[Congressional Record (Bound Edition), Volume 155 (2009), Part 21]
[Senate]
[Pages 28837-28847]
[From the U.S. Government Publishing Office, www.gpo.gov]




             SERVICE MEMBERS HOME OWNERSHIP TAX ACT OF 2009

  The ACTING PRESIDENT pro tempore. Under the previous order, the 
Senate will resume consideration of H.R. 3590, which the clerk will 
report.
  The 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.

  Pending:

       Reid amendment No. 2786, in the nature of a substitute.
       Mikulski amendment No. 2791 (to amendment No. 2786), to 
     clarify provisions relating to first dollar coverage for 
     preventive services for women.
       McCain motion to commit the bill to the Committee on 
     Finance, with instructions.

  The ACTING PRESIDENT pro tempore. Under the previous order, the time 
until 11:30 will be for debate only, with the Republicans controlling 
the first 30 minutes and the majority controlling the next 30 minutes, 
with the remaining time equally divided and controlled between the two 
leaders or their designees and with Senators permitted to speak therein 
for up to 10 minutes each.
  The Senator from Arizona is recognized.
  Mr. KYL. Mr. President, I ask unanimous consent that during the 30 
minutes controlled by the Republicans, we be allowed to engage in a 
colloquy.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. KYL. Mr. President, I will begin by making some comments about 
the amendment Senator McCain, my colleague from Arizona, has filed. 
This is an amendment that, as the minority leader just said, will 
protect America's seniors. It will disallow the Medicare cuts this bill 
includes.
  The economist Milton Friedman famously said, ``There is no such thing 
as a free lunch,'' and that applies to health care as well. There is no 
such thing as free health care. Someone has to pay. Since this bill is 
a $2.5 trillion bill, the first question is, Who pays? The first answer 
to who pays is, it is America's seniors, because about half of the cost 
of the bill is allegedly paid for by cuts to Medicare.
  Let me break down a little bit more specifically than the Republican 
leader did exactly what that means. This is about $500 billion in 
Medicare cuts as follows: $137.5 billion from hospitals who treat 
seniors; $120 billion from Medicare Advantage, which is the insurance 
program that provides benefits to seniors which will be cut more than 
in half as a result of this $120 billion reduction; $14.6 billion from 
nursing homes that treat seniors; $42.1 billion from home health care 
for seniors; and $7.7 billion from hospice care, one of the most cruel 
cuts of all.
  Obviously, with cut this dramatic there is no way to avoid 
jeopardizing the care seniors now enjoy, and seniors know this. That is 
why they have been writing our offices and attending townhall meetings 
to let us know they disapprove. I quoted from two letters constituents 
of mine from Arizona sent asking to please not cut their Medicare 
Advantage Program. This has been called the crown jewel of the Medicare 
system, and many of them rely on Medicare Advantage for dental care or 
vision care or hearing assistance they have come to rely on. They are 
not buying the claims that somehow or other we can make $\1/2\ trillion 
cuts in Medicare without somehow hurting their care. They know better 
than that, and they are right. The care they have been promised will be 
compromised to pay for this new government entitlement under the bill.
  Finally, many are wondering what happened to the promise that they 
get to keep the care they have. We all heard the President say that 
many times: If you like the care you have, you get to keep it. That is 
simply not true. There are 337,000 Arizonans who are Medicare Advantage 
patients. They like what they have. Yet we know, according to the 
Congressional Budget Office, that the benefits they have under Medicare 
Advantage are going to be cut by more than half. They are saying: What 
happened to the policy I like? I am not going to be able to keep it if 
this bill passes.
  This is why the McCain amendment must pass. If our Democratic 
colleagues are not willing to protect Medicare, then I cannot imagine 
how the bill could otherwise be made acceptable since it starts with 
the commitments that Congress and the President have made to our senior 
citizens.
  The ACTING PRESIDENT pro tempore. The Senator from Tennessee is 
recognized.
  Mr. ALEXANDER. I congratulate the Senator from Arizona on his 
analysis of the Medicare cuts. I heard the Democratic leader talk about 
figures and how we have some figures and the Democrats have other 
figures. I agree with him. I think someone watching this must think we 
are on two different planets sometimes, so let me focus in on the 
figures.
  I believe I heard my colleague say to pay for this health care bill 
over 10

[[Page 28838]]

years there would be $465 billion in the Medicare cuts. Where does that 
figure come from?
  Mr. KYL. Mr. President, I say to my friend from Tennessee, first of 
all it comes from a reading of the bill. It is very clear in the bill 
as to how much money is taken from Medicare. The number the Senator 
from Tennessee just articulated is the correct number.
  In addition to that, the Congressional Budget Office and the Joint 
Tax Committee analyzed the specific numbers. Obviously they were given 
the numbers in the bill, but the numbers they are using are--I just 
broke it down into four or five general categories. There are other 
divisions within that. But as I said, for notional purposes here: 
$137.5 billion from hospitals; $120 billion from Medicare Advantage. 
That number might be $118 billion; I am not precisely certain of it, 
but it is very close. There is $14.6 billion from nursing homes, $42.1 
billion from home health, and $7.7 billion from hospice care. If any of 
our colleagues would like to contest these numbers, I would be happy to 
be corrected, but I believe those are the correct numbers.
  Mr. ALEXANDER. I think the Senator from Arizona is right. The 
President of the United States, in his address to us about health care, 
and the New York Times, the Wall Street Journal--everyone who has 
reported on the Congressional Budget Office figures said the same 
thing. We are going to pay for this bill, which is $2.5 trillion over 
10 years when fully implemented, by $465 billion cuts in Medicare.
  What Senator McCain in his amendment that we are in support of is 
saying is, don't cut grandma's Medicare to pay for someone else's 
insurance. He goes on to say, if you are going to find some savings in 
waste, fraud, and abuse in grandma's Medicare, spend it on grandma. The 
reason for that is that the Medicare trustees have said to us that 
there is $38 trillion in unfunded liabilities for the Medicare Program 
and that the program will start going bankrupt between 2015 and 2017. 
According to the Medicare trustees, they say, ``We need timely and 
effective action to address Medicare's financial challenges,'' and the 
proposal, if I may say to the Senator from Arizona, who is on the 
Finance Committee and deeply involved in what we need to do about our 
Nation's finances, I don't think the Medicare trustees were thinking 
that the timely and effective action we could take to keep Medicare 
from going broke was to take $465 billion out of it and spend it on 
some new program.
  Mr. KYL. On a new program. That is exactly correct. What the Medicare 
trustees were saying is, if we can effect cost savings in Medicare, and 
surely there are some to be had there, they should go to strengthen the 
Medicare Program itself and not allow it to go bankrupt, rather than it 
being used to create a new government program.
  Perhaps one of the reasons why there are different numbers from one 
side of the aisle to the other is that sometimes we are not talking 
apples to apples. We are talking apples to oranges, and perhaps both 
numbers are correct in their context. The Senator from Tennessee used 
the number $2.5 trillion when the program is fully implemented. That is 
a very important statement. The other side will argue it is only $1\1/
2\ trillion for the first 10 years of the program. That is a correct 
statement. But it is $2.5 trillion for the first 10 years of total 
implementation of the program. What is the reason for the difference? 
For the first 4 years, money is being collected, but very few benefits 
are going out. The benefits start after year No. 4. So if we take the 
first 10 years of the program, we are collecting money to pay for it 
over the entire 10 years, but almost all of the benefits only occur 
during the last 6 years. Naturally, we have collected more money than 
we have paid out. But when we take the first 10 years of full 
implementation, it is as my colleague from Tennessee noted, a cost of 
$2.5 trillion. That is how sometimes we get somewhat different numbers.
  As long as we are clear about what we are talking about, one thing is 
crystal clear: Whether it is $1\1/2\ trillion or $2.5 trillion, we are 
talking real money. Somebody has to pay for it. If America's seniors 
are being asked to pay for half of it, that is not fair to America's 
seniors, given the commitment we have made to them. That is the point 
of the McCain amendment. Protect Medicare, protect America's seniors. 
We can do that with the simple amendment Senator McCain has which is 
send the bill back to committee--it would only take 1 day--and send it 
back here without those Medicare cuts in the bill.
  Mr. ALEXANDER. I see the Senator from Idaho here. I wish to hear his 
observations. If there is any issue in this entire health care debate 
that symbolizes why we on the Republican side want to change the debate 
to a step-by-step approach to reducing the cost of premiums, it would 
be the Medicare issue. As the Senator from Arizona said, what we need 
to do about Medicare is make it solvent as quickly as we can, as 
effectively as we can. The Senator from Kansas said the other day that 
the proposal to take $465 billion from grandma's Medicare and spend on 
it some new program is like writing a check on an overdrawn account in 
a bank to buy a big, new car. There is a lot of truth to that.
  The President said earlier this year something I agree with. He said 
this health care debate is not just about health care. It is about the 
role of the Federal Government in the everyday life of Americans. He is 
exactly right about that. This health care debate, which we are 
beginning this week, is not just about health care. It is about the 
stimulus package, about the takeover of General Motors. It is about the 
trillion dollar debt. It is about the Washington takeovers. It is about 
too much spending, too much taxes, too much debt. The Medicare 
provisions in this bill are a perfect symbol of that. That is why 
Senator McCain is right. What he is saying is, don't cut grandma's 
Medicare and spend it on some new program. If you can find some savings 
in the waste, fraud, and abuse of grandma's Medicare, spend on it 
grandma. Make sure those of us who are older and those of us who are 
younger and looking forward to Medicare can count on its solvency.
  Later this week we will talk more about premiums going up. There was 
a lot of discussion yesterday because, according to the Wall Street 
Journal, some health premiums would rise. For people who get their 
insurance from large employers, this bill won't make much difference. 
And for small employers, if you get your insurance from a small 
employer, it won't make much difference. If you are going to the 
individual market to buy insurance yourself, your premiums will go up, 
except we are going to get some money from somewhere to help pay part 
of your premiums, at least for about half of Americans who are in the 
individual market. Where are we going to get that money? From grandma. 
We are going to get it from Medicare. So that is what is wrong with 
this bill. And what is right about the McCain amendment is, it says 
simply, don't cut Medicare. If we find savings, which we hope we can in 
Medicare, we should spend it on making Medicare solvent.
  I wonder if the Senator from Idaho is hearing from seniors in his 
State about the proposed $465 billion cuts to Medicare and how they 
feel about taking that money and spending it to create a new program?
  Mr. CRAPO. I thank the Senator from Tennessee. Very definitely we are 
hearing from seniors in Idaho who see through this. It is very clear to 
the folks in Idaho that what we are seeing is a proposed massive growth 
of the Federal Government by over $2.5 trillion, when fully 
implemented, that is to be funded on the backs of American taxpayers 
and senior citizens through cuts in Medicare. In fact, in addition to 
those who have contacted me who are seeing their health benefits lost, 
I have also been contacted by a number of the providers. We are talking 
about those who are in home health care or hospice health care, skilled 
nursing facilities or hospitals and the like.
  They make a very interesting point. Their point is that not only will 
senior citizens--in Medicare Advantage in particular--literally be 
losing their benefits dramatically, but that other senior citizens who 
are in traditional

