitlement program. In the midst of the worst recession this country 
has seen in decades, how can these job-killing tax increases be 
justified?
  I believe the provisions contained in this bill are bad for America. 
We must work to enact policies that preserve patient access to care, 
rein in ever increasing costs in the health system while ensuring the 
viability of current programs, and promote choice. This bill is a 
budget buster that does none of those things.
  Mr. President, I cannot support this bill.
  The PRESIDING OFFICER. The Chair recognizes the Senator from Montana.
  Mr. BAUCUS. Mr. President, a noted psychologist once said:

       To be mature means to face, and not evade, [a] crisis. . . 
     .

  Our health care system is in a crisis. This crisis has been decades 
in the making, and history has made clear that this crisis will not 
solve itself. It is time for us to face the crisis. It is time for 
Congress to show mature leadership. It is time for us to reform health 
care, once and for all.
  For years now, we have prepared for this moment. The Finance 
Committee and the HELP Committee studied the issues thoroughly. We have 
held nearly 70 hearings, roundtables, and walk-throughs. We have 
studied this issue very thoroughly and exhaustively. We each produced a 
blueprint for reform--each committee--and we worked together with 
Leader Reid and President Obama to combine those blueprints into one 
solid plan. This week, tonight, we have brought that plan to the Senate 
floor. Tonight, we seek to begin that momentous debate. Tonight, we 
seek, at last, to face the crisis.
  We have a bill that will put Americans, patients, and their doctors 
back in control. We have a bill that will end harmful insurance 
industry practices. Under our bill, no longer will insurance companies 
be allowed to deny you health insurance. No longer will insurance 
companies be allowed to hike up rates for Americans with preexisting 
conditions, such as heart disease, cancer, or diabetes. No longer will 
health insurance companies be able to take away your health insurance 
or reduce benefits when people get sick. Under our bill, no longer will 
insurance companies be able to limit the amount of health care you can 
use in a lifetime. No longer will insurance companies be able to put 
unreasonable limits on the amount of health care you can use in 1 year. 
If you pay your bill, the insurance company must renew your coverage 
and provide your benefits. No longer will insurance companies be able 
to discriminate based on gender or health status. No longer will 
insurance companies be able to charge more for women or for people who 
are sick.
  Our bill will also require insurance companies to disclose the share 
of premiums that goes to medical benefits. That is new and very 
important. No longer will insurance companies receive tax credits when 
they use their profits to provide excessive executive paychecks.
  Our bill is fully paid for. It is fiscally responsible. It will lower 
health care costs, and it will reduce the Federal budget deficit.
  According to the Congressional Budget Office, our bill will reduce 
the deficit by $130 billion in the first 10 years. Over the next 
decade, it will further reduce the deficit by about one-quarter of 1 
percent of gross domestic product. That is hundreds of billions of 
dollars in deficit reduction.
  As well, our bill will provide billions in tax cuts for American 
families and small businesses. Our bill will create new marketplaces 
called insurance exchanges. Individuals and small businesses will be 
able, quickly and easily, to view, compare, and buy health insurance 
plans.
  Today, many Americans already receive quality health care coverage 
through their employers. Many are happy with their current insurance 
plans. This bill will not change that. We keep the best of our current 
health care system. People who are satisfied with their current health 
insurance coverage will be able to keep it. But too many others do not 
have access to insurance, to quality insurance. For too many, this 
system is broken.
  Under our bill, new exchanges will provide one-stop shops where plans 
are

