[Congressional Record (Bound Edition), Volume 155 (2009), Part 22]
[Senate]
[Pages 29522-29574]
[From the U.S. Government Publishing Office, www.gpo.gov]




                   RECOGNITION OF THE MINORITY LEADER

  The PRESIDING OFFICER. The Senator from Kentucky.
  Mr. McCONNELL. Mr. President, I am going to proceed on my leader 
time, which I assume will not be charged on this side.
  The PRESIDING OFFICER. The Senator is correct. His leadership time 
has been reserved.
  The Chair will note, there is 3\1/2\ minutes remaining on the 
Democratic side allocated on the debate; and then, of course, there is 
another 45 minutes, under the unanimous consent agreement, that will be 
allotted to the Republican side of the aisle.
  Mr. DODD. Mr. President, I would like to yield my 3\1/2\ minutes to 
my distinguished friend from Kentucky and my friend from Arizona and my 
friend from Utah and my friend from Florida and my friend from Wyoming 
as well--3\1/2\ minutes for all of them.
  The PRESIDING OFFICER (Mr. Begich). The Republican leader.
  Mr. McCONNELL. Mr. President, we all know the U.S. health care system 
is in serious need of reform. Costs are too high, they are rising, and 
if we do nothing, they will continue to consume a larger and larger 
share of Federal dollars and of the budgets of millions of middle-class 
American families, of young workers trying to get their start in life, 
and, of course, of seniors.
  For months, the administration and its allies in Congress promised a 
solution to these problems, a solution they said would lower costs and 
help the economy. They assured us that under their proposal anyone who 
likes the health care plans they have would be able to keep them, and 
they said their proposal would save Medicare.
  But, in the end, what matters is not what we say. It is what we do. 
This week, the proponents of this plan did more with a single vote than 
they did all year in talking about all the things their health care 
plan would do.
  How? Because in voting to cut a $\1/2\ trillion from the Medicare 
Program for seniors, our Democratic friends undercut not only the 
roughly 40 million seniors who depend on Medicare, they also undercut 
their own promises about reform.
  As I said, the President and congressional Democrats have noted, 
again and again, that under their measure those who like their plans 
will be able to keep them. After Thursday's vote, even Democrats are 
admitting that is no longer true.
  Here is how one of our Democratic colleagues put it:

       We're not going to be able to say that ``If you like what 
     you have, you can keep it.''

  Then he added:

       . . . and that basic commitment that a lot of us around 
     here have made will be called into question.

  As for the oft-repeated pledge to save Medicare, well, nobody buys 
that one after the vote on Thursday to cut it by $\1/2\ trillion.
  These Medicare cuts will impact the quality of care for millions of 
American seniors. Nearly 11 million seniors on Medicare Advantage will 
see a reduction in benefits. Hospice care will see massive cuts. 
Hospitals that treat Medicare patients will see massive cuts. Nursing 
homes are cut. More than $40 billion is cut from home health care 
agencies--agencies that provide an appealing alternative to seniors who 
would rather receive the care and attention they need in the comfort 
and privacy of their own homes.
  I hear from seniors all over Kentucky worried about the impact these 
cuts will have.
  Anita, from Hebron, KY, says she is worried about the impact these 
cuts will have on her husband, a Vietnam vet with multiple sclerosis. 
Every 2 weeks, she writes, a home health care nurse visits her husband 
to perform procedures prescribed by his doctors. Now Anita is worried 
those visits might be limited or curtailed under this bill. It is not 
clear they will not be because cutting $40 billion from a benefits 
program is bound to affect the benefits that people such as her husband 
receive.
  Joy, from Somerset, KY, works for a home health care agency. She 
wrote my office because she is also concerned about cuts to home health 
care. She asked me to protect the rights of the chronically ill, 
elderly Medicare population that she and her colleagues care for every 
day in Kentucky through cost-effective home health care.
  Robin, from Independence, KY, writes that her father is almost 80 and 
receives home health care twice a week. She says he depends on a walker 
and a wheelchair to get around and that it is hard for him to get out 
of the house. Robin's father is the kind of person home health care is 
meant to help. Frankly, I do not know what to tell her--I literally do 
not know what to tell her--except that $40 billion in cuts to this 
program is not a very encouraging sign for people such as her dad.
  I noticed that some years ago one of the top Senators on this issue 
on the Democratic side used the very same image I have used to decry 
these cuts. Back then, he warned, as I have in recent months, not to 
use Medicare as a piggy bank. Yet that is precisely what our friends 
are doing with Medicare. They are not fixing it. They are raiding it--
raiding it--to create an entirely new government entitlement program, 
raiding Medicare not to help save Medicare but to create an entirely 
new entitlement program. In fact, one of the largest single sources of 
money for this 2,074-page bill is the money they get from Medicare.
  I am not sure what has changed since our friends decried cuts to 
Medicare as immoral and irresponsible. But today I would, once again, 
urge them to reconsider their vote from earlier this week. They have 
voted now to cut Medicare, and they have now voted twice to cut the 
important Medicare Advantage Program for nearly 11 million seniors.
  Today we will have a chance to restore the cuts they authorized to 
home health care. A vote in favor of the Johanns amendment is a vote in 
favor of the men and women who have been writing our offices, sharing 
their stories about the benefits of home health care. Americans never 
expected that health care reform would mean that they would have to 
give up the health care they have and like. They didn't expect it 
because they were told it wouldn't happen. Unfortunately, that pledge 
was broken this week. That pledge was broken this week. Today our 
friends have an opportunity to help repair some of that damage.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The minority now has 45 minutes for debate.
  The Senator from Arizona.
  Mr. McCAIN. Mr. President, I ask unanimous consent that the Senator 
from Utah, the Senator from Kentucky, the Senator from New Hampshire, 
the Senator from Georgia, the Senator from Florida, and the Senator 
from Wyoming be allowed to participate in a colloquy.
  The PRESIDING OFFICER. Without objection, it is so ordered.

[[Page 29523]]


  Mr. McCAIN. Mr. President, very quickly, I wish to remind my 
colleagues that the AARP continues to be referred to as endorsing this 
legislation and supporting it and opposing amendments that would have 
done things that they in the past have supported. So I urge my 
colleagues to look at this Washington article--one of my favorite 
sources of information and opinion, the Washington Post:

       But not advertised in this lobbying campaign have been 
     AARP's substantial earnings from insurance royalties and the 
     potential benefits that would come its way from many other 
     reforms.