[[Page 28839]]

Medicare will also be losing access and quality of care. How is that 
the case? We know from the details of this bill that we are going to 
see major cuts in hospice care, home health care, skilled nursing 
facilities, and hospitals.
  The points made to me by those providers are that they have already 
gone through a series of very deep cuts, cuts to the point that in 
Idaho for home health care, we have lost something like 30 percent of 
our facilities already. The way one of them explained to it me was that 
if you reduce the compensation we are receiving, then we have to reduce 
something in our budget. He said: We can't just start taking bricks off 
of our buildings. What we will end up having to do is to reduce 
personnel. That would be the nurses and the doctors and the other care 
providers who are there to provide support for these individuals. We 
will have to reduce the number of rooms we operate or the facilities we 
provide. In the end, there will be a reduction of services and access 
available to senior citizens, including a reduction in the quality of 
the care they are able to be provided.
  Mr. ALEXANDER. In discussing the Medicare cuts, another provision of 
the bill which we will be talking about this month and next month as we 
go through the health care debate is what about the problem of paying 
doctors and hospitals who see Medicare patients. They get paid about 83 
percent of the rate they would be paid if they were seeing a private 
care patient. Every year Congress has to make an adjustment in 
something we did a few years ago which automatically cuts the amount of 
money that we pay doctors who are seeing Medicare patients.
  That is a big problem for Medicare patients. Because if the doctors 
can't be paid, they won't see the patients, and Medicare patients may 
find themselves increasingly in the condition that Medicaid patients 
do, low-income Americans who are covered through the State program--
that is our largest government-run program--where they are paid about 
60 percent of what doctors who see private patients are paid and about 
half of Medicaid doctors won't see new patients.
  I ask the Senator, does he see anywhere in this bill a provision for 
the $\1/4\ trillion that will be needed to pay doctors 10 years from 
now what they are making today? If it is not in the bill, where is that 
$\1/4\ trillion going to come from? Is it going to come from Medicare 
cuts, or will it come from adding to the deficit?
  Mr. CRAPO. Obviously, it will come from cuts in Medicare or increased 
taxes or simply more debt on the Federal level.
  The Senator raises a very interesting point. This question of fixing 
the compensation rates for physicians in Medicare is a huge question, 
one which we have been fighting for for a number of years to try to 
find a solution to, as each year we delay the expected cuts that will 
happen. I have talked about this factor in the context of being a 
budget gimmick in this bill. What do I mean by that? Those who say this 
bill reduces the deficit are able to say so only because it has about 
$500 billion of new taxes, about $500 billion of Medicare cuts, and a 
number of budget gimmicks that delay the implementation of the spending 
side of the bill or, in this case, don't even include at all one of the 
major expenses that needs to be accommodated, and that is the fix for 
physician compensation. If any of those things were not in this bill, 
this bill would drive up the deficit tremendously.
  What we are going to see, in addition to these fiscal impacts on the 
Federal Treasury in terms of huge increases in the debt or huge 
increases in more taxes, even more than we are talking about with this 
bill, is we are going to see the very real potential that access to 
medical care for seniors will be again reduced because of this factor.
  Let me give a couple of statistics. In their June 2008 report, the 
Medicare Payment Advisory Commission, or MedPAC, said that 29 percent 
of Medicare beneficiaries who were surveyed were looking for a primary 
care physician and had trouble finding one to treat them. In other 
words, about 30 percent of Medicare beneficiaries today are having 
trouble finding a physician who will take a Medicare patient. That is 
before the $465 billion of cuts and before simply not including 
physicians at all in this legislation.
  A 2008 survey by the Texas Medical Association found that only 58 
percent of the State's doctors took new Medicare patients, and only 38 
percent of the primary care doctors accepted new patients. Again, it is 
an example from MedPAC and from one State that indicates what we know 
is happening around the country; namely, that doctors in increasing 
numbers are no longer taking new Medicare patients, just as they have 
been doing with Medicaid patients for years. Yet we see these massive 
cuts to Medicare being proposed that will have the same impact on 
hospice care and home health service and skilled nursing facilities and 
hospitals, and we see that doctors are not even included at all, 
meaning they are projected now to receive major reductions. I think it 
is over 20 percent reduction in their compensation for taking Medicare 
patients.
  The solution here to establishing a massive new Federal entitlement 
program is not to cut Medicare. I want to repeat something both the 
Senators from Arizona and Tennessee have already said that is critical. 
Reducing the Medicare budget by $464 billion, by any number, is 
something that has been encouraged in terms of trimming the growth path 
for Medicare. That is something this Congress has looked at in the 
past. But never was it intended by those who made these projections 
about needing to control the spiraling cost of Medicare that we address 
the fiscal circumstances in Medicare with the intended purpose of 
creating another new, massive Federal entitlement program that will 
grow the Federal Government by over $2 trillion--we talked about the 
numbers; the full 10-year period is $2.5 trillion--and leave Medicare 
with these dramatic cuts, this loss of service and loss of benefits to 
the recipients, while they see this new government growth with a new 
government program. That was not in the mind of anybody who was asking 
us to deal with the solvency issues on Medicare, and I don't think it 
was in the mind of anybody who asked that we have some kind of health 
care reform to deal with the rising cost of premiums.
  Mr. ALEXANDER. Mr. President, how much time remains on the Republican 
side?
  The ACTING PRESIDENT pro tempore. The Senator has 8\1/2\ minutes.
  Mr. ALEXANDER. Would the Chair let me know when 4 minutes remain.
  The Senator from Idaho will conclude our remarks at that time.
  The Senator from Idaho has made an important point, anticipating our 
Democratic friends will have the next 30 minutes and some other things 
they may be saying the rest of the day. There was a lot of talk 
yesterday about the CBO report about the effect of this $2.5 trillion 
proposal on premiums. Rather than take my word for it, let's go to the 
news section of the Wall Street Journal of today which has the 
headline: ``Some Health Premiums to Rise.'' That means going up. That 
means the cost of your insurance is going up for some Americans.
  So my question is, why would we spend $2.5 trillion over 10 years, 
cut Medicare, raise taxes, and run up the debt to raise some health 
premiums? I thought the whole exercise was to lower the cost of health 
care premiums.
  The article says:

       The analysis released Monday by the nonpartisan 
     Congressional Budget Office and the Joint Committee on 
     Taxation--

  We are supposed to pay some attention to these outfits as 
nonpartisan--

     painted a more complicated and uncertain picture. It said 
     people who pay for their own insurance would see a higher 
     bill, albeit for more generous benefits--

  That is the government-approved insurance you are going to be forced 
to buy.

     unless they are lower earners who qualify for a new 
     government tax credit.