[[Page 28778]]

presented in a simple, consistent format. Americans will be able to 
know exactly what they are buying. Insurance companies will have to 
compete on price and on quality, not on their ability to select the 
healthiest people or hide restrictions. Americans will be able to count 
on the health care coverage they buy. And tax credits will help to 
ensure all Americans can afford quality health insurance.
  Small businesses will also have access to exchanges and tax credits. 
Through small business exchanges, these companies will be able to pool 
together to spread their risk, increase their leverage, and enhance 
their choice, just as big companies do.
  Members of Congress will be required to buy their health insurance 
through the same exchanges that people in their own States use--exactly 
the same. No longer will there be a separate congressional health plan.
  Our bill will strengthen Medicare. It will improve benefits for 
seniors. And it will help to ensure Medicare is sustainable for future 
generations. Our bill will cut costs, but it will not cut benefits. Our 
bill will increase Medicare benefits. Our bill will provide seniors 
with free preventive care and wellness checkups. It will improve care 
for seniors with chronic conditions. And it will provide a 50-percent 
discount on brand-name prescription drugs to help close the doughnut 
hole, the gap in benefits in the Medicare prescription drug program.
  Our plan is a good, commonsense answer to the crisis facing American 
families and businesses.
  On this floor, here in the Senate, tonight, we have a historic 
opportunity to consider this plan. We have the chance to make it even 
better. We hope to have a full debate. But more important than the 
process or rhetoric, we have the opportunity, at last, to face the 
crisis. We have the opportunity to show mature leadership. At long 
last, we have the opportunity, the historic opportunity, to reform 
health care, once and for all. History is knocking on the door. Let's 
open it. Let's begin the debate to improve this bill before us today 
and provide the service all Americans expect us to perform when they 
elect us to this office.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Connecticut.
  Mr. DODD. Mr. President, I rise in very strong support of this melded 
bill, drafted and put together by our distinguished leader, the Patient 
Protection and Affordable Care Act.
  Before I begin with some brief remarks, let me extend my heartfelt 
thanks to our majority leader for his tireless work and thank Max 
Baucus of Montana for his tireless work and the members of the 
committees who have worked over the past many months to bring us to 
this moment.
  Others this evening have spoken with great eloquence, in my view, 
about the provisions of this bill, what we hope to achieve for our 
fellow citizens with the adoption of this legislation.
  I commend the Senate HELP Committee, which did such heroic work 
during the writing of our portion of the bill--my colleagues, Tom 
Harkin of Iowa, Barbara Mikulski of Maryland, Jeff Bingaman of New 
Mexico, Patty Murray of the State of Washington, and so many others.
  I thank my Republican colleagues on that committee as well. While we 
did not end up with a bipartisan vote at the end of that very long 
process, we did end up adopting more than 160 amendments offered by my 
Republican colleagues to that bill, which I think strengthened the 
legislation, made it a better piece of legislation, and many of which 
are a part of this legislation this evening.
  I also want to pause for a moment, if I can, to recognize a colleague 
who is here tonight only in spirit, Ted Kennedy. So much has been said 
and written about his lifelong quest to ensure that every American--
every American--has decent health care. Tonight and in the days to 
come, we will pay him the highest compliment, as our colleague, by 
fulfilling that quest of achieving the goal all Americans aspire for; 
that is, a national health care plan that serves every one of our 
citizens.
  I would like to speak briefly, if I could, to the American people who 
are at home this evening and I suspect are just tuning in to this 
debate.
  This important vote will occur momentarily. Why does this issue and 
this debate matter? Why are we here on a Saturday evening? But then 
again, for that matter, why are you watching C-SPAN on a Saturday 
evening, I might add?
  Well, for one thing, health care represents one-sixth of our economy 
and affects 100 percent, as we all know, of the population of this 
country. And it is true that skyrocketing health care costs are the 
single biggest threat to the financial future of our fellow citizens.
  But the reason tonight's vote is so historic, beyond those last two 
points, is that never, ever before--never before--has this body, 
elected to serve the American people, confronted directly this simple 
truth: Nothing, absolutely nothing, matters more to you and to your 
family than the ability to get the health care you need, when you need 
it, from the doctor you choose, at the price you can afford.
  Health care is our most basic need. Health care is the most basic 
commitment we should be willing to make to each other. No matter what 
your family finances, no matter what your hopes and dreams are, no 
matter who you are or where you live or what your job is in America, in 
our 21st century America, you should be able to get the care you need.
  But for too many American families--perhaps your family, as you watch 
this tonight from your homes--health care has become your most basic 
fear. If you do not have health insurance, you go to bed every single 
night knowing that if you wake up sick or your child does, you might 
not be able to see that doctor or afford one if you can even find one. 
Even if you have health insurance, you are paying more and more in 
premiums and getting less and less coverage for your money.
  Millions of you are seeing your premiums skyrocket. Yet you lie awake 
at night--millions do--wondering: What if I lose my job? What if I get 
sick and find out my policy does not cover the costs and the care I 
need--or, even worse, your insurance company cancels your policy 
altogether? What if you run out of benefits and have to pay out of your 
pocket? I wish I could say these fears are irrational fears, but they 
are not. There is nothing irrational about those fears. Insurance does 
not allow you to be sure of anything these days.
  Our system, all 100 of us here know, is broken. People are losing 
their homes because they get sick. People are dying because they cannot 
afford the cure. This is just not acceptable in our America. That is 
why we are here on a Saturday night.
  If you have watched the news over the past few months, you have 
probably noticed there is a wide range of opinions on how we should fix 
things. And that is as it should be. We need all the good ideas we can 
get, and hopefully this debate will produce that. But if you have also 
watched the debate in the Senate over the last 2 days, you have 
probably noticed something else as well. I don't believe a single 
person in this body has stood up at any point and said we are OK doing 
nothing at all. Therefore, in the weeks ahead we will have a full and 
open debate about every provision of this bill.
  But tonight's vote is nothing more than a choice--a choice between 
doing something or doing nothing. I urge my colleagues this evening to 
join us, hopefully unanimously, to say we should do something. We 
should do something about this most basic right that all Americans 
deserve.
  I yield the floor.
  The PRESIDING OFFICER. The Republican leader is recognized.
  Mr. McCONNELL. Mr. President, the Nation is watching the Senate 
tonight. The American people know how important this vote is. They have 
seen the bill the Democratic leaders want to impose upon them, and they 
want to know where the rest of us will stand.
  This bill itself is a massive monument to bureaucracy and spending. 
But at its core it is quite simple. At a moment when more than 1 of 10 
working Americans is looking for a job, at the