  So we have been looking into that, and guess what. The AARP 
endorsement of more than $400 billion in Medicare savings--according to 
its own financial statements from 2008, AARP generated 38 percent of 
its $1.1 billion in revenue or more than $414 million in royalty fees. 
They also obviously will--if we take away Medicare Advantage, then 
Medigap sales will have to go up because that provides for the services 
that are being taken away. So under the AARP, they would generate in 
their endorsements--they have generated $414 million, putting them in 
fifth place of all of the health insurance companies in America behind 
United Health, Wellpoint, Aetna, and Humana. So we have before the body 
an amendment that would modify any health insurer's remuneration to the 
same level as the salary of the President of the United States.
  So I ask unanimous consent at this time that the AARP executives be 
added in under the effect of this pending amendment from the Senator 
from Arkansas.
  The PRESIDING OFFICER. Is there objection?
  Mr. BAUCUS. Mr. President, I object.
  The PRESIDING OFFICER. Objection is heard.
  Mr. McCAIN. Mr. President, I also understand that Walmart sells 
health insurance policies. They are based in Arkansas. I ask unanimous 
consent that Walmart be included in this curb on excessive remuneration 
that will now place them under the same level.
  The PRESIDING OFFICER. Is there objection?
  Mr. BAUCUS. Reserving the right to object, to be totally candid, 
these are stunt amendments which we have not seen. I have never heard 
of the amendments.
  Mr. McCAIN. It is not complicated. It is pretty simple. It is people 
who sell health insurance.
  The PRESIDING OFFICER. Is there objection?
  Mr. BAUCUS. Reserving the right to object, because I have not even 
seen these amendments, I object.
  The PRESIDING OFFICER. Objection is heard.
  Mr. McCAIN. I am sorry the Senator from Montana cannot understand 
that they are people who sell health insurance as well. AARP does, 
Walmart does. If we are going to have this kind of demagogic amendment, 
then we should include them, especially Walmart, that does a lot of 
business.
  Mr. McCONNELL. Mr. President, I would ask the Senator from Arizona if 
I may ask a question. I would ask the Senator from Arizona, is this the 
same AARP that I recall opposed a $10 billion reduction in the rate of 
increase in Medicare spending back in 2005?
  Mr. McCAIN. I would say to my colleague they not only opposed it, 
they got all of their members fired up in opposition to it. We all 
heard from them back in 2005. These were reductions in spending. This 
was not $438 billion taken out of Medicare and put in to create a new 
entitlement program of $2.5 trillion.
  Mr. McCONNELL. Could I ask my friend one more question? Is this the 
same bill that back in 2005 my counterpart, the majority leader, 
decried as immoral?
  Mr. McCAIN. As I recall, that is exactly it. I think the Senator from 
New Hampshire recalls that debate.
  Mr. GREGG. Mr. President, if the Senator will yield, absolutely. I 
was chairman of the Budget Committee at the time. As the Republican 
leader is alluding to, we attempted to reduce the rate of growth of 
Medicaid by $10 billion of a $1 trillion base over 5 years, less than 
one-tenth of 1 percent, I believe that was. It was opposed aggressively 
by the AARP, and it was opposed by the other side of the aisle. Not one 
Member of the other side of the aisle voted for that. Do you know what 
that change was going to be? It was going to require that wealthy 
people who benefited from the Part D drug benefit would have to pay 
part of their premiums rather than getting them all for free. So Warren 
Buffett, for example, would actually have to contribute to his drug 
benefit, assuming he is on Part D. Maybe he isn't. Maybe he hasn't 
opted for it. But as a practical matter it was a very reasonable 
amendment.
  Now we are seeing, as the Senator from Arizona has pointed out, a 
$460 billion cut over the first 10 years of this bill; a $1 trillion 
cut in Medicare, $3 trillion over the first 20 years of this bill--$3 
trillion--when we already know Medicare, according to this chart, is 
insolvent to the extent of $38 trillion--insolvent. Yet we are going to 
take this money out of Medicare, as the Senator from Arizona has 
pointed out, and we are going to fund a brandnew entitlement.
  We are going to expand Medicaid to 133 percent of poverty with this 
money, and we are going to create this brandnew entitlement which has 
nothing to do with Medicare. None of the people who are going to get 
this benefit probably have ever paid into the hospital trust fund, 
which is what funds Medicare. That seems totally inconsistent with the 
purposes of Medicare.
  Shouldn't Medicare funds benefit Medicare recipients, I would ask the 
Senator from Arizona or the Republican leader? If there are going to be 
reductions in Medicare, should it not go to make Medicare more solvent 
and not to create a new entitlement?
  Mr. McCAIN. One would think so. There are two doctors in the Senate; 
there are lots of lawyers, two doctors. Both of them have hands-on 
experience. I don't know if Dr. Barrasso has seen this morning's New 
York Times, another of my favorite sources of news information and 
opinion. On the front page this morning: ``Home Care Patients Worry 
Over Possible Cuts.''
  I understand the purpose of health care reform as proposed by the 
other side is to reduce health care costs. Is there a way to reduce 
health care costs better than treating people at home than instead of 
in a hospital? I am curious about the Senator's experience.
  Mr. BARRASSO. Well, as the Senator from Arizona knows, I have treated 
patients in Wyoming, families in Wyoming, for 25 years. The story in 
the New York Times has a wonderful picture of Bertha Milliard, a 94-
year-old lady, who is very similar to many of the patients I have taken 
care of in families in Wyoming who depend on this care. There is a 
picture of Bertha dealing with her nurse. Bertha greets the nurse who 
has come to check her condition and review the medications she takes 
for chronic pain, for heart failure, and for stroke. Ms. Milliard says 
those visits have been highly effective, she says, in keeping her out 
of the hospital.
  That is the whole idea: Keep them out of the hospital so they can 
lower the cost of care. But the home care that she receives could be 
altered, according to the front page of the New York Times, under the 
legislation passed by the House and pending on the Senate floor today. 
The legislation would reduce Medicare spending on home health services, 
which is a lifeline for homebound Medicare beneficiaries which keeps 
them out of hospitals as well as out of nursing homes.
  So there you have it. What could be better for our seniors than to 
have the dignity of being in their own homes, to have someone coming 
into their homes to help them, to make their lives better, and that is 
going to include skilled nursing care, physical therapy, occupational 
therapy, sometimes speech and language therapy, and different medical 
and social services? That is where the care ought to be given, in the 
home. That is what we want for our seniors: the dignity at home, 
opportunities at home, to stay in their surroundings. That is what we 
want for not just all seniors such as Bertha, we want that for our 
Nation because that will help keep down the cost of care.

[[Page 29524]]

  This bill does the exact opposite. That is why we have to have this 
amendment that says don't cut Medicare for our seniors and certainly 
not to start a whole new program.
  In the Wall Street Journal today is an editorial by the dean of Johns 
Hopkins Medical Center, a wonderful, world class center: ``Health 
Reform Could Harm Medicaid Patients.''
  So we are taking the money from Medicare, hurting Medicare patients, 
and they are using it in a way that is actually going to make it worse 
for patients on Medicaid, as they have dumped 15 million people into 
this program that is absolutely broken.
  Mr. BAUCUS. Will the Senator yield for a question? Will the Senator 
yield for a question?
  Mr. BARRASSO. I will yield to the Senator from Arizona.
  Mr. McCAIN. If it is taken out of your time, just exactly as you 
responded when someone asked if you would yield for a question from 
them yesterday. Is it taken out of your time?
  Mr. BAUCUS. Yes.
  Mr. McCAIN. I ask unanimous consent that the time for the Senator's 
question not be taken out of the time that is allotted to us.
  The PRESIDING OFFICER. It will not be.
  The Senator from Montana.
  Mr. BAUCUS. Do the Senators realize and do they know that yesterday 
the Home Care and Hospice Association, the National Association for 
Home Care and Hospices, the umbrella organization for home health and 
hospice, wrote a letter to me, which basically says:

       [F]or all of these reasons, we support the provisions of 
     your health care reform legislation as it relates to home 
     health care.

  Is the Senator aware of that letter, the Home Care and Hospice 
Association's support for this legislation? Is the Senator aware of 
that letter?
  Mr. McCAIN. My response is, I don't know what deal has been cut in 
Senator Reid's office, as the deal was cut with the pharmaceutical 
companies and the deal was cut with the AMA and the deal was cut with 
the hospital association. But I know what the effect is. I know what 
the effect is. The bill would slice $55 billion----
  Mr. BAUCUS. This is not on my time because he is going to filibuster 
over there.
  Mr. McCAIN. The House bill would slice $55 billion over 10 years for 
projected Medicare spending on home health services while the Senate 
bill would take $43 billion. I know that. But I don't know the details 
of the deal that was cut over where the white smoke comes out. I don't 
know what the deal was. I know what the deal was with PhRMA. I know 
what the deal was with PhRMA. They told them they would oppose drug 
reimportation from Canada, and they told PhRMA they would not allow 
competition for Medicare patients.
  So I don't know the deal that was cut that bought them, but I know 
deals have been going on, and I know they are unsavory. I know people, 
such as the lady who was just referred to, Bertha Milliard, are not too 
interested in seeing their home health care cut.
  Mr. BAUCUS. If the Senator will yield, with time being equally 
divided on both sides for this colloquy.
  Mr. McCAIN. I don't know what the deal was----
  Mr. BAUCUS. I can tell the Senator the deal. I am going to tell the 
Senator the deal.
  The PRESIDING OFFICER. The Senator from Arizona has the floor.
  Mr. McCAIN. I don't know what the deal was, but we will find out, 
just like the deals that were cut with all of these other 
organizations.
  Mr. BAUCUS. I will tell the Senator what the deal was.
  Mr. McCAIN. This place is full of lobbyists. I can't walk through the 
hallway without bumping into one of their lobbyists. If the Senator 
keeps interrupting, he is violating the rules of the Senate. He needs 
to learn the rules of the Senate.
  Mr. BAUCUS. Will the Senator yield to know what the deal was?
  Mr. McCAIN. I would like to finish my answer to you, if I may; that 
is, I don't know the deal that was cut with them, but we will find out. 
I know Bertha Milliard was not there when the deal was cut that 
generated that letter. That is my answer.
  Mr. BAUCUS. Will the Senator yield for another question?
  Mr. McCAIN. I will yield for one more, but we have other Senators who 
wish to speak.
  Mr. BAUCUS. Does the Senator know that the so-called deal was that 
whereas MedPAC and the administration and the House wanted to make 
domestic cuts to home health care, but rather we went to the home 
health care industry, worked with them, and took two of their major 
suggestions about fraud and abuse as well as outliers, so we modified 
so that the home health industry thought this was fair and reasonable?
  Does the Senator know that was the agreement that was reached?
  Mr. McCAIN. My quick answer is, I don't know what the deal was, but I 
know the people who are in the home health care business, who will see 
$43 billion in cuts to their business, the funding for their business, 
were not there when the lobbyists showed up.
  We have already heard the stories of the meetings you and the 
majority leader have had with these people saying: Get on board or when 
we shape the final parameters of this bill, we are going to hurt you.
  We know they have been threatened.
  Mr. GREGG. I was wondering if that was the deal. We know there are a 
lot of deals around here. I know the Senator from Arizona pays a fair 
amount of attention to earmarks and other things done around here. I 
hope we will get an amendment from the Senator from Arizona that lists 
the special deals like the ones that exempted a few States from the 
Medicare Advantage cuts, like the deals that got allegedly a few votes 
on their side of the aisle so we could get cloture and proceed to this 
bill.
  Do you think it is part of the deal that they would not--if there 
really was a deal, should we not put in here that this money would go 
to benefit Medicare recipients and not to create a new entitlement? If 
you were going to take $42 billion out of Medicare money going to home 
health, shouldn't it have gone to making the system more solvent rather 
than creating a new entitlement with that and taking that money from 
seniors and giving it to somebody else? Shouldn't that have been part 
of the deal?
  Mr. McCAIN. As is often said, it is what it is.
  The Senator from Georgia has a comment.
  Mr. ISAKSON. If there was a deal, it wasn't made with everybody. I 
have a letter that was sent December 4 of this year to me from Judy 
Adams, executive director of the Georgia Association for Home Health 
Care Agencies, endorsing the Johanns amendment. So they must not have 
been part of the deal. They represent Georgia. Further, in here----
  Mr. McCAIN. They will probably be called up to Senator Reid's office 
very soon.
  Mr. ISAKSON. They estimate that 68 of the 100 Medicare-approved home 
health care agencies in Georgia will go out of business. So if there 
was a deal, it wasn't made with every State because the State of 
Georgia is on record.
  I ask unanimous consent to have this letter printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                           Georgia Association for