  Where is the money going to come from for those subsidies? It is 
going to come from grandma. It is going to come from Medicare. It is 
going to come from taxes. And it is going to come from increasing the 
debt.

[[Page 28840]]

  Those are facts.

       Employees of small firms--

  Says the Wall Street Journal--

     would effectively see their insurance premiums unchanged--

  So for small firms, we are going to spend $2.5 trillion over 10 
years, cut Medicare, cut taxes, and run up premiums for millions of 
Americans, so your insurance will continue to go up at about the rate 
it already was. Why should we be doing that?

     while workers at large firms would see something between 
     unchanged and slightly lower premiums under the bill--

  Compared to what would already happen--

     according to the analysis.

  We need to change the debate. We need to start over. Instead of this 
comprehensive 2,000-page bill that is full of taxes, mandates and, as a 
general effect, raises premiums and taxes and cuts Medicare, we should 
set a clear goal, reducing costs, and begin to go step by step toward 
that goal--reducing junk lawsuits against doctors, allowing health care 
to be purchased across State lines to increase competition, allowing 
small businesses to combine in health plans so they can offer more 
insurance to employees at a lower cost.
  These three bills I mentioned have been offered and rejected so far 
by the Democratic majority. We should have more flexibility in health 
savings accounts, efforts at waste, fraud, and abuse, which are, in 
effect, Medicaid--the largest government program--and Medicare--the 
second largest--and more aggressive steps to encourage wellness and 
prevention.
  One approach, the comprehensive 2,000-page bill, Washington-takeover 
approach, Americans are very leery of. In my respectful opinion, this 
bill is historic in its arrogance for thinking we could take a system 
that affects almost all 300 million Americans, 16 percent of the 
economy, and change it all at once.
  Instead, why don't we go step by step to re-earn the trust of the 
American people? Republicans will be making those proposals on the 
floor this month and next month and as long as it takes to try to see 
that we get real health care reform. Cutting grandma's Medicare by $\1/
2\ trillion and spending it on a new program at a time when Medicare is 
going broke is not real health care reform.
  Mr. CRAPO. Mr. President, how much time remains?
  The ACTING PRESIDENT pro tempore. There is 4\1/2\ minutes remaining.
  The Senator from Idaho.
  Mr. CRAPO. Thank you, Mr. President. I wish to conclude with our time 
this morning by focusing on the larger picture a little bit, as my 
colleague from Tennessee has done in his concluding remarks.
  When you ask Americans whether they want health care reform, the vast 
majority would say yes. When you ask them what they mean by that, the 
vast majority in the polls and in my personal experience are saying: We 
want to see the spiraling costs of health care and our health insurance 
brought under control and reduced, and we want to see increased access 
to quality health care for those who do not have access today and for 
those who have limited access today.
  This bill fails on those two central points. What this legislation 
does, instead, is increase the size of government by $2.5 trillion of 
new Federal spending, establishing massive new Federal controls over 
the economy, and even creating a Federal Government insurance company. 
It increases taxes by about $500 billion, and not just on the so-called 
wealthy. The vast majority of these taxes is going to squarely hit 
those who President Obama said would not be hit: those who make less 
than $200,000 a year and, frankly, all the way down the income chain.
  It cuts Medicare by $464 billion. It puts a major new unfunded 
mandate on our States, which are already struggling in their fiscal 
budgets. As my colleague indicated, it causes the price of insurance 
premiums to go up for the individual market, to go up in the small 
group insurance market, and to be basically unchanged in the large 
insurance market, according to the CBO study.
  By the way, one of the things that is not pointed out in that CBO 
study very much is in that large market, which it says will be the only 
part of the market that does not see insurance rates go up, one of the 
reasons is because their health care will go down. In other words, 
there is a tax on these larger, high-cost insurance premiums that is 
going to be either passed through and cause their insurance to go up or 
will be avoided by reducing the cost of their insurance and reducing 
coverage of the benefits in these policies. So one way or the other, 
all Americans are going to see their health care premiums go up or, in 
the large groups, see their health care premiums be held the same by 
reducing the quality of the insurance they have.
  If you go back to those two reasons Americans wanted health care 
reform, did we see premiums go down? No. Did we see increased quality 
or increased access to care? Well, there are some who are going to get 
a subsidy in this program for this new massive Federal program. But at 
what price? Mr. President, $2.5 trillion, $464 billion of cuts in 
Medicare, the establishment of a major new government program that 
would essentially be funded on the backs of massive new tax increases, 
massive Federal tax increases, and Medicare cuts, and in the end we 
will still be in a system in which we are seeing spiraling increases in 
health care costs. To me, that is not the kind of reform we need.
  My colleague from Tennessee indicated there are a number of reforms 
on which we can find common ground that will reduce health care costs. 
There are a number of reforms on which we can find common ground that 
will help us to increase access to quality care. That is where our 
focus should be. That is why I stand here today in support of my 
colleague John McCain, his motion to commit this legislation to the 
Finance Committee. As was indicated, it could be done in 1 day, to 
simply remove the Medicare cuts that are contained within it. Let's fix 
that part of this bill, and then let's work forward.
  I see my time has expired. I encourage this Senate to focus closely 
on the legislation and to let us work together in a bipartisan fashion 
rather than speeding ahead and trying to pass legislation that has not 
had the opportunity for this kind of bipartisan effort to develop a 
good work product for the American people.
  The ACTING PRESIDENT pro tempore. The Senator from Connecticut.
  Mr. DODD. Mr. President, our colleague from Maryland, Senator 
Mikulski, I believe is on her way to the floor of the Senate. She and 
several other Members, in the time we have allocated to us between now 
and 11:30, will address her amendment she proposed yesterday. But 
pending her arrival, I want to respond, if I could, very briefly to 
some of the conversation here this morning.
  First, I know some people have short memories, but I am somewhat 
intrigued to hear our good friends and colleagues talk about preserving 
Medicare. I have been around here a few years and recall very vividly 
the debates of 1995 and 1997 on the issue of Medicare, where our 
friends, who were in the majority in those days, were talking about 
slowing the growth of Medicare and one of the proposals they had for 
doing so was to cut into the benefits of Medicare recipients.
  We do not do that in this bill at all. Quite to the contrary, despite 
the language about ``big cuts in Medicare,'' we strengthen the Medicare 
Program substantially. That is the reason the AARP and other major 
organizations involved with the elderly have endorsed our proposals. 
They would hardly be doing so if they thought this was some massive cut 
into the Medicare Program that has been so critical to so many of our 
fellow citizens.
  Just for a little bit of history here--In 1995 our Republican 
colleagues proposed cutting benefits to Medicare beneficiaries. Newt 
Gingrich, our former Speaker and friend from the other body, was quoted 
as saying ``let's let Medicare wither on the vine.'' That is not 
ancient history. That is not 1965. That is just a few years ago in all 
of this debate.