[[Page 28779]]

time when the Chinese are lecturing us about our debt, this bill--this 
bill right here--costs $2\1/2\ trillion the government doesn't have and 
cannot afford. It imposes punishing taxes on almost everyone. It raises 
health insurance premiums on the 85 percent of Americans who already 
have health insurance. And if that were not bad enough, it slashes 
Medicare by $\1/2\ trillion. Anyone who votes aye tonight is voting for 
all of these things.
  It is a fact: A vote in favor of proceeding to this bill is a vote in 
favor of adding to the tax burden of the American people in the midst 
of double-digit unemployment. A vote in favor of proceeding to this 
bill is a vote to raise health insurance premiums on people who were 
told--they were told--that they could expect their health insurance 
costs to go down. A vote in favor of proceeding to this bill is a vote 
in favor of deep cuts to Medicare for tens of millions of seniors who 
depend on it totally. A vote to proceed to this bill is a vote to 
continue the completely out-of-control spending binge this Congress has 
been on all year. A vote in favor of this bill tells every American 
family sitting in a waiting room tonight, wondering when they will get 
to see a doctor or how much it is going to cost: It is not our concern. 
Worst of all, a vote in favor of this bill is a vote in favor of the 
spending binge that is leading to a massive and unsustainable, long-
term debt that will shackle our children to a future they can't afford.
  That is what tonight's vote is all about. If it weren't, none of us 
would be here on a Saturday night with the Nation watching and waiting 
to see what we do. They are watching because they know that none of 
this--none of this--is inevitable.
  All it takes is one vote--just one. The simple math is this: If there 
were one Democrat, just one of our friends on the other side of the 
aisle, just one who would say no tonight, none of this would happen. 
The voices of the American people would be heard. We have seen all the 
surveys. We know how they feel. If one Democrat were to say no tonight, 
he would be saying no to the premium increases, no to the tax cuts, no 
to the Medicare cuts--just one on the other side of the aisle. Then we 
could start over with a commonsense, step-by-step approach to fix the 
problem that got us here in the first place, and that is that health 
care costs too much.
  That is the sad irony of this whole debate. The problem that got us 
here is that health care costs are out of control. Yet the neutral, 
nonpartisan Congressional Budget Office, the scorekeeper around here, 
says under this bill--this massive bill--health care costs are actually 
going to go up, not down, and the American people thought that is what 
this whole debate was about in the first place. So 2,074 pages and 
trillions of dollars later--2,074 pages and trillions of dollars 
later--this bill doesn't even meet the basic goal the American people 
had in mind in what they thought this debate was all about--to lower 
costs. This bill will actually make the situation worse, and now we are 
about to vote on it.
  We have heard some Senators come to the floor today and say that they 
oppose this bill, but they don't want to stop the debate. They oppose 
the bill, but they don't want to stop the debate. Nobody is suggesting 
we stop the debate. No one. Not a single Senator on this side of the 
aisle have I heard suggest that we stop the debate. But if we don't 
stop this bill tonight, the only debate we will be having--the only 
debate we will be having--is about higher premiums, not savings for the 
American people; higher taxes instead of lower costs, and cuts to 
Medicare rather than improving seniors' care. That is what the debate 
will be about.
  The American people and 40 of us in this room sitting on this side of 
the aisle are not asking to end the debate. That is not what we have in 
mind, to end the debate. What we want to do is change the debate--not 
end it, change it--because once we get on this bill, ladies and 
gentlemen, the basic dimensions will not change. The basic dimensions 
will not change.