                                   Home Health Agencies, Inc.,

                                   Marietta, GA, December 4, 2009.
     Hon. Johnny Isakson,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senator Isakson: The members of the Georgia 
     Association for Home Health Agencies, Inc. fully support 
     Senator Johann's motion to commit Senator Reid's Patient 
     Protection and Affordable Care Act back to the Senate Finance 
     Committee with instructions to eliminate the home health 
     cuts.
       According to a study conducted by the National Association 
     for Home Care and Hospice, under Senator Reid's bill 72.15 
     percent of home health agencies in Georgia will have negative 
     margins by 2016 in the Senate bill, and approximately 68 
     percent of the 100 Medicare Certified home health agencies in 
     Georgia will go out of business and the patients they serve 
     will be rehospitalized or forced to seek alternative more 
     costly care.

[[Page 29525]]

       We appreciate the opportunity to offer our support for 
     Senator Johann's motion and thank you for being an advocate 
     for the sick and elderly citizens of Georgia.
           Sincerely,
                                                       Judy Adams,
                                               Executive Director.

  Mr. LeMIEUX. If I may, I will follow up on my colleagues' comments 
about what happened in Georgia.
  I walked to one of the largest home health care providers in Florida. 
We have a letter to the editor in the Sarasota Herald Tribune of 
November 16 where this person, who works for one of these home health 
care companies--one of the bigger ones, which aren't going to be in as 
much trouble--they say:

       Contrary to the other assertions that senior care will be 
     unaffected by health care reform in Florida, this scenario 
     could be devastating for older Floridians. More than 56 
     percent of Florida's home health agencies could be in the red 
     as early as 2011.

  So we are going to take the smaller home health agencies--the mom-
and-pops--in Florida, we have 1.9 million small businesses. They are 
not going to be able to function because we are going to take this 
money out.
  I want to make a point, also, that today in the New York Times, a 
good point was made that there is going to be no new insurance money 
coming in for home health care agencies--or very little. It is not as 
if there are going to be folks having this new public option or new 
insurance-backed program because home health care is for seniors. There 
is not going to be any extra money. So what is going to happen? We are 
going to have our moms, dads, and grandparents who are benefiting from 
this home health care in Florida and across this country instead of 
having to go to a nursing home, instead of having to go to an assisted 
living facility away from their home and family--they are not going to 
be able to go anymore.
  By the way, I don't believe that will save any money. I think that 
will increase costs because we know nursing home care is far more 
expensive than home health care. It is estimated that 1 day of hospital 
costs, for example, is 43 times as much as home health care. When you 
get rid of home health care, you are actually going to increase costs.
  I want to follow up on a comment, if I can, of my friend from New 
Hampshire. I am new here, and I am still understanding the ways of 
Washington, DC. Everybody in America needs to know this bill will not 
help seniors at all. This bill takes money from senior health care. If 
there was a legitimate and straightforward effort to actually help 
seniors, we would take Medicare savings and keep the money in Medicare. 
But, as our leader said today, we are robbing the piggy bank, taking 
money out of health care for seniors and putting it into this new 
program.
  Mr. McCAIN. Let me remind the Senator from Montana, sometimes there 
is good news and sometimes it is bad. There was an article earlier this 
year where the staff of the Senator from Montana called in the high-
paid lobbyists and told them not to meet with Republicans, saying that 
if they did, it would be treated as a hostile act. I can provide that 
article for the Record. I hope it is not true, but I think it is.
  Mr. BENNETT. I say to the Senator from Arizona and others who have 
commented, home health care is not the only way seniors will be hurt by 
this. I am quoting from an article by Tom Scully, one of the designers 
of the Medicare Part D benefit, on the impact of this bill on Medicare 
Part D for seniors. Let me quote the key points of the article. I ask 
unanimous consent to have the entire article printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

              Medicare Part D `Reforms' Will Harm Seniors

                            (By Tom Scully)

       There is a little-noticed provision buried deep in both the 
     House and Senate health-care reform bills that is intended to 
     save billions of dollars--but instead will hurt millions of 
     seniors, impose new costs on taxpayers, and charge employers 
     millions in new taxes.
       As part of the Medicare Modernization Act in 2003, Congress 
     created a new drug benefit--called Medicare Part D--for 
     retirees at a cost of about $1,900 per recipient per year. 
     Many private employers already provided drug coverage for 
     their retirees, and the administration and Congress did not 
     want to tempt employers into dropping their coverage. 
     Actuaries calculated that if the government provided a 
     subsidy of at least $800, employers would not stop covering 
     retirees.
       The legislation created a $600 tax-free benefit (the 
     equivalent of $800 cash for employers), and it worked. 
     Employers continued to cover about seven million retirees who 
     might have otherwise been dumped into Medicare Part D.
       It was a good arrangement for all involved. An $800 subsidy 
     is cheaper than the $1,900 cost of providing drug coverage. 
     And millions of seniors got to keep a drug benefit they were 
     comfortable with and that in many cases was better than the 
     benefit offered by the government.
       But now that subsidy is coming in to be clipped. This fall 
     congressional staff, looking for a new revenue source to pay 
     for health reform, proposed eliminating the tax deductibility 
     of the subsidy to employers. The supposed savings were 
     estimated by congressional staff to be as much as $5 billion 
     over the next decade.
       It sounds smart--except that nobody asked how many 
     employers will drop retiree drug coverage. Clearly, many 
     will. The result is that, instead of saving money, the 
     proposed revenue raiser will force Medicare Part D costs to 
     skyrocket as employers drop retirees into the program.
       The careful calculation that was made in 2003 to minimize 
     federal spending and maximize private coverage will go out 
     the window if this provision becomes law. Any short-term cost 
     savings that Congress gets by changing the tax provision will 
     be overwhelmed by higher costs in the long run.
       Some members in the House want to mitigate the cost of this 
     provision by mandating that employers maintain existing 
     levels of retiree coverage despite the reduced subsidy. But 
     it's not that simple. A mandate would increase costs on 
     businesses, which in turn would make it harder for those 
     businesses to hire new employees. The mandate would 
     effectively be a tax on employers that provide retiree 
     benefits; this in turn will simply induce some unknown number 
     of employers to terminate their retiree drug programs before 
     the mandate kicks in.
       In short, if the changes that are proposed for employer 
     subsidies in the current Medicare Part D program are enacted, 
     everyone will lose. Unions will lose as employers seek ways 
     to drop retiree drug coverage. Seniors will lose as employers 
     drop them into Medicare Part D. Medicare and taxpayers will 
     lose as they face higher costs. And employers will lose as 
     they find it harder to provide benefits.
       To make matters worse, accounting rules for post-retirement 
     benefits will require companies that keep their retiree 
     benefits to record the entire accrued present value of the 
     new tax the day the provision is signed into law. This would 
     cause many employers to immediately post billions in losses, 
     which could significantly impact our financial markets.
       There are many reasons to pass health-care reform. There is 
     no reason to hurt seniors, employers and taxpayers in the 
     process. Businesses are struggling, and the Medicare trust 
     funds have plenty of problems as it is. It makes no sense to 
     make these problems worse.