[[Page 28841]]

  There are some very strong provisions in the bill that reduce 
premiums and co-pays for seniors, ensure seniors are able to see their 
own doctors, and keep Medicare from going bankrupt for an additional 5 
years. If we adopt the McCain amendment, we are being told today by CBO 
and others that Medicare becomes insolvent in 8 years. So vote for the 
McCain amendment and you are going to have an insolvent program in 8 
years. That is a fact.
  We extend the life here an additional 5 years. We provide new 
preventive and wellness benefits for seniors, lower prescription drug 
costs, allow seniors to stay in their homes and not end up in nursing 
homes.
  This is a long bill. It is a big bill. But instead of complaining 
about its size, I would encourage my colleagues to read it and 
understand what is being done for Medicare. This is a complicated area, 
but, nonetheless, critically important.
  Mr. President, I see my colleague from California, Senator Boxer, who 
is here, and others who want to address the issue of the Mikulski 
amendment, and I will yield the floor so they can be heard. I believe 
it is going to be each for 5 minutes. There are about seven of our 
colleagues who want to be heard on the issue before 11:30.
  Mrs. BOXER. Mr. President, if I might respond.
  The ACTING PRESIDENT pro tempore. The Senator from California is 
recognized.
  Mrs. BOXER. The plan is, women colleagues will be coming to the 
floor. As they come, I will yield to them, until Senator Mikulski gets 
here, and then she will yield the time, if that is all right.
  Mr. DODD. Very good.
  Mrs. BOXER. Mr. President, before I start, I want to say to my 
colleague from Connecticut how much I appreciate his work and the work 
of Senator Baucus and Senator Reid. What a remarkable moment we have 
here.
  When I go home--and I was home for the holidays--people are urging us 
to get this done. They know their biggest chance of going into 
bankruptcy is a health care crisis--62 percent. They know, as my friend 
Senator Dodd has said almost every day of this debate, every morning 
14,000 people lose their health care. They know if we do not intervene 
with a good bill, their premiums--in my home State, I say to the 
Senator--will be 41 percent of their income, the average income, by 
2016.
  Can you imagine? That is unsustainable. For people who say: Why don't 
we address the economy instead of health care, let me say what happens 
to my constituents if they have to pay 41 percent of their income for 
premiums. Even if they have a good job, I say to my friend from 
Connecticut, they cannot make it. So the status quo is cruel, and it is 
particularly cruel to women.


                           Amendment No. 2791

  Mrs. BOXER. Mr. President, I am proud to support the Mikulski-Harkin-
Boxer amendment to improve preventive health coverage for women. The 
Mikulski amendment addresses this critical issue by requiring that all 
health plans cover comprehensive women's preventive care and 
screenings--and cover these recommended services at little or no cost 
to women. These health care services include annual mammograms for 
women at age 40, pregnancy and postpartum depression screenings, 
screenings for domestic violence, annual women's health screenings, and 
family planning services.
  The preventive services covered under this amendment would be 
determined by the Health Resources and Services Administration to meet 
the unique preventive health needs of women. HRSA is an agency within 
the Department of Health and Human Services. HHS Secretary Kathleen 
Sebelius has already said that ``Mammograms have always been an 
important life-saving tool in the fight against breast cancer and they 
still are today.'' The Secretary made clear that recommendations by the 
U.S. Preventive Services Task Force ``do not set federal policy and 
they don't determine what services are covered by the federal 
government.''
  This is not the first time that experts have disagreed about this 
issue. I have been in this battle before, with Senator Mikulski, who 
called a hearing with all of the women Senators in 1994 where I 
insisted that routine mammograms for women over 40 must be covered. And 
thank goodness we fought back then, and in 1997 and in 2002 when this 
issue was raised again and again. Since 1991, the death rate from 
breast cancer has been reduced by over 20 percent.
  According to a 2007 Partnership for Prevention report, 3,700 
additional lives would be saved each year if we increased to 90 percent 
the portion of women age 40 and older who have been screened for breast 
cancer in the past 2 years. The most recent data show us that 
approximately 17 percent of breast cancer deaths occurred in women who 
were diagnosed in their forties. That is why the American Cancer 
Society continues to recommend annual screening using mammography and 
clinical breast examination for all women beginning at age 40. 
Mammograms are still the most effective and valuable tool for 
decreasing suffering and death from breast cancer. The Mikulski 
amendment will ensure women are able to get access to this and other 
lifesaving preventive services at no cost.
  The underlying bill introduced by Senator Reid already requires that 
preventive services recommended by the U.S. Preventive Services Task 
Force be covered at little to no cost. These recommendations already 
include some women's preventive services such as osteoporosis 
screenings.
  But they do not include certain recommendations that many women's 
health advocates and medical professionals believe are critically 
important, such as screenings for ovarian cancer--a disease that will 
claim the lives of nearly 15,000 women this year. We know that when 
ovarian cancer is diagnosed early, more than 93 percent of women 
survive longer than 5 years.
  Women are often the decisionmakers for their families when it comes 
to health care. But women too often put the health needs of their 
family members and their children ahead of their own.
  By passing this amendment, we are saving the lives of countless 
mothers, daughters, grandmothers and sisters who would otherwise forgo 
preventative health care because of high copays and expensive 
deductibles.
  I would like to share with my colleagues a story from a doctor in my 
home State of California, William Leininger, that drives home the 
importance of this amendment:

       In my last year of residency, I cared for a mother of two 
     who had been treated for cervical cancer when she was 23. At 
     that time, she was covered by her husband's insurance, but it 
     was an abusive relationship, and she lost her health 
     insurance when they divorced.
       For the next five years, she had no health insurance and 
     never received follow-up care (which would have revealed that 
     her cancer had returned). She eventually remarried and 
     regained health insurance, but by the time she came back to 
     see me, her cancer had spread.
       She had two children from her previous marriage--her 
     driving motivation during her last rounds of palliative care 
     was to survive long enough to ensure that her abusive ex-
     husband wouldn't gain custody of her kids after her death. 
     She succeeded. She was 28 when she died.

  That is not a story that should be told in the richest nation in the 
world.
  As I said, I am so proud to support the Mikulski-Harkin-Boxer 
amendment to improve preventive health care coverage for women. Here is 
why. It is a fact that women are increasingly delaying or skipping 
altogether preventive health care, and they are doing it because of 
costs.
  I read a statistic done by a nonpartisan group that said about 39 
percent of men are delaying going to a physician to check on a problem. 
But over 50 percent of women are doing that either because they do not 
have health coverage or they are fearful of the copay. So we could sit 
here and do nothing--that is the easy thing to do: Scare people, do 
nothing--or we could step to the plate, save Medicare, which is very 
important to save, and that is what this bill does. Because we say we 
are not going to spend money on waste, fraud, and abuse. We are going 
to spend money on health care for our people.
  And to believe that my friends on the other side are the ones who are 
going

[[Page 28842]]

to save Medicare? You just have to read history. Senator Dodd explained 
it; Newt Gingrich saying: Let Medicare wither on the vine; Bob Dole, 
our friend, who said, at the time of his Presidential campaign: I 
fought against Medicare. It was a failure.
  Well, if you ask our seniors, I think they are the group most pleased 
with their coverage. It is not perfect, but it is critical, and we save 
it here. We extend the life of Medicare.
  So here we are in a situation where many women are delaying going to 
the doctor, getting their preventive services, and the Mikulski 
amendment addresses this critical issue. It requires that all health 
plans cover comprehensive women's preventive care and screenings, and 
cover them at little or no cost.
  The reason this is so important is--first of all, in the HELP 
Committee, under Senator Dodd's and Senator Kennedy's leadership, this 
piece of the package was in the bill because Senator Mikulski and 
others pushed so hard to get it placed into the bill.
  Mr. President, I would ask my friend from Maryland, Senator Mikulski, 
if I could complete my remarks and then give the floor over to her?
  Mr. President, I thank the Senator.
  I am so proud to work with Senator Mikulski. I say to the Senator, we 
worked on this issue over the years. I just asked my staff to go back 
and look at the first time we teamed up to ensure that women get 
mammograms at age 40. That was in 1994. Then, again, over the years, 
every 3 or 4 years, this whole notion would rear its ugly head: Well, 
women can do without mammography. The question I have is, What is going 
to replace it? They would keep trying to take away our tools of self-
examination and mammography. We know if you look through the years--and 
Senator Mikulski and I are proud of a lot of the work we do, but this 
goes right at the top of the list--we know mortality for breast cancer 
is way down since the early 1990s. It is 20 percent down since the 
early 1990s. We have had to stand our ground to protect women, to make 
sure they get those services they need, those lifesaving services, at 
little or no cost.
  I would also say the American Cancer Society continues to recommend 
annual screening using mammography and clinical breast exams for all 
women beginning at age 40. There are a lot of other very important 
tests that are included in the Mikulski amendment--very important 
tests--to deal with cervical cancer and ovarian cancer, finding the 
markers so we know how to deal with these deadly diseases. To give up 
the tools we have, to turn it over to some organization that does not 
report to the Secretary of HHS, makes no sense.
  What my friend has done with her amendment is to make sure the group 
that decides this is under the jurisdiction of the HHS Secretary. We 
know the HHS Secretary has already said she wants to make sure women, 
starting at age 40, get those mammograms.
  I am going to close by reading from an article in the March 10, 1994, 
San Francisco Chronicle. It says:

       Joining what became a phalanx of six female Senators 
     staring down at federal health officials Boxer said she will 
     insist that routine mammograms and a host of other women's 
     health needs be part of any new nationwide benefit package.