  So I ask: Why should we consider a bill we already know the American 
people oppose? This is not anything anybody is in doubt about. The 
American people think if you don't like this bill, you have an 
obligation to try to stop it, and that opportunity will come at 8 
o'clock.
  I am sure this won't come as a surprise to any Member of the Senate, 
but it is going to take 60 votes to change this bill. That means the 
bill as introduced--this bill we are looking at right here--will 
fundamentally be the bill we will be asked to pass sometime in the 
future. That is a fact.
  After tonight's vote we will all go home and face our constituents. 
We will have to tell them how we voted on raising their premiums, 
raising their taxes, and cutting their Medicare. For some of us, that 
is not going to be a very easy conversation, but it doesn't have to be 
that way. If you want to lower costs and premiums, then we can work 
together step by step and pass the commonsense reforms the American 
people have been asking for all along.
  We can end junk lawsuits against doctors and hospitals which drive up 
costs. We can encourage healthy choices such as prevention and wellness 
programs which hold down costs. We can lower costs by letting consumers 
buy coverage across State lines. We can allow small businesses to band 
together to get lower insurance rates. And certainly we can address the 
rampant--absolutely rampant--waste, fraud, and abuse that drives up 
costs. All of those, my colleagues, are changes worth making.
  The American people are looking at the Senate tonight. They are 
hoping we say no to this bill so we can start on a better plan that 
fixes the problem the American people care about most, and that is 
cost. They want us to start over. There is nothing about this massive 
bill they like. They want us to start over. They want us to address 
their real concerns. All it would take, Mr. President and my 
colleagues, is one Member of the other side of the aisle--just one--to 
give us an opportunity not to end the debate but to change the debate 
in the direction the American people would like us to go.
  I yield the floor.
  The PRESIDING OFFICER. The majority leader.
  Mr. REID. Mr. President, my dear friend, the Republican leader, has 
had since Wednesday to read this bill. Obviously he hasn't done so 
because the facts he is talking about do not exist except in the minds 
of a few people who don't understand this legislation.
  For 200 years we have styled ourselves the world's greatest 
deliberative body. Deliberation necessarily implies discussion and 
great issues, necessarily requires great debate. Today we vote on 
whether to even discuss one of the greatest issues of our generation; 
indeed, one of the greatest issues this body has ever faced: whether 
this Nation will finally guarantee its people the right to live free 
from fear of illness and death which can be prevented by decent health 
care for all. In the coming weeks, we will finally put people, not 
insurance companies, in charge of their lives.
  The road to this point has been started many times. It has never been 
completed. Merging two such large and consequential bills has never 
been done before. It has been an enormous undertaking and we would not 
be in this position without the unflagging dedication of many Senators 
and extremely loyal staff members. At the top of the list are Chairmen 
Baucus and Dodd who have shown dedication and determination in recent 
weeks and months that has rarely been seen.
  I am proud of every single Senator's input, and I am especially proud 
of the two most recent classes of Senators. Elected with strong 
mandates for progress, they have demonstrated a studious approach to 
our historic endeavor and an unwavering belief that all Americans 
should be able to afford to live a healthy life.
  I wish to explain why we are holding this important vote at this 
hour. As a matter of principle that I respect, the senior Senator from 
Arkansas insisted we vote only after Senators had time to read and 
understand this bill. Senators all have now had ample time to do so. 
That is because of the chairman of the Agriculture Committee, Senator 
Blanche Lincoln, of Arkansas.