  Mr. BENNETT. He says:

       There is a little-noticed provision buried deep in both the 
     House and Senate health care reform bills that is intended to 
     save billions of dollars--but instead will hurt millions of 
     seniors, impose new costs on taxpayers, and charge employers 
     millions in new taxes.

  Here is the core of it:

       This fall, congressional staff, looking for a new revenue 
     source to pay for health reform, proposed eliminating the tax 
     deductibility of the subsidy to employers. The supposed 
     savings were estimated by congressional staff to be as much 
     as $5 billion over the next decade.
       It sounds smart--except that nobody asked how many 
     employers will drop retiree drug coverage. Clearly, many 
     will. The result is that, instead of saving money, the 
     proposed revenue raiser will force Medicare Part D costs to 
     skyrocket as employers drop retirees into the program.

  He concludes with this comment:

       There are many reasons to pass health care reform. There is 
     no reason to hurt seniors, employers and taxpayers in the 
     process. Businesses are struggling and the Medicare trust 
     funds have plenty of problems as it is. It makes no sense to 
     make these problems worse.

  So not only are the programs going to be cut, but the drug costs are 
going to be dumped into the program, with an increased number of people 
involved. You are going to see tremendous financial distortions as a 
result of the passage of this bill.
  Mr. McCAIN. I yield to the Senator from North Carolina for a question 
and then the Senator from Tennessee.

[[Page 29526]]


  Mr. BURR. I will make this point and ask this question: The President 
set out in this debate and targeted two things--quality and savings. He 
assured the American people that we were going to save health care and 
we were going to maintain quality.
  Would it not be accurate to say that, as you take money away from 
home health, one, you remove from that population that tool that 
maintains disease, that keeps that from getting worse, and you chase 
seniors back to the hospitals for the services. So, one, the acuity of 
the senior patient is much worse and, two, the cost of the delivery of 
the service because by the time they hit the hospital, it has 
deteriorated. So we flunk on both points. We don't decrease cost by 
cutting home health, we increase it. From the standpoint of the 
quality, the outcome of the patient is worse because we put them into a 
hospital setting. Is that not what we are trying to eliminate?
  Mr. McCAIN. It seems to me, yes.
  I yield to the Senator from Tennessee.
  Mr. CORKER. I was watching this in my office.
  Mr. McCAIN. It is a lot of fun, isn't it?
  Mr. CORKER. It is. I would rather not be any other place than on the 
floor talking about the most important piece of legislation we probably 
will deal with in our tenure here.
  Mr. McCAIN. Based on the principle that a fight not joined is a fight 
not enjoyed.
  Mr. CORKER. I can tell. I have never seen the Senator from Arizona as 
happy as he is today in the fight against something that is so 
devastating.
  I don't understand what it is that would cause my friends on the 
left, on the other side of the aisle, to throw seniors under the bus. 
There is no doubt that there ought to be some changes in Medicare to 
make it more solvent. We all want to ensure that seniors, down the 
road, have the ability to benefit from Medicare. no question. I think 
we have all said from day one that we want to join with Senator Gregg 
and others to make sure Medicare is here for seniors.
  I do not understand--I listened to the last segment of my friends on 
the other side of the aisle talking about the many needs in this 
country. Many people don't have health insurance, and many of us have 
offered bills to solve that.
  I don't understand, and I hope you can explain it to me, why the left 
would be willing to throw seniors under the bus. Regardless of what you 
say about the bill, they are being thrown under the bus, and doctors 
are going to get a 23-percent cut in a year, and they are not even 
dealing with that, and they are taking $464 billion out of Medicare. 
What is it that would drive our friends on the left who in the past--
not today--have supported seniors but today are willing to throw them 
under the bus for a political victory? What drives them?
  Mr. McCAIN. I do not understand it. Perhaps my other colleagues can 
explain it better.
  I also want to return for a second to the question of the Senator 
from Montana. The AMA is a classic example. When I go back to Arizona 
and talk to doctors and providers, they say: What is going on? You made 
a deal with the lobbyists. That is my answer to you. You made a deal 
with the lobbyists--not the home health care providers, not the nurses, 
not the doctors, the people who are the users of pharmaceuticals who, 
this year, have seen an 8- to 9-percent increase in the cost of 
prescription drugs--because your deal is going to protect them. My 
answer to you is, I don't know what you bought that letter for, but it 
was probably a pretty high price.
  The Senator from----
  Mr. BAUCUS. Will the Senator yield? I can answer the Senator's 
question.
  The PRESIDING OFFICER. The Senator from Arizona has the floor.
  Mr. McCAIN. I know the answer to it. I just gave you the answer.
  I yield to the Senator from Wyoming.
  Mr. BARRASSO. I agree with the Senator. It is astonishing that the 
Senator from Montana would read a national organization's letter 
instead of one from his home State.
  In Wyoming, we have 43 different home health care agencies, and some 
of them are in communities that don't even have hospitals. Therapists 
drive long distances. We have colleagues from rural States here, and 
Montana is certainly one of them. Those home health care agencies know 
they are not even going to get paid enough from Medicare to put gas in 
the car to drive out to the ranches and the farms where people are who 
are staying at home, trying to stay out of the hospitals and nursing 
homes. We have home health agencies throughout the States, and they 
drive tens of thousands of miles every year, with therapists and nurses 
and home care aides going out to help people stay at home and therefore 
give them dignity and allow them to keep down the cost of care for 
everybody.
  Mr. McCAIN. Mr. President, how much time remains?
  The PRESIDING OFFICER. Twenty minutes 22 seconds.
  Mr. McCAIN. The salary of William B. Novelli, who has since stepped 
down--an old friend--last year was $1,797,751. Mr. Tauzin, a 
pharmaceutical research and manufacturers lobbyist, only made $1.5 
million last year. Scott Serota, of BlueCross BlueShield, made $1.6 
million. Chicken feed.
  I yield to the Senator from Utah.
  Mr. BENNETT. Mr. President, I thank the Senator from Arizona.
  My mind goes back to a personal experience I had that I would like to 
share with my friends on the left. It was an entirely different bill--
No Child Left Behind. We were all for it on this side of the aisle 
because our President had proposed it. My staffer said to me, listening 
to the debate: You know, Senator, if President Clinton had proposed 
this, you would vote against it because you would think it was too 
heavyhanded with government interference. I said: You know, you are 
right. I have to do the right thing. I was one of the few Senators who 
voted against it.
  If we had proposed what the Democrats had proposed, every argument we 
are currently hearing from the right side of the aisle would be coming 
with great roars and insistent statements on the other side of the 
aisle. But because it is their President who proposed it, they are 
somehow keeping their consciences under control. I hope they will 
recognize the irony of that and that at least one Senator--that is all 
we need in order to stop this bill--would recognize that conscience 
ought to prevail and this bill ought to be stopped.
  Let's be clear. If this bill is stopped, health care reform will not 
die as a cause. Indeed, health care reform will be reborn in a 
bipartisan sense of, let's solve the problem, rather than in a partisan 
sense of, let's jam something down somebody's throat.
  I hope that is what will happen, that conscience will prevail 
somewhere and one member of the Democratic Party who feels in his or 
her heart that this is a dumb idea will let his or her conscience 
prevail.
  I see the Republican leader.
  Mr. McCONNELL. Will the Senator yield for an observation? Senator 
McCain has pointed out where the lobbyists are on this bill. Senator 
Isakson has pointed out where the people of Georgia are on this bill. 
Senator Barrasso has pointed out where the people of Wyoming are on 
this bill. We also know where the American people are.
  I have not seen a survey in months--in months--by anybody that 
indicates the American people are for this bill. It is not in doubt. We 
have heard that President Clinton came up to their lunch. The President 
may be coming back himself. The argument they are making on the other 
side? Ignore the American people, make history. Make history? What I 
hear the American people saying to us is: Vote for this bill and you 
will be history.
  This is not in the gray area. The American people are asking us to 
stop this bill and start over. They do not want a 2,074-page 
monstrosity of complexity and Medicare cuts and tax increases and 
higher premiums for everybody else. They want us to stop and start over 
and get it right.
  Mr. McCAIN. I ask the Senator from New Hampshire very quickly, is it 
your understanding that AARP does sell