  The article goes on. It is very clear. What I said at the time is:

       After all of these years of women being told it is crucial 
     by age 40 to get a baseline mammogram, now to have this 
     tremendous confusion hit us is very disturbing.

  Well, it was disturbing on March 10, 1994, when I first got involved 
in this issue. It was disturbing when Senator Snowe, 3 years later, had 
us pass S. Res. 47 which said this is our only tool. Let's do it. Thank 
goodness we have now in this body women and men who get the fact that 
we refuse as women to be stripped of the only tools we have. Making all 
of these important tests part of this package is going to save lives. 
It is going to save money. It is going to mean our families can breathe 
a deep sigh of relief out there.
  So I wish to thank Senator Mikulski for her leadership on this issue 
and to always stand right at her side on this issue of mammography. We 
also worked on standards for mammography. Remember that one? It was the 
deregulation fever that hit the Republican side. They wanted to take 
away the regulations for mammography, roll them back. We fought the 
fight, and we will continue to fight the fight.
  So thank you very much. I strongly support this amendment.
  I yield the floor for my friend, Senator Mikulski.
  The ACTING PRESIDENT pro tempore. The Senator from Maryland is 
recognized.
  Ms. MIKULSKI. Mr. President, as we debate health care reform, we need 
to recognize in the United States of America that health care is a 
women's issue. Health care reform is a must-do women's issue, and 
health insurance reform must be a must-change women's issue.
  Too often when we look at when health care is even available to us, 
we face discrimination. We face continually the punitive practices of 
insurance companies that charge women more and give us less in a 
benefit. A 25-year-old woman pays more for health insurance than her 
male counterpart of the same health status. A 40-year-old woman pays 
almost 35 percent more for her insurance than a male of the same age, 
same health status. We want to change that in health care reform. We 
want to end the punitive practices of the private insurance companies 
in their gender discrimination.
  We, the women of the Senate, are concerned that even being a woman is 
being viewed by the insurance companies as a preexisting condition.
  Now we have the opportunity to change the law and change the 
direction of health care. I have offered an amendment to expand the 
screening and preventive services available to women in order to save 
our lives, make sure our lives are not impaired as we get older and, at 
the same time, be able to save money. We know early detection saves 
lives, curtails the expansion of disease, and, in the long run, saves 
money.
  There are certain killers of women, the dread ``c'' word, cancer--
breast cancer, ovarian cancer, cervical cancer that are unique to we 
women. Then there is the dread disease of lung cancer that affects men 
and women but is emerging as a main killer of women. Then there is the 
other issue of heart disease and vascular disease. We know for years 
women were often left out of the research on heart disease. For years 
women's heart disease went undetected and unrecognized because our 
symptoms are different. We can change this law.
  In my amendment we expand the key preventive services for women, and 
we do it in a way that is based on recommendations from the Centers for 
Disease Control and from HRSA. It will be based on the benefit package 
available to Federal employees. It means if our amendment passes, the 
women of America will have the same access to preventive and screening 
services as the women of Congress. What is good enough for a United 
States Senator should be good enough for any woman in the United States 
of America.
  That is why we ask not only the women to join us but the good men of 
quality who support us. We know people such as Senator Dodd, Senator 
Reid, Senator Baucus, men of quality, never fear we women who seek 
equality. They have raced for the cure as long and as hard as we have 
and have fought for mammogram standards. This is why we are wearing 
pink today. Pink is the universal color that says while we race for the 
cure, we want to have access to it when we find it. But to have access 
to the cure, we are going to need to have access to mammograms to be 
able to get that diagnosis, and then we are going to have to have 
health insurance to be able to pay for the treatment we have.
  This is the Titanic battle we have today: Are we going to have access 
to health insurance and are we going to have access to these preventive 
services?
  We do know in the area of heart disease and cancer and silent, 
undetected killers such as diabetes, it is often undetected. What 
happens is, for many women they do not get that early detection and 
screening, No. 1, because

[[Page 28843]]

they can't afford it. They can't afford it because they either don't 
have health insurance and there are other demands on their family or, 
No. 2, when they go, if they do have insurance, they find their benefit 
might not be covered. So many of these benefits are based on State 
mandates, but worse than that it is the copayments and high 
deductibles.
  Many women say: Well, my insurance company provides for it, but this 
copayment and deductible, I have to choose between my children's shoes 
or my deductible. We want to either eliminate or shrink those 
deductibles and eliminate that high barrier, that overwhelming hurdle 
that prevents women from having access to these early detection and 
screening programs.
  Much is being debated about mammograms. We believe access to 
mammograms should be universal, universal access. But the decision on 
whether to get one should be made with your doctor. Well, that is great 
to say, but you need to have access to your doctor. You need to not 
have to overcome the high hurdle of deductions or copayments to be able 
to do it.
  We know mammogram screenings decrease breast cancer by over 40 
percent. Regular pap smears reduce cervical cancer by 40 percent. This 
year, 4,000 women will die of cervical cancer. Then let's take the 
dread, but often overlooked, diabetic screening. Diabetes is the 
underlying cause of two-thirds of chronic illness in both younger and 
older women. If we find it early and get everybody in the right 
program, they are going to be able to get the treatment they need so 
they don't lose an eye, they don't lose a kidney, they don't lose a 
leg.
  We can't lose any more time. We need to provide universal access to 
health care to the American people and we need to make sure they have 
access to the screening and early preventive actions that will save 
lives.
  Mr. President, I urge the adoption of the Mikulski amendment, and I 
thank you for your leadership on this issue.
  I ask unanimous consent that the remaining time be equally divided 
between Governor Shaheen, Senator Hagan, Senator Murray, and Senator 
Gillibrand.
  The PRESIDING OFFICER (Mr. Dodd). Without objection, it is so 
ordered.
  Who seeks recognition?
  The Senator from New Hampshire.
  Mrs. SHAHEEN. Mr. President, I rise today in support of Senator 
Mikulski's amendment to ensure that women have access to preventive 
health care screenings and care at no cost. I wish to thank Senator 
Mikulski for her leadership not just in this effort but over the years 
to make sure women are treated fairly when it comes to our health care.
  As a woman, a mother of three daughters and a grandmother of three 
granddaughters, this is an issue that is critically important to me 
personally. But as a former Governor, now a Senator and a policymaker, 
I understand these preventive services are not just good for women but 
they are good for families--for the children and husbands and brothers 
and fathers of the women we are talking about today. This amendment is 
good for our society as a whole.
  Women must have access to vitally important preventive services such 
as screenings for breast cancer, cervical cancer, pregnancy, and 
postpartum depression screenings, annual well-woman visits, and 
preconception counseling that promotes healthier pregnancies and 
optimal birth outcomes. It is the right thing to do, but it is also 
fiscally responsible.
  Not only does diagnosing disease early significantly increase a 
woman's chance for survival, but it also significantly decreases the 
projected costs of treatment. In fact, one recent study estimated that 
almost 80 percent of all health care spending in the United States can 
be attributed to potentially preventable chronic illness. This 
amendment takes a great step forward to early diagnosis of these costly 
and potentially preventable diseases. We must ensure these important 
services are provided at no cost.
  Too often, women forgo their health care needs because they are not 
affordable. We know cost plays a greater role in preventing women from 
accessing health care than it does men. In 2007, more than half of all 
women reported problems accessing needed health care because of costs.
  It is clear we need to support Senator Mikulski's amendment that will 
give women access to important health care screening.
  The PRESIDING OFFICER. The Senator from New York is recognized.
  Mrs. GILLIBRAND. Mr. President, I rise in support of Senator 
Mikulski's amendment, which improves the health care measures that are 
already in this act.
  Women must shoulder the worst of the health care crisis, including 
outrageous discriminatory practices in care and coverage. Not only do 
we pay more for the coverage we seek for the same age and the same 
coverage as men do, but in general women of childbearing age spend 68 
percent more in out-of-pocket health care costs than men.
  Some of the most essential services required by women are currently 
not covered by many insurance plans, such as childbearing, Pap smears, 
and mammograms. A standard in-hospital delivery can cost between $5,000 
and $10,000 and much more if there are complications. You cannot 
imagine what it is like for a pregnant woman to recognize she may not 
have coverage for the essential services she needs for herself and her 
child. The health care bill before us ensures that this will no longer 
happen.
  However, there is much room for improvement. In America today, too 
many women are delaying or skipping preventive care because of the 
costs of copays and limited access. In fact, more than half of women 
delay or avoid preventive care because of its cost.
  This fundamental inequity in the current system is dangerous and 
discriminatory and we must act.
  The prevention section of the bill before us must be amended so 
coverage of preventive services takes into account the unique health 
care needs of women throughout their lifespan.
  With Senator Mikulski's amendment, even more preventive screening 
will be covered, including for post-partum depression, domestic 
violence, and family planning.
  Covering more preventive screening at no cost to women will encourage 
that more women go to the doctor, improving their health, saving lives 
and, as Senator Mikulski brought out, saving money.
  The whole point of this health care bill is to lower costs across the 
board. When you shift America's health care system to preventive 
services over the current emergency room services, you are going to do 
exactly that.
  This amendment will ensure that the coverage of women's preventive 
services is based on a set of guidelines developed by women's health 
experts.
  This amendment will also preserve the doctor-patient relationship, to 
allow the patient to consult with their doctor on what services are 
best for them.
  This amendment will cost $490 million over 10 years and it is fully 
paid for.
  The health care crisis in America must be addressed, and I am very 
supportive of Senator Mikulski's amendment.
  The PRESIDING OFFICER. The Senator from North Carolina is recognized.
  Mrs. HAGAN. Mr. President, I rise in support of the amendment offered 
by the senior Senator from Maryland.
  This amendment tackles a serious problem: Women are increasingly 
skipping critical preventive health care screenings because of costs, 
even when they have health insurance.
  This summer, I received an e-mail from a woman named Julie in 
Raleigh, NC, about her sister who had no insurance and waited years to 
get a mammogram because she couldn't afford to pay the $125 fee for a 
mammogram. Then she found a lump in her breast.
  Eventually, the mass grew so large Julie's sister finally got her 
mammogram and paid for it with cash. The mammogram confirmed what she 
had