[[Page 28780]]

  As I have done many times this year privately, personally, as well as 
publicly, I again invite my Republican colleagues to join on the right 
side of history. I, again, invite them to join us, at the very least, 
in a debate about our future.
  Around dining room tables in Nevada and across the Nation, families 
are agonizing over what to sacrifice next to buy health insurance. They 
are questioning whether to fill a prescription or go without it and 
hope for the best. Employers are wondering whether they can afford to 
provide health care to their employees. They are asking how their 
businesses can survive while health care costs grow faster than ever. 
Americans need health insurance reform.
  Debate is constant between television commentators and the editorial 
pages of great newspapers and magazines. The only place where silence 
is even considered is in the Senate of the United States.
  Tonight--finally--we have the opportunity to bring this debate where 
it belongs. We finally have the opportunity to bring this great 
deliberation to this great deliberative body. That--and nothing more--
is what tonight's vote does. A ``yes'' vote says to America: I know 
this issue is important to your family and to our country, and the 
Senate should, at the very least, talk about it.
  Let's be real transparent. Beyond all the hype, the hyperbole, and 
the hyperventilation, that--and nothing more--is what tonight's vote 
does. A ``yes'' vote says to America: I know this issue is important to 
your family and to our country, and the Senate should at least talk 
about it.
  Some of my Republican friends would like the American people to think 
that voting to debate the bill is voting to pass the bill. Any high 
school civics textbook will tell you that suggestion is absolutely 
false. Tonight's vote is not the end of the debate, it is only the 
beginning of the debate.
  It is clear by now that my Republican colleagues have no problem 
talking about health care in press conferences, radio interviews, 
television interviews, and townhall meetings. My distinguished 
counterpart, the Republican leader, has given many speeches in this 
Chamber on the issue of health care reform.
  Yet now that we have the actual legislation to debate, to amend, and 
build on--now that we have a plan on paper and not just wild rumors--
will they refuse to debate?
  After all, if we are not debating, if we refuse to let the Senate do 
its job, what are we doing here? If Senators refuse to debate about a 
profound crisis affecting every single citizen, the Nation must ask, 
what do you fear? In whose voice do you speak? In whose interest do you 
vote?
  Surely, deliberating health reform cannot be more difficult than 
deciding, as Americans have to do, whether to pay your mortgage or your 
medical bills. It can't be more painful than not taking your child to 
the doctor because it costs too much. It cannot be more humbling than 
facing your own employees and telling them: I am sorry, you can't count 
on me for your health insurance next year. You are on your own.
  It can't be more upsetting than having an insurance company take away 
your coverage at the exact moment you need it the most.
  My Republican friends, there is nothing to fear in debate. President 
Kennedy once said:

       Let us not be afraid of debate or discussion. Let us 
     encourage it.