[[Page 29527]]

health insurance and Wal-Mart sells health insurance?
  Mr. GREGG. Both of those are correct.
  Mr. McCAIN. Then would it make sense they would be included in the 
amendment to modify the limit on excessive remuneration paid by certain 
health insurance providers to set the limit at the same level as the 
salary of the President of the United States? Wouldn't the CEO of Wal-
Mart and the head of AARP, who only made $1.8 million last year, fall 
under that umbrella?
  Mr. GREGG. The underlying proposal is a blatant act to try to 
Europeanize our economy and move us to a process where the government 
decides what the market should do. But consistency would require that 
both of those organizations be included in that if the author is going 
to be consistent with the theme of the amendment, which is absolutely 
wrong in my opinion because there is no reason that we as a Congress 
should decide the compensation levels for people who are in the private 
sector.
  Mr. McCAIN. The Senator from Georgia.
  Mr. ISAKSON. I want to put a face on what home health care means to 
the quality of health care and the lowering of the cost of health care 
in America.
  My youngest son was in a horrible accident in 1989. He was 
hospitalized for 8 weeks, had four surgeries, developed an infection, 
and had some bone marrow threats. He was put in home health care after 
those 8 weeks. At a cost of pennies on the dollar, a visiting nurse 
came and helped my wife and me administer antibiotic drips periodically 
so he could continue to have the protection he needed to fight off the 
infection.
  The 8 weeks he was in the hospital cost over $100,000. The 8 weeks 
following that, when he was at home, home health care cost only a few 
thousand dollars.
  We are taking an agency and a service that has provided to the 
American people that greatly reduces the cost of health care, improves 
the quality of life of the individual and forcing the only option for 
somebody hurt like that to be in a hospital. Granted, my son was not in 
Medicare, but people in Medicare are in accidents and have the same 
type of thing happen.
  The patent effect of this is, on the one hand you save money to pay 
for somebody else's government option health insurance, but you take 
away an affordable, effective way to deliver health care.
  Mr. McCAIN. The Senator from Tennessee.
  Mr. CORKER. I was thinking about last year's campaign. The Senator 
from Arizona was highly involved in that campaign. I know he offered 
some health care solutions that were greatly maligned. But I think back 
on that, and I wonder, had our sitting President run on a health care 
reform bill that took money out of Medicare, which was insolvent, 
created a new entitlement, hurt seniors through home health, eliminated 
choices, making sure doctors got a 23-percent cut in a year, if he ran 
on a platform of health care reform that did that--had unfunded 
mandates to States, raised taxes--and told the American people while he 
was campaigning that their premiums were going to go up, I do wonder if 
the outcome would have been the same.
  As a matter of fact, I cannot imagine a health care policy being 
presented that is more off base than the one we are debating. But one 
that makes Medicare insolvent, has unfunded mandates to States when 
they are troubled, raises taxes and raises premiums. That is what we 
are discussing. Why my friends on the left want to give our President a 
victory on that basis is astounding to me.
  I don't know, but since you were up close and personal to that, I 
wonder if you might respond.
  Mr. McCAIN. I thank the Senator from Tennessee. I am very reluctant 
to take a trip down memory lane again. Could I say, one of the phrases 
throughout the campaign was: If you like the insurance policy you have, 
you can keep it. You tell me how people who now have Medicare Advantage 
can keep it under this proposal? It is impossible.
  Maybe the other side is right. Maybe these reductions have to be made 
in Medicare Advantage. Maybe those changes have to be made. I don't 
happen to agree, although cost savings should be there. But no one can 
believe that you can keep the same Medicare Advantage policy that 11 
million seniors in America have today under this proposal. It is 
impossible.
  The Senator from Florida.
  Mr. LeMIEUX. If the Senator from Arizona will allow, I want to ask 
one question of my friend, the medical doctor, about infections in 
hospitals. My understanding is that home health care is actually better 
for the patient, it is better for the efficacy of the treatment because 
a big problem we have in hospitals is that patients get staph 
infections and other infections. In fact, it is one of the leading 
causes of death in a hospital. You don't go in with this infection, you 
get it there.
  Isn't this proposal that is going to take people out of home health 
care and send them to hospitals going to actually hurt patients?
  Mr. BARRASSO. This proposal is going to hurt patients in a lot of 
ways. It is going to hurt patients psychologically. They are in a 
hospital when they want to be at home. It is going to hurt patients in 
terms of their health. The better place to be is at home, as long as 
somebody is coming around to check on them. That is why for so many 
reasons, doctors have for decades said: Try to help patients get home 
as quickly as they can. That is the best place for them to heal.
  We have heard from the Senator from Georgia a remarkable story about 
pennies on the dollar, the effectiveness of this program. It is good 
for folks, and it is good for the whole health care of our Nation if we 
have people healing at home, not in the hospital.
  Mr. McCAIN. Thanks to our crack staff who are a good example of the 
success of work release programs, I remind my friend from Montana, a 
Rollcall article as of June 11:

       Top aides to Senate Finance Chairman Max Baucus called a 
     last-minute, pre-emptive strike on Wednesday with a group of 
     prominent Democratic lobbyists, warning them to advise their 
     clients not to attend a meeting with Senate Republicans set 
     for Thursday.
       Russell Sullivan--

  Whom I don't happen to know--

     the top staffer on Finance, and Jon Selib, Baucus' chief of 
     staff, met with a bloc of more than 20 contract lobbyists, 
     including several former Baucus aides.

  Who have made a nice transition.

       ``They said, `Republicans are having this meeting and you 
     need to let all of your clients know if they have someone 
     there, that will be viewed as a hostile act,''' said a 
     Democratic lobbyist who attended the meeting.
       ``Going to the Republican meeting will say, `I'm interested 
     in working with Republicans to stop health care reform,''' 
     the lobbyist added.

  Again, PhRMA, the New York Times, again my favorite. Tauzin, the 
$1.5-million-per-year representative of PhRMA said:

       ``We were assured: `We need somebody to come in first. If 
     you come in first, you will have a rock-solid deal,''' Billy 
     Tauzin, the former Republican House member from Louisiana . . 
     . said. ``Who is ever going to get into a deal with the White 
     House again if they don't keep their word? You are just going 
     to duke it out instead.''

  They cut a deal. That is, again, in answer to the Senator from 
Montana, that is probably how they got the letter, the same way Tauzin 
wrote his letter.
  The majority leader--the minority leader, hopefully majority leader 
soon.
  Mr. McCONNELL. I say to my friend from Arizona, at the risk of being 
repetitious, what we all know is going on here is there is a total 
disconnect between inside-the-beltway lobbyists who cut their special 
deals and the American people who are speaking loudly to all of us in 
all of the surveys saying: Please stop this thing.
  I have never been involved in an issue in all the years I have been 
here, I say to my friend from Arizona and other colleagues, on which 
people spontaneously stop me in the airport and say: Please stop this 
bill.
  I am sure there are people in Kentucky who are for it. I have not met

[[Page 29528]]

one. There must be a doctor in Kentucky who is for this. I have not 
heard from one.
  This is an incredibly unpopular bill. Thus, their only rallying cry: 
Make history, ignore the American people. What an act of arrogance. 
What an act of total arrogance. We know better than you. Why don't all 
you American people, all 300 million of you, shut up, sit down, and we 
will do it for you. We will restructure one-sixth of the economy. We 
know what is best for you. This is an act of total arrogance.
  As the Senator from Utah pointed out, we just need one Democratic 
Senator to say no: No, I am not going to do this. I know the President 
would like me to make history, but this is wrong for the country, and I 
will not participate in it. Just one can make a difference.
  Mr. McCAIN. The Senator from North Carolina.
  Mr. BURR. The Washington Post in October of this year, talking about 
the story on AARP, said:

       The group and its subsidiaries collected more than $650 
     million in royalties and other fees last year from the sale 
     of insurance policies, credit cards and other products that 
     carry the AARP name . . .