[[Page 28844]]

suspected, that she had breast cancer. But now that she had a 
diagnosis, she had no way to pay for the treatment.
  She lost her battle with breast cancer in March of this year. Julie's 
sister, perhaps, could have beaten this cancer if she had had access to 
affordable, preventive care and, after her diagnosis, access to 
insurance or medical care to cover her cancer treatment.
  In this heartbreaking situation, Julie's sister was sick and stuck. 
This health care reform bill will provide people such as Julie's sister 
with access to affordable, quality health insurance.
  The President of Randolph Hospital in Asheboro, NC, wrote to me 
recently that a few years ago, he was in a meeting with 20 to 30 of his 
nursing assistants who were covered by the hospital's insurance plan. 
Of those who were old enough to require a mammogram, only 20 percent 
had actually gotten one. The reason, they said, was the high out-of-
pocket costs they would have to pay.
  When these women had to choose between feeding their children, paying 
the rent, and meeting other financial obligations, they skipped 
important preventive screenings and took a chance with their personal 
health.
  The hospital then decided to remove the financial barrier to 
preventive care and pay for 100 percent of preventive screenings.
  With the passage of Senator Mikulski's amendment, we will do the same 
for all women. A comprehensive list of women's preventive services will 
be covered with no added out-of-pocket expenses.
  With this amendment, we will ensure that, as the old saying goes, 
``An ounce of prevention is worth a pound of cure,'' for women across 
America.
  The PRESIDING OFFICER (Mrs. Gillibrand). The Senator from Washington 
is recognized.
  Mrs. MURRAY. Madam President, I add my thanks to the Senator from 
Maryland, Ms. Mikulski, for bringing forth this important issue as we 
address health care reform in this country to ensure that all our 
families have access to health care.
  One of the most important things we can do is make sure the 
caregivers in our families--the women--get access to preventive care so 
they can take care of their families.
  This amendment will require all the health plans to cover 
comprehensive women's preventive care and screenings at no cost to 
women. That is extremely important. We all understand that--but 
especially in these tough economic times, when families across the 
country are struggling. One of the results has been that a lot of women 
are skipping or delaying their health care. We all know this 
personally. As moms, you take care of your kids first. When you do 
that, you often leave your families at risk because you haven't gotten 
the necessary preventive care.
  We know that, in 2007, a quarter of women reported delaying or 
skipping health care because of the costs. In May of 2009, a report by 
the Commonwealth Foundation found that more than half of women delayed 
or avoided preventive care because of its cost.
  This amendment will ensure that those women don't delay their 
preventive care because they cannot afford it. It is extremely 
important for this bill, it is important for women in this country, and 
it is important for men and children in this country as well.
  I add my thanks to the senior Senator from Maryland and all our 
Senate colleagues who have been down here to make sure that one of the 
first things we do as we move the bill to the floor is make sure 
women's preventive care is covered.
  I yield the floor.
  Ms. MIKULSKI. Madam President, that concludes our discussion and our 
responses to this portion of the health care reform bill.
  I must say: Alert, alert, alert. We have just been informed that a 
shrill advocacy group is spreading lies about this amendment. They are 
saying that because it is prevention, it includes abortion services. 
There are no abortion services included in the Mikulski amendment. It 
is screening for diseases that are the biggest killers for women--the 
silent killers of women. It also provides family planning--but family 
planning as recognized by other acts. Please, no more lies. Let's get 
off of it and save lives.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Montana is recognized.
  Mr. BAUCUS. Madam President, I yield myself 1 minute. Very much 
straight to the point here, there has been some discussion about CBO's 
assessment on the health care premiums. The letter was out yesterday. 
That letter shows that for all Americans--all Americans--premiums will 
be lower. They will be modestly lower to those larger employers. We 
have a range between those small businesses of between a 1-percent 
reduction and a 2-percent increase, and for the individual market there 
is more variation because there is much more variation today currently 
in the individual market.
  Those who purchase in the individual market will be getting a lot 
better quality of insurance than they are getting today--much better. 
About 60 percent of those in the individual market will find that their 
premiums are actually lower after the tax credit/subsidies are taken 
into consideration.
  So netted all out together, all Americans are going to see their 
premiums are lower for what they get today. About 7 percent will see an 
increase, but they are getting better coverage than today--quite a bit 
better coverage. On a net basis, basically, bottom line, everyone were 
will see his or her premiums lower. For the 7 percent that are not 
lowered, they will get a lot better quality of insurance. That will 
more than offset the increase in premium. That is what that CBO letter 
says. I urge all folks who are interested to read that letter.
  I have one other minor point on the so-called Cadillac plans. CBO 
said that those who receive Cadillac plans will find their premiums 
reduced, not increased--I think it is by about 6 or 7 percent. That, 
too, is very important. There has been a lot of discussion about the 
effect of premiums on Cadillac plans. CBO says those premiums will be 
reduced.
  My minute is probably up. I wish to use the last seconds to just say 
that the net, all the way across the board, CBO says premiums will be 
reduced when you take subsidies into consideration and compare the 
plans people get today with what they would otherwise get in the 
future, the quality of coverage.
  The PRESIDING OFFICER. The Senator from Oklahoma is recognized.
  Mr. COBURN. Madam President, how much time remains on the Republican 
side?
  The PRESIDING OFFICER. Three minutes.
  Mr. COBURN. Madam President, I ask unanimous consent to consume that 
3 minutes and the other 15 minutes allotted to our side on the 
executive nomination, and when that 18 minutes is up, the remainder be 
followed by the time on the Democratic side and the nomination be 
reported.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. COBURN. Madam President, I wished to spend a few minutes on this.
  As a physician who cared for Medicare patients for 25 years, I cannot 
tell you how worried I am about what this bill is going to do to my 
senior patients. When Medicare was first written, two things were put 
into the law--very straightforward, very direct. Let me read them to 
you, for a minute. I hope Americans listen to this. Here is what the 
law is. CMS is breaking the law today and, with the new Medicare 
Commission, they are going to break it even further under this bill.
  Section 1801 says this:

       Nothing in this title shall be construed to authorize any 
     Federal officer or employee to exercise any supervision or 
     control over the practice of medicine or the manner in which 
     medical services are provided, or over the selection, tenure, 
     or compensation of any officer or employee of any 
     institution, agency, or person providing health services; or 
     to exercise any supervision or control over the 
     administration or operation of any such institution, agency, 
     or person.