  Be not afraid of debate. It is our job, and it is exactly what the 
legislative process is all about--discussing, amending, improving. We 
Democrats stand ready to do what needs to be done. We welcome debate, 
encourage debate.
  Does any Senator seriously think the Founders conceived the Senate 
rules in the hopes that legislation would never be deliberated? Of 
course not.
  Did the Framers of the Constitution explicitly enumerate the powers 
of the Senate but in truth hope this body would avoid the hardest and 
most urgent questions of the day? Of course not.
  Did our Nation's visionaries build this Capitol Building and design 
this great Chamber we stand in tonight only so it would remain dark and 
silent? Quite to the contrary.
  Imagine if, instead of debating either of the historic GI bills--
legislation that has given so many brave Americans the chance to attend 
college--this body stood silent. Imagine if, instead of debating the 
bills that created Social Security or Medicare, the Senate voices had 
been stilled.
  Imagine if, instead of debating whether to abolish slavery, instead 
of debating whether giving women and minorities a right to vote, those 
who disagreed had muted discussion and killed any vote.
  I say to my Republican Senators, don't try to silence a great debate 
over a great crisis. Don't let history show that when given the chance 
to debate and defend your position and work with us for the good of our 
constituents, you ran and hid. You cannot wish away a great emergency 
by closing your eyes and pretending it doesn't exist.
  There is an emergency that exists, and it exists now. The right 
response to disagreement is not dismissal, it is discussion. Democracy 
is discussion. Democracy needs deliberation. Let us debate our 
differences. On some, we will find common ground; on others, we may 
not. But let's at least tell America their legislators in the Senate 
are willing to find where we can come together.
  Nobel Prize awardee Andre Sakharov, one of the great thinkers of the 
past century, knew that when opposing sides come together, some of 
their ideas can outweigh its parts. Sakharov said:

       Profound thoughts arise only in debate, with a possibility 
     of counter-argument. . . .

  So come on, my friends, let us share our ideas in the Senate. Let us 
legislate. Let us negotiate. Let us deliberate. Let us debate. Our 
country cries for this debate. Our country deserves this debate. Our 
country needs this debate.
  I extend my great appreciation to the truly tireless men and women at 
the Senate Finance Committee, Senate HELP Committee, Congressional 
Budget Office, Senate Office of the Legislative Counsel, Joint 
Committee on Taxation, the Department of Health and Human Services, the 
Center for Medicare and Medicaid Services and the White House:


                      Congressional Budget Office

       Doug Elmendorf, Director; Holly Harvey, Deputy Assistant 
     Director for Budget Analysis; Kate Massey, Unit Chief, Low-
     Income Health Programs and Prescription Drugs Cost Estimates; 
     Tom Bradley, Unit Chief, Health Systems and Medicare Cost 
     Estimates; Phil Ellis, Unit Chief, Health Policy Analysis; 
     Jean Hearne, Lara Robillard, Lori Housman, Mindy Cohen, 
     Stephanie Cameron, and the rest of their staffs.


                Senate Office of the Legislative Counsel

       Jim Fransen, Bill Baird, Ruth Ernst, John Goetcheus, Kelly 
     Malone, Mark Mathieson, Mark McGunagle, Stacy Kern-Scheerer, 
     Allison Otto, and the rest of their staffs.


                      Joint Committee on Taxation

       Thomas Barthold, Adam Block, John Bloyer, Tanya Butler, Jim 
     Cilke, Tom Dowd, Robert Harvey, Marjorie Hoffman, Melanie 
     Houser, Deirdre James, Rachel Levy, Julie Marshall, Pam 
     Moomau, John Navratil, Ned Newland, Mary Risler, Cecily Rock, 
     Bernard Schmitt, Chris Simmons, Carrie Simons, Lori Stuntz, 
     Kristeen Witt.


                Department of Health and Human Services

       Jeanne Lambrew, Meena Seshamani, Caya Lewis.