  Mr. McCAIN. Wouldn't that mean that AARP executive would naturally 
fall under the Lincoln amendment?
  Mr. BURR. Absolutely, because it says ``the majority of its $1.14 
billion in revenue'' that AARP collected, according to the tax records, 
were made up of sale of these insurance products.
  Mr. GREGG. I think the Senator from North Carolina has made an 
excellent point. Consistency would require for the AARP to be included 
in this amendment, if the amendment is going to go forward. I hope the 
amendment is not adopted. But clearly it should be consistent with all 
the different interest groups. It appears it is not included because 
some deal was cut. Is that the implication here?
  Mr. McCAIN. The Senator from Utah?
  Mr. COBURN. If I might, I ask unanimous consent to have printed in 
the Record the consolidated audited financial statements of AARP. They 
are the fifth largest insurance sales company in America.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                                     KPMG LLP,

                                   Washington, DC, March 30, 2009.

                      Independent Auditors' Report

     The Board of Directors,
     AARP, Inc.
       We have audited the accompanying consolidated statements of 
     financial position of AARP, Inc. and affiliates 
     (collectively, AARP) as of December 31, 2008 and 2007, and 
     the related consolidated statements of activities and cash 
     flows for the years then ended. These consolidated financial 
     statements are the responsibility of AARP management. Our 
     responsibility is to express an opinion on these consolidated 
     financial statements based on our audits.
       We conducted our audits in accordance with auditing 
     standards generally accepted in the United States of America. 
     Those standards require that we plan and perform the audit to 
     obtain reasonable assurance about whether the financial 
     statements are free of material misstatement. An audit 
     includes consideration of internal control over financial 
     reporting as a basis for designing audit procedures that are 
     appropriate in the circumstances, but not for the purpose of 
     expressing an opinion on the effectiveness of AARP's internal 
     control over financial reporting. Accordingly, we express no 
     such opinion. An audit also includes examining, on a test 
     basis, evidence supporting the amounts and disclosures in the 
     financial statements, assessing the accounting principles 
     used and significant estimates made by management, as well as 
     evaluating the overall financial statement presentation. We 
     believe that our audits provide a reasonable basis for our 
     opinion.
       In our opinion, the consolidated financial statements 
     referred to above present fairly, in all material respects, 
     the financial position of AARP as of December 31, 2008 and 
     2007, and the changes in its net assets and its cash flows 
     for the years then ended in conformity with U.S. generally 
     accepted accounting principles.
       As discussed in note 2 to the consolidated financial 
     statements, AARP adopted Financial Accounting Standards Board 
     Statement No. 157, Fair Value Measurements, in 2008.
                                                         KPMG LLP.

  CONSOLIDATED STATEMENTS OF FINANCIAL POSITION, DECEMBER 31, 2008 AND
                                  2007
                             [In thousands]
------------------------------------------------------------------------
                                           2008               2007
------------------------------------------------------------------------
Assets:
    Cash and cash equivalents                $472,006           $325,154
     (note 2(c))..................
    Accounts receivable, net (note             70,419             79,122
     5)...........................
    Prepaid expenses and other                 26,013             34,805
     assets (note 8)..............
    Prepaid pension asset (note     .................              4,789
     10)..........................
    Investments (note 4)..........            916,146          1,087,082
    Property and equipment, net               315,166            304,778
     (note 6).....................
                                   -------------------------------------
        Total assets..............          1,799,750          1,835,730
                                   =====================================
Liabilities:
    Accounts payable and accrued              100,030            143,680
     expenses.....................
    Insurance premiums payable                711,242            662,974
     (note 3).....................
    Deferred revenue and other                 31,701             25,057
     liabilities..................
    Deferred membership dues......            435,597            388,280
    Accrued pension liability                 113,764  .................
     (note 10)....................
    Accrued postretirement health              69,823             67,808
     benefits (note 11)...........
    Notes payable (note 7)........            230,069            230,053
                                   -------------------------------------
        Total liabilities.........          1,692,226          1,517,852
                                   -------------------------------------
Net assets:
    Unrestricted:
        Undesignated..............             17,186            101,481
        Board designated (note 14)             81,348            205,461
                                   -------------------------------------
            Total unrestricted net             98,534            306,942
             assets...............
    Temporarily restricted (note                8,990             10,936
     15)..........................
                                   -------------------------------------
            Total net assets......            107,524            317,878
                                   -------------------------------------
            Total liabilities and           1,799,750          1,835,730
             net assets...........
                                   =====================================
------------------------------------------------------------------------
See accompanying notes to consolidated financial statements.


                       CONSOLIDATED STATEMENT OF ACTIVITIES, YEAR ENDED DECEMBER 31, 2008
                                                 [In thousands]
----------------------------------------------------------------------------------------------------------------
                                                                                  Temporarily
                                                                 Unrestricted      restricted         Total
----------------------------------------------------------------------------------------------------------------
Operating revenues:
    Membership dues..........................................        $249,314   ...............        $249,314
    Royalties (note 3).......................................         652,701   ...............         652,701
    Publications advertising.................................         119,696   ...............         119,696
    Grant revenue (note 9)...................................          89,649   ...............          89,649
    Program income...........................................          82,114   ...............          82,114
    Contributions............................................          41,113             $879           41,992

[[Page 29529]]

 
    Other operating income...................................          19,683   ...............          19,683
    Net assets released from restrictions....................           2,825           (2,825)  ...............
                                                              --------------------------------------------------
        Operating revenue before investment loss.............       1,257,095           (1,946)       1,255,149
    Investment loss (notes 3 and 4)..........................        (175,063)  ...............        (175,063)
                                                              --------------------------------------------------
        Total operating revenues.............................       1,082,032           (1,946)       1,080,086
                                                              --------------------------------------------------
Operating expenses:
    Program services:
        Programs and field services..........................         298,310   ...............         298,310
        Publications.........................................         177,638   ...............         177,638
        Member services......................................         284,086   ...............         284,086
        Legislation and research.............................          58,844   ...............          58,844
                                                              --------------------------------------------------
            Total program services...........................         818,878   ...............         818,878
                                                              --------------------------------------------------
Supporting services:
    Membership development...................................         114,096   ...............         114,096
    Management and general...................................         204,879   ...............         204,879
                                                              --------------------------------------------------
            Total supporting services........................         318,975   ...............         318,975
                                                              --------------------------------------------------
            Total operating expenses.........................       1,137,853   ...............       1,137,853
                                                              --------------------------------------------------
            Change in net assets from operations.............         (55,821           (1,946)         (57,767)
Other income (expenses):
    Investment loss from sinking fund (notes 4 and 7)........         (22,513)  ...............         (22,513)
    Income taxes (note 8)....................................         (17,427)  ...............         (17,427)
    Charges other than net periodic benefit cost (notes 10           (106,239)  ...............        (106,239)
     and 11).................................................
                                                              --------------------------------------------------
        Change in net assets before effect of adoption of            (202,000)          (1,946)        (203,946)
         measurement provisions of FASB Statement No. 158....
    Effect of adoption of measurement provisions of FASB               (6,408)  ...............          (6,408)
     Statement No. 158 (note 2)..............................
                                                              --------------------------------------------------
        Change in net assets.................................        (208,408)          (1,946)        (210,354)
Net assets, beginning of year................................         306,942           10,936          317,878
                                                              --------------------------------------------------
Net assets, end of year......................................          98,534            8,990          107,524
                                                              ==================================================
----------------------------------------------------------------------------------------------------------------
See accompanying notes to consolidated financial statements.