  That says that the Federal Government cannot practice medicine. That 
is what it says.

[[Page 28845]]

  Section 1802 says this--and this is where it is important for my 
Medicare patients and everyone out there:

       Any individual entitled to insurance benefits under this 
     title may obtain health services from any institution, 
     agency, or person qualified to participate under this title 
     if such institution, agency, or person undertakes to provide 
     him such services.

  Well, what we have in this bill is the gutting of those two 
foundational principles of Medicare. The first is the Medicare Advisory 
Commission is going to tell you what you can and cannot have. Here is 
what we are going to see: You will choose what I tell you to choose if 
you are a Medicare patient.
  Not only do we have almost $500 billion in cuts to Medicare, under 
the auspices that we have to control entitlement spending; not only are 
we taking away plans from people who are very satisfied with what they 
have today, but we have enhanced, and will enhance, the ability of the 
Federal Government to practice medicine.
  My colleagues on the other side of the aisle, who have never 
practiced medicine, who know the legalese but don't know the 
consequences of right now the rationing of Medicare on drugs such as 
Epigen and Neupogen--you see, Medicare has decided when oncologists can 
use those drugs. They have taken a blanket position, although they have 
released it somewhat. But what it says is this--I will give you a 
patient who has breast cancer. She is 67 years old. She is being 
treated for breast cancer. She becomes anemic and neutropenic. That 
means her white blood cell count, her ability to fight infection goes 
down.
  We have wonderful drugs that raise the white blood cell count and 
raise the red blood cell count. But Medicare, in its obvious wisdom of 
practicing medicine, has told the oncologists when they can and cannot 
use it. That is fine for 75 percent of the patients, but it totally 
ignores the other 25 percent of the patients who happen to have 
complicating factors, such as congestive heart failure or if they 
become anemic under breast cancer chemotherapy and have congestive 
heart failure as well. The government says you cannot have 
erythropoietin at this level of hemoglobin regardless of whether you 
have congestive heart failure.
  What happens is the practice of medicine out of Washington or 
Maryland, more specifically, determines who can and cannot have a drug; 
in this case, erythropoietin.
  What is the consequence of that? The consequence is that the patient 
did not die of breast cancer; she died of congestive heart failure that 
could have easily been treated had we not had medicine practiced by CMS 
denying the ability of the physician to give the patient exactly what 
she needed when she needed it.
  We are starting down that road with this bill--aggressively starting 
down that road--because the Medicare Payment Advisory Commission, 
combined with the Comparative Effectiveness Panel will not look at 
complications and will not look at secondary diseases. They will look 
at the average.
  I want to tell my colleagues, when you are sitting in an office with 
your doctor, you are not average. You are you, and you are a specific 
individual with a set of factors that nobody else has. The judgment in 
the practice of medicine cannot be done by an insurance company or CMS 
at a distance without them having a hand on the patient. They never 
have their hand on a patient.
  The whole art of medicine, which is 40 percent of getting people 
well, is the knowledge and training and experience and gray hair that 
comes with looking at the total patient, being one on one, not having 
the government between the doctor and their treatment of a patient.
  What this bill does--this bill is a lie one of two ways. One, it says 
we are going to take this money out of Medicare and you are not going 
to notice any difference. That cannot be true. If we take $500 billion 
or $400 billion-plus out of Medicare, millions of seniors are going to 
notice a difference in their health care and what they get under 
Medicare. If we say that is not true, then the only way that is not 
true is the game that is being played on the financing of this program; 
that is to say, we are going to cut this money out of Medicare and then 
with a wink and a nod know we are never going to do it.
  The majority leader said yesterday there is nothing more important in 
this Nation right now than passing health care reform. I differ with 
that statement. I think 10.2 percent unemployment is a whole lot more 
important, and finding those people jobs, than passing health care 
reform. I think a $12 trillion debt is more important to address than 
fixing health care right now. I think the fact that we have $350 
billion worth of waste, fraud, and duplication in the Federal 
Government every year, and we are not addressing it, is more important 
than fixing health care right now. I think the fact that our economy is 
still on its back and people are continuing to lose jobs is more 
important than fixing health care right now.
  I understand the political dynamics, but I also understand very well 
with my quarter of a century of practicing medicine that what this bill 
is going to do is destroy the best health care system in the world, and 
it is going to undermine the security of every senior in this country 
because what starts as a small couple of things, such as Neupogen and 
Epogen or like when you can have bone densitometry and whether your 
osteoporosis can truly be evaluated, CMS has already said how much you 
can do that, whether your bones are falling apart or not. It is the 
start of the government practicing medicine.
  It is the beginning of our seniors having the government step in 
between them and their physician in terms of the physician wanting to 
do what is best for that senior and the government saying: No, I will 
tell you what you are going to have. I will tell you what you will 
have.
  Thomas Jefferson taught us a lot. He predicted we would have ``future 
happiness for us if we can prevent the government from wasting the 
labors of the people under the pretense of taking care of them.''
  I want to see a lot of things changed in health care. I want to see 
true competition in the insurance industry. I want to make sure nobody 
loses their insurance because they get sick. I want to make sure 
everybody can get insurance if they are sick. I do not disagree with 
the basic premise. What I disagree with is moving $2.5 trillion more 
under government control, which will raise costs ultimately in the 
health care sector. If it does not raise costs and we are truly going 
to take this money from Medicare, what it is going to do to our 
seniors, I have a message for you: You are going to die soon, and they 
are going to say that is not true, that it is not true.
  When you restrict the ability of the primary caregivers in this 
country to do what is best for their senior patients, what you are 
doing is limiting their life expectancy. We are saying CMS, the 
Medicare Payment Advisory Commission, and the Comparative Effectiveness 
Panel will tell the doctors what they can and cannot do, ignoring the 
20 percent of the people for whom that is exactly the wrong 
prescription. So for 20 percent of our seniors, this bill is going to 
be a disaster, but it is going to save money because you are not going 
to be around for us to spend any money on you because the government 
will have already told us what the treatment plan will be for you. We 
will decide in Washington through the Center for Medicare and Medicaid 
Services what you will receive.
  They will dispute that, but the people who are going to be disputing 
that are lawyers; they are not doctors. They have never laid a hand on 
a patient. They have never put their hand forward on a Medicare patient 
knowing the consequences of the total patient, the background, the 
medical history, the sociologic factors that fit, the family dynamics, 
the past medical history, the family history, and the present state of 
mind of that patient.
  Even more important, what this bill is going to do is divide the 
loyalty of your doctor away from you. When you go to the doctor today, 
most of the time that doctor's No. 1 interest is in you and your well-
being. When you have this Medicare Payment Advisory