               Center for Medicare and Medicaid Services

       Erin Clapton, Ira Burney, Amy Hall, Maria Martino, Isabella 
     Leung, Anne Scott, Nancy DeLew, Sharon Arnold, Allison Orris, 
     Jennifer Snow, Jill Gotts, Chantelle Britton, Molly Long, 
     Adam Aten, Lisa Joldersma, Sylvia Yu, Laura McWright, Greg 
     Jones, Dan Miller, Ariel Novick, Rick Foster.
       Program Experts in the following offices/centers (in 
     alphabetical order): Center for Drug and Health Plan Choices 
     (Tim Hill); Center for Medicare Management (Jon Blum, Liz 
     Richter); Center for Medicaid & State Operations (Cindy Mann, 
     Penny Thompson); Office of Clinical Standards & Quality 
     (Barry Straube); Office of E-Standards and Services (Tony 
     Trenkle); Office of Financial Management (Deborah Taylor); 
     Office of General Counsel (Janice Hoffman); Office of 
     Legislation; Office of Research, Development and Information 
     (Tim Love).


                            The White House

       Nancy-Ann DeParle, Mike Hash.


[[Page 28781]]


  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. REID. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. REID. Mr. President, I ask unanimous consent that Senators vote 
tonight from their desks.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. REID. Mr. President, I ask consent that we start the vote 5 
minutes early.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The PRESIDING OFFICER (Mr. Dodd). Under the previous order, the clerk 
will report the motion to invoke cloture.
  The assistant legislative clerk read as follows:

                             Cloture Motion

       We, the undersigned Senators, in accordance with the 
     provisions of rule XXII of the Standing Rules of the Senate, 
     hereby move to bring to a close debate on the motion to 
     proceed to Calendar No. 175, H.R. 3590.
         Harry Reid, Tom Harkin, Jack Reed, Edward E. Kaufman, 
           Jeff Merkley, Roland W. Burris, Daniel K. Akaka, Patty 
           Murray, Richard J. Durbin, Sherrod Brown, Michael F. 
           Bennet, Jeanne Shaheen, Sheldon Whitehouse, Bill 
           Nelson, Mark Udall, Benjamin L. Cardin, Christopher J. 
           Dodd, Patty Murray.

  The PRESIDING OFFICER. By unanimous consent, the mandatory quorum 
call is waived.
  The question is, Is it the sense of the Senate that debate on the 
motion to proceed to H.R. 3590, the Service Members Home Ownership Tax 
Act of 2009, shall be brought to a close? The yeas and nays are 
mandatory under the rule.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Ohio (Mr. Voinovich).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 60, nays 39, as follows:

                      [Rollcall Vote No. 353 Leg.]

                                YEAS--60

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

                                NAYS--39

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

                             NOT VOTING--1

       
       Voinovich
  The PRESIDING OFFICER. On this vote, the yeas are 60, the nays are 
39. Three-fifths of the Senators duly chosen and sworn having voted in 
the affirmative, the motion is agreed to.
  (Disturbance in the galleries.)
  The PRESIDING OFFICER. Expressions of approval are not allowed.
  Under the previous order, all postcloture time is yielded back, and 
the motion is agreed to.
  The clerk will report the bill by title.
  The assistant legislative clerk read as follows:

       A bill (H.R. 3590) to amend the Internal Revenue Code of 
     1986 to modify the first-time home buyers credit in the case 
     of members of the Armed Forces and certain other Federal 
     employees, and for other purposes.


                           Amendment No. 2786

  Mr. REID. Mr. President, I call up my amendment that is at the desk.
  The PRESIDING OFFICER. The clerk will report the amendment by title.
  The legislative clerk read as follows:

       The Senator from Nevada [Mr. Reid], for himself, Mr. 
     Baucus, Mr. Dodd, and Mr. Harkin, proposes an amendment 
     numbered 2786.

  Mr. REID. Mr. President, I ask unanimous consent that the reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (The amendment is printed in the Record of Thursday, November 19, 
2009, under ``Text of Amendments.'')
  Mr. McCONNELL. I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. The majority leader.

                          ____________________