                       CONSOLIDATED STATEMENT OF ACTIVITIES, YEAR ENDED DECEMBER 31, 2007
                                                 [In thousands]
----------------------------------------------------------------------------------------------------------------
                                                                                  Temporarily
                                                                 Unrestricted      restricted         Total
----------------------------------------------------------------------------------------------------------------
Operating revenues:
    Membership dues..........................................        $249,353               --         $249,353
    Royalties (note 3).......................................         497,635               --          497,635
    Publications advertising.................................         121,518               --          121,518
    Grant revenue (note 9)...................................          82,431               --           82,431
    Program income...........................................          90,850               --           90,850
    Contributions............................................          42,353           $6,878           49,231
    Other operating income...................................           2,938               --            2,938
    Net assets released from restrictions....................             888             (888)              --
                                                              --------------------------------------------------
        Operating revenue before investment income...........       1,087,966            5,990        1,093,956
    Investment income (notes 3 and 4)........................          79,951               --           79,951
                                                              --------------------------------------------------
        Total operating revenues.............................       1,167,917            5,990        1,173,907
                                                              --------------------------------------------------
Operating expenses:
    Program services:
        Programs and field services..........................         302,518               --          302,518
        Publications.........................................         184,572               --          184,572
        Member services......................................         294,631               --          294,631
        Legislation and research.............................          60,581               --           60,581
                                                              --------------------------------------------------
            Total program services...........................         842,302               --          842,302
                                                              --------------------------------------------------
    Supporting services:
        Membership development...............................         112,960               --          112,960
        Management and general...............................         204,079               --          204,079
                                                              --------------------------------------------------
            Total supporting services........................         317,039               --          317,039
                                                              --------------------------------------------------
            Total operating expenses.........................       1,159,341               --        1,159,341
                                                              --------------------------------------------------
            Change in net assets from operations.............           8.576            5,990           14,566
Other income (expenses):
    Investment income from sinking fund (notes 4 and 7)......           4,479               --            4,479
    Income taxes (note 8)....................................          (8,902)              --           (8,902)
                                                              --------------------------------------------------
            Change in net assets before effect of adoption of           4,153            5,990           10,143
             recognition provisions of FASB Statement No. 158
    Effect of adoption of recognition provisions of FASB                 (580)              --             (580)
     Statement No. 158 (note 2)..............................
                                                              --------------------------------------------------
            Change in net assets.............................           3,573            5,990            9,563
Net assets, beginning of year................................         303,369            4,946          308,315
                                                              --------------------------------------------------
Net assets, end of year......................................         306,942           10,936          317,878
                                                              ==================================================
----------------------------------------------------------------------------------------------------------------
See accompanying notes to consolidated financial statements.


[[Page 29530]]


CONSOLIDATED STATEMENTS OF CASH FLOWS, YEARS ENDED DECEMBER 31, 2008 AND
                                  2007
                             [In thousands]
------------------------------------------------------------------------
                                              2008             2007
------------------------------------------------------------------------
Cash flows from operating activities:
    Change in net assets..............       $(210,354)          $9,563
    Adjustments to reconcile change in
     net assets to net cash provided
     by operating activities:
        Depreciation and amortization.          27,606           24,846
        Reserve for uncollectable                  248              (22)
         accounts.....................
        Effect of adoption of FASB               6,408              580
         Statement No. 158............
        Charges other than net                 106,239               --
         periodic benefit cost........
        Net loss (gain) on investments         258,420          (19,554)
        Deferred income taxes.........           1,447             (327)
        Amortization of premium on                  18              120
         investments..................
    Changes in operating assets and
     liabilities:
        Cash and cash equivalents held              --           41,506
         as collateral................
        Accounts receivable...........           8,455          (24,173)
        Prepaid expenses and other               7,345            1,325
         assets.......................
        Prepaid pension asset.........           4,789            4,570
        Accounts payable and accrued           (43,650)           2,139
         expenses.....................
        Insurance premiums payable....          48,268           50,331
        Securities loan payable.......              --          (41,506)
        Deferred revenue and other               6,644            2,484
         liabilities..................
        Deferred membership dues......          47,317           29,629
        Accrued pension liability.....          (1,408)              --
        Accrued postretirement health            4,540            5,336
         benefits.....................
                                       ---------------------------------
            Total adjustments.........         482,686           77,284
                                       ---------------------------------
            Net cash provided by               272,332           86,847
             operating activities.....
                                       ---------------------------------
Cash flows from investing activities:
    Purchases of property and                  (37,978)         (31,350)
     equipment........................
    Proceeds from sale and maturities          995,414        1,304,705
     of investments...................
    Purchases of investments..........      (1,082,916)      (1,358,527)
    Investment in joint venture.......              --              (33)
                                       ---------------------------------
        Net cash used in investing            (125,480)         (85,205)
         activities...................
                                       ---------------------------------
        Net increase in cash and cash          146,852            1,642
         equivalents..................
Cash and cash equivalents, beginning           325,154          323,512
 of year..............................
                                       ---------------------------------
Cash and cash equivalents, end of year         472,006          325,154
                                       =================================
Supplemental disclosures:
    Cash paid for interest............          12,979           14,623
    Cash paid for income taxes........          17,928            6,646
------------------------------------------------------------------------
See accompanying notes to consolidated financial statements.

  Mr. BENNETT. Mr. President, I have enjoyed this colloquy. I have 
enjoyed the enthusiasm that is here. I noticed that the sense of 
passion to get something done properly for the American people is on 
this side of the aisle. A great of sense of defensiveness is on the 
other side of the aisle.
  We all have an been caught one time or another in the struggle 
between support for a leadership position or a Presidential position 
and our own sense of what is the right thing to do. I join with my 
leader from Kentucky in saying that the people of Utah have never been 
more worked up about any issue than this one. I have never seen any 
circumstance where they have been more firm and unanimous in their 
demand that this bill be stopped.
  The Senator from Kentucky said if there is somebody in Kentucky who 
is for this bill, he has not met him. I have met some people in Utah 
who are for this bill. They have spoken to me about it, as I pass 
through airports or I walk down the street in the hearing of other 
people from Utah. As soon as anybody hears someone tell me, Vote for 
this bill, there is a chorus of voices that spontaneously come up 
around that and say: Don't listen to him; listen to us. This is a 
terrible bill. This is a terrible circumstance.
  I have been proud in the debate to point out that in Utah, the 
Dartmouth study says we have the best health care available in the 
United States, and if everybody got their health care there, it would 
not only be the best, it would be one-third cheaper than the national 
average.
  I have spent a lot of time talking with the people who provided that 
result. Unanimously they tell me this bill would damage that result. It 
would damage the quality, and it would raise the price. Why in the 
world would we want to do those two things?
  Mr. McCAIN. Dr. Barrasso from Wyoming.
  Mr. BARRASSO. It has been a privilege to take care of patients in 
Wyoming for the last 25 years. This bill is going to hurt them. It is 
going to hurt the future of care. It is going to hurt the future of 
Medicare in America. You cannot take $464 billion away from Medicare, a 
program on which the seniors of this country depend, and say it will 
not affect their care. It will affect them in the hospitals, it will 
affect them in the doctors' offices, it will affect them in the home, 
it will affect them in the final days of their lives in the hospices. 
That is what I hear about across Wyoming.
  I have not met doctors who support this--not at all. I have not met 
very many patients who support it, and they are also told by others: We 
don't want this. The townhall meetings have been overwhelming in 
opposition.
  This is a bill that will be bad for our small businesses and bad for 
people who want to get insurance. It will be bad for people who have 
insurance because they know their premiums are going to go up. It will 
be bad for people who pay taxes because those are going to go up. But 
specifically for home health care, this will be awful. It will affect 
small communities--in all of the small communities of America, not just 
in Wyoming. I can't imagine anyone in a small community being for this.
  Mr. McCAIN. And put more people in the hospital.
  The Senator from Tennessee.
  Mr. CORKER. Mr. President, I have been listening to the debate, and 
it is seldom that debate on the Senate floor has much impact on me, I 
must add. But the fact is, I do think this amendment--the Lincoln 
amendment--is a terrible amendment. We should not be voting on 
compensation.
  But I am wondering, I ask Senator McCain, if we should offer a 
unanimous consent agreement to change the amendment to take into 
account AARP, PhRMA, and others. I wonder if the other side would be 
willing to take that unanimous consent request.
  Mr. McCAIN. Not to mention the chief executives of the pharmaceutical 
companies. Why wouldn't we want to bring them in on it? After all, they 
are paying for lobbyists at $1.7 million every year to cut these deals 
at the White House that they describe on the front page of the New York 
Times.
  I would hope the Senator would be glad to modify her amendment to 
include all these other people who have gotten extremely wealthy--
PhRMA, an 8-percent increase in drug prices in the last year. Again, I 
refer to the New York Times.
  Anyone else? Senator Burr.
  Mr. President, how much time remains?
  The PRESIDING OFFICER. One minute.
  Mr. McCAIN. Senator Burr will wrap it up.
  Mr. BURR. The Senator from Arizona has stated this case very well 
over a number of days, and it will continue to be stated--they are 
cutting Medicare to fund a new government program. They are taxing the 
American people through drugs and devices and more money for their own 
insurance policies so that government can have a larger hand in health 
care.
  You know what. At the end of the day, the American people realize now 
that they are going to pay more and the quality of their health care is 
going to go down. It is no more obvious than the current amendment on 
slashing the reimbursements to nursing homes or to hospice or to any 
other area under Medicare.
  This is wrong, it should be stopped, and the American people's voices 
should be heard in this debate.
  I thank the Senator.
  Mr. McCAIN. It has been a great time. We are going to do it again, a 
lot, between now and the time the vote is forced, and the American 
people are on our side.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Montana.
  Mr. BAUCUS. Mr. President, this is very frustrating because we have 
these blocks of time, with Senators lining up to take control of the 
time and to make their points, and then they flee the Senate floor and 
we cannot get into a debate or a colloquy. We cannot make points that 
rebut the points they have made because they have all left the floor.
  Mr. CORKER. I am glad to stay here.
  The PRESIDING OFFICER. The Senator from Montana has the floor.
  Mr. BAUCUS. They all come in and make their points and then they 
flee.
  Mr. McCAIN. We are here.
  Mr. BAUCUS. Good, I am glad they are staying because I want them to