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Commission and you have this Comparative Effectiveness Panel, what that 
does is that causes the physician--he or she--to take their eyes off of 
you. Now they are going to put their eyes on what the government says 
because the consequences of not doing what the government says will 
ultimately result in some type of sanction.
  Do we want physicians to be patient-centered and focused on their 
patients or do we want physicians to have their eye on the government 
and half of an eye on the patient? Which do you think is going to give 
us the best care? Which do you think is going to give us the greatest 
quality of life? What is going to give us the greatest longevity with 
the greatest quality of life? Is it the government practicing medicine, 
or is it the trust that has been developed through years between a 
patient and a doctor to do what is in the best, long-term interest of 
that patient?
  I cannot tell you the number of people who die from the CMS 
regulations on Epogen for oncologists. But there were hundreds--
hundreds--because Medicare never looked at the patient; they looked at 
dollars.
  As we go forward in this debate, what I want seniors in America to 
know--and I am fast approaching Medicare age; I am 3 years from it--I 
want them to know the key thing they are going to lose in this bill is 
the loyalty and primacy of their physician thinking about them. We are 
going to divide that loyalty to where the physician is going to be 
looking at the government. If you think that is not true, just look at 
what has happened so far when CMS has decided to start practicing 
medicine.
  In the HELP Committee, I offered an amendment to change the language 
so there would be absolutely a prohibition on rationing care and 
directing the care from Washington. It was rejected out of hand--
rejected out of hand. Not one of my colleagues on the other side of the 
aisle voted to prohibit rationing of health care.
  Why would they do that? Because the ultimate intention through the 
Comparative Effectiveness Panel is to ration care. It is to ration the 
care. It is to limit the amount of dollars we spend and never look at 
the individual patient.
  If we think about the Medicare cuts in this bill, we are going to 
take $135 billion out of the hospitals. Do you think seniors will ever 
notice that? I do. I think when you ring your button and you are 
hurting and you need pain medicines or you need to go to the bathroom, 
the time it takes for somebody to get there will not be sufficient. 
What will happen is you will wait. You will have a complication. If you 
have acute shortness of breath and press the button, the available 
nurses will not be there. There will be a consequence to cutting $135 
billion from payments to hospitals in this country.
  We are going to take $120 billion out of the seniors--the one in five 
seniors who now have Medicare Advantage. I agree, it is more expensive 
than Medicare. It needs to have some cost containment through 
competitive bidding, but we should not be decreasing the services, 
which is exactly what is going to happen. If you are a senior on 
Medicare Advantage, you are going to lose benefits you now have. You 
are going to lose them.
  One of the ideas of Medicare Advantage was preventive services. One 
of the things that improved the care in rural America was Medicare 
Advantage. Yet we are going to take that away. The vast majority of the 
benefits we are going to cut in half.
  We are going to take $15 billion from nursing homes. That may or may 
not be appropriate, but the way to do that is through a competitive 
experience based on quality and outcome rather than some green-eyeshade 
staffer saying we can take $15 billion out of Medicare from payments to 
nursing homes.
  One little secret that is not in this bill, that has not been 
addressed in this bill, is the estimate by a Harvard researcher that 
there is $120 billion to $150 billion a year in fraud in Medicare 
alone. HHS admits to $90 billion. We know it is well over $100 billion 
a year. Cleaning up the fraud in Medicare would pay for a lot of health 
care for a lot of folks in this country. There is $2 billion in this 
whole bill to clean up the fraud.
  Why would we not fix that first? Why would we take money from 
Medicare to create a new program when in fact we are wasting 10 to 15 
percent?
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. COBURN. I will close with this remark. If you are a senior and 
you are on Medicare, you better be afraid of this bill. I don't come to 
the floor and say that very often, but your health care is totally 
dependent, in terms of being decreased by this bill.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Connecticut.
  Mr. DODD. Madam President, I ask unanimous consent I be allowed to 
speak for 1 minute 7 seconds and the time be taken from that of my good 
friend and colleague from Vermont, the chairman of the Judiciary 
Committee.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DODD. Madam President, Senator Tom Coburn and I have become great 
friends. We have spent a lot of time together this summer in my HELP 
Committee. He talked with great eloquence about that distance that can 
occur between a doctor and patient, and obviously as someone who 
practiced medicine for a long time, he speaks from strong personal 
experience, and I admire and respect that immensely. But let me say to 
my colleagues, without this bill we are talking about here, this comes 
to a simple choice. Under existing law, the way things are today, one 
institution stands between a doctor and patient and that is your 
insurance company. They ration care all the time. In fact, I am a 
living example of rationed care, having been through surgery, getting 
preapproval twice before surgery and then being rejected by the very 
insurance company I paid premiums to for a long time as a Member of 
this body. We are working it out, I believe, because they thought--I am 
65--that Medicare ought to pay for my surgery rather than the company I 
paid premiums to for a long time.
  They were rationing my care. That insurance company, it wasn't some 
government entity or someone else, they are the ones. Without our bill, 
the only one getting to decide what health services anyone receives is 
the insurance industry.
  I hope we would have a chance to debate this further, as I am 
confident we will.
  Let me also say how much I support the effort by Senator Mikulski on 
her efforts to see to it that women are treated equally, and 
particularly in preventive care, and I strongly urge the adoption of 
her amendment and ask to be added as a cosponsor to that amendment.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DODD. I thank the Chair.
  Mr. LEAHY. Madam President, our Nation is in the midst of a historic 
debate about how to reform our health insurance system. Three House 
committees and two Senate committees have spent countless hours trying 
to answer the question of how best to introduce competition and make 
health insurance affordable for all Americans. I applaud their efforts, 
and I applaud the efforts of the many Senators who have fought to bring 
this important debate to the Senate floor.
  I have pushed and will continue to push for provisions that 
accomplish the ``three C's'' of health insurance reform: choice, 
competition, and cost control. I recently reaffirmed my support for a 
public option.
  A public option would give consumers more choices to purchase an 
affordable and quality health insurance plan and will help drive down 
overall health care costs. I will continue to push for inclusion of a 
public option in the final Senate bill.
  Amid this discussion of how best to introduce competition into the 
health insurance industry, it is important to remember that today the 
health insurance industry does not have to play by the same rule of 
competition as other industries. Due to a six decade-old special 
interest exemption, the business of insurance is not subject to the 
Nation's antitrust laws. If there was ever a good

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reason for such an exemption, it no longer exists.
  While there are divergent views on the best way to introduce choice 
and competition into health insurance market, we can surely agree that 
health and medical malpractice insurers should not be allowed to 
collude to set prices and allocate markets.
  Today, I am filing the Health Insurance Industry Antitrust 
Enforcement Act of 2009 as an amendment to the Patient Protection and 
Affordable Care Act. This legislation, which I introduced in September 
and which is cosponsored by 18 Senators, will repeal the antitrust 
exemption for health insurance and medical malpractice insurance 
providers, and ensure that the basic rules of fair competition apply to 
the industry as part of the reforms that the larger health care bill 
will enact. Our Nation's antitrust laws exist to protect consumers, and 
it is vital that the health insurance and medical malpractice insurance 
companies are subject to these laws.
  These laws promote competition, which ensures that consumers will pay 
lower prices and receive more choices.
  The Majority Leader, an original cosponsor of this legislation, 
testified before the Senate Judiciary Committee that ``[i]t is of the 
upmost importance that we make sure the insurance industry is playing 
by the same rules as everyone else, and that they are subject to 
competition.'' I could not agree more, and I encourage the leader to 
schedule a vote on this amendment early in this debate. The President 
also recently supported Congress's efforts to determine whether any 
justification remains for permitting price fixing.
  The vast majority of the companies doing business in the United 
States are subject to the Federal antitrust laws.
  However, a few industries have used their influence to maintain a 
special, statutory exemption from the antitrust laws. The insurance 
industry is one of those few remaining industries. In the markets for 
health insurance and medical malpractice insurance, patients and 
doctors are paying the price, as costs continue to increase at an 
alarming rate, while patients and small businesses suffer. This is 
wrong, and this amendment fixes this problem.
  The Health Insurance Industry Antitrust Enforcement Act is supported 
by a cross-section of groups interested in promoting competition, 
including the Consumer Federation of America, Health Care for American 
Now, and the American Hospital Association. I also received a letter 
from a coalition of 10 State attorneys general who voiced their 
specific need for this legislation.
  The top law enforcement officers in those States argue that ``Repeal 
of the McCarran-Ferguson exemption would enhance competition in health 
and medical malpractice insurance by giving state enforcers, as well as 
federal enforcers, additional tools to combat harmful anti-competitive 
conduct.'' The letter goes on to state that ``The McCarran-Ferguson 
exemption serves no plausible public interest.''
  This amendment will prohibit the most egregious anticompetitive 
conduct--price fixing, bid rigging and market allocations--conduct that 
harms consumers, raises health care costs, and for which there is no 
justification. Subjecting health and medical malpractice insurance 
providers to the antitrust laws will enable customers to feel confident 
that the price they are being quoted is the product of a fair 
marketplace.
  The lack of affordable health insurance plagues families throughout 
our country, and this amendment is a first step towards ensuring that 
health insurers and medical malpractice insurers are subject to fair 
competition. I hope all Senators will join me in support of this 
important amendment.
  Madam President, I note my amendment removes the outdated, 
antiquated, unnecessary antitrust protection given to our insurance 
companies, a protection which, instead of allowing them to thrive and 
give us lower premiums, has perversely acted in such a way that our 
premiums continue to rise 15 percent in the last year alone. This will 
help change that.

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