[[Page 29531]]

hear this. Maybe we will all learn something.
  First of all, clearly, we all care about home health care. I mean, 
let's obviously agree that we all do. I see the Senator from Arizona 
nodding his head in agreement; he does care about home health care. 
This Senator cares about home health care. The Senator from Wyoming, 
Dr. Barrasso--here he is, over here--he cares about home health care. 
He has talked about home health care.
  We all know seniors would rather be home than in the hospital or a 
nursing home, if that is medically appropriate. We all know that. I 
know that personally. My mother was in the hospital 2 weeks ago, and 
she is now, thankfully--praise the Lord--out of the hospital, and she 
is home. We have a home health care person coming in every day to see 
my mom.
  When I am there with the home health care person, I am very 
impressed. They do a super job. It is really something to behold. My 
mother loves it and I love it. We clearly are not going to do anything 
to cut home health care.
  But another point I would assume all my colleagues agree with is that 
we want to cut waste, if there is waste. We want to cut waste out of 
the health care system. Why should we allow waste, as representatives 
of our people--the taxpayers? We want to cut out waste. Again, I see 
the Senator from Arizona is nodding his head, yes, that clearly we want 
to cut out waste that may or may not occur in the system.
  Now, the next question--and it is a question--is, there are lots of 
forms of waste, and one is fraud--people just ripping taxpayers off and 
ripping seniors off. That is clear. There is a lot of waste. Let me 
take one small example in the home health provisions in the Senate 
bill, and that is this: The General Accountability Office found that in 
the home health industry there are a lot of outlier expenditures which 
are fraudulent; that is, some home health agencies classify their 
expenditures for home health as outliers--as extra payments--for very 
sick people.
  In fact, there is one county in Florida which accounts for 60 percent 
of all outlier reimbursements, whereas they provide health care for 
only 1 percent of the Nation's people. The GAO has found lots of 
examples where the outlier portion of home health is abused. It is 
fraud. It is abused. Well, guess what. The home health care industry 
came to us and said: Gee, we have some ideas how to stop that because 
we don't like rotten apples spoiling our barrel. We want to stop this 
fraud that exists with excessive outlier payments.
  So they came to us with some ideas. I know it is easy to think that 
suggestions might be classified as deals or whatnot, but that has not 
happened. They came with an idea of how to cut excessive costs in 
outliers, and we have done that. That is in this bill. There are a lot 
of other provisions with respect to home health care.
  I know the Senators have letters from their home States. I don't know 
if they are referring to a House-passed bill, which is very aggressive 
in cutting home health care benefits, or whether they have read the 
most recent language in the Senate bill, which essentially is much less 
aggressive because in talking to the agencies, they were saying: Yes, 
we can live with these changes--such as rebasing and market basket 
updates, phasing them in instead of immediately--with the idea, again, 
of getting rid of excessive payments and fraudulent payments.
  I say excessive because the home health care industry is enjoying an 
11-percent growth rate annually, as it is right now in dollars. Well, 
some think it is 17 percent. The chart I have is 11 percent, but maybe 
17 percent. Then the national health care spending rate, spending for 
all care, goes up about 6 percent a year, about 6 percent a year 
nationwide. Home health without reform is between 11 and 17 percent. It 
is almost double.
  Under this legislation spending will be about 8 percent. Remember, 
national health spending is 6 percent, and the home health industry did 
write a letter saying: Yes, we can live with that.
  My approach, frankly, in regard to legislation, is to work with 
groups, to work with industries and talk to them and not just be 
draconian and not be arbitrary in cuts or changes. You talk to them to 
see what accommodations can be made consistent with your principles.
  One of my principles is stopping a lot of the fraud and to see if 
there is a way to cut excessive spending because sometimes there is 
excessive spending around here, and that is what we have done in the 
home health industry.
  I could go into more detail, but I want my colleagues to know there 
is real, solid, sound reason for these changes in the home health 
provisions, and it is my judgment this will not hurt home health care 
for patients. That is a very important point to make.
  The same is basically true with the other industries--say with regard 
to the hospital industry. We worked with them and said: OK, we know you 
should be cut. I talked to a lot of hospital administrators privately 
and said: What do you think?
  They said: Yeah, Max, we should take a haircut. Our hospital should 
take a haircut.
  As you well know, you sometimes go to a hospital and you say: Good 
gosh, why do they have that big fountain out front? Why do they have 
all that marble? Why does this look like the Taj Mahal? You don't need 
that for health care.
  So then they crank that back for the need of their health care. Some 
of the executives say to me privately: Yeah, there should be some 
reductions in hospital payments. So we go to the hospitals and say: 
What is reasonable? Remember, this is over a 10-year period.
  They say: We could take a $155 billion cut. But they say that, in 
part, because they know what they lose on the margin they can make up 
in volume because of everybody's health insurance. That means, too, 
that we can get health care reform.
  You know, it is hard to get the health insurance industry to work 
with us if there is no health insurance for most Americans. If there is 
no health insurance for most Americans, then the health insurance 
industry is inclined to revert back to their old ways--or try to 
anyway--underwriting insurance, denying policies based on preexisting 
conditions, et cetera.
  So this whole effort is to work with groups--work with consumer 
groups, with labor, with hospitals, doctors, the insurance industry, 
pharmaceuticals--to see what is reasonable. That is democracy--to try 
to get some kind of broad-based kind of rough justice agreement to put 
this together. That is the effort we have undertaken in this 
legislation.
  I hear criticism, well, gee, we are cutting this and cutting that. 
But let's remember--and I know my colleagues agree with this--the waste 
in the American health care system is somewhere between $300 billion a 
year to upper estimates of $800 billion a year. It is waste, and we 
have to figure out a way to get rid of the waste without sacrificing 
care and actually, at the same time, improving the quality of care. 
That is the major goal.
  So when you see reductions in some of the payments to providers, a 
lot of that is an honest attempt to get rid of the waste or excessive 
payments. Let's take Medicare Advantage. Somebody quoted Tom Scully 
today. I have a quote from Tom Scully that says there is way too much 
spending in Medicare Advantage. I don't have the exact quote, but it is 
basically a public quote that we should cut Medicare Advantage spending 
because there is way too much expense in Medicare Advantage.
  It is a question of judgment as to how much to cut, I grant you. But 
still there are areas where there is excessive spending, there is 
waste, and home health care is a good area where we worked hard to 
refine the changes to get rid of some of the fraud--the outliers I 
mentioned--but in a way that helps seniors get good home health care.
  The PRESIDING OFFICER. The Senator from Tennessee.
  Mr. CORKER. Mr. President, I noticed the senior Senator from Montana

[[Page 29532]]

referred to us being here, and I wonder if he would yield for a very 
short question.
  Mr. BAUCUS. I agree, so long as it comes off their future time.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. CORKER. Well, I think we have a lot of time today, so I think 
that will work.
  Mr. President, I was wondering if the Senator from Montana might 
educate us--and all seniors in this country who receive Medicare--if 
his intent is to make Medicare work better--and, by the way, I think he 
is, in some cases, working sincerely to do that--why is he taking those 
savings away from Medicare? And being the distinguished chairman of the 
Finance Committee, he knows as well as anybody in this country that 
Medicare is insolvent. Why is he not using whatever he believes to be 
good savings--and we may disagree with those savings--to make Medicare 
solvent, or at least to pay the physicians who treat Medicare 
recipients? They are going to get a 23-percent cut next year, and it 
will take $250 billion just to make them equal in 10 years. Why is he 
not using those savings to actually make Medicare work for the people 
who are already receiving it versus leveraging all the entitlement from 
one insolvent entitlement to another insolvent entitlement? Why would 
the chairman of the Finance Committee consider doing something like 
that?
  Mr. BAUCUS. Mr. President, I would very much like to respond to that 
question. First of all, I appreciate the implied premise in the 
statement that the Senator agrees there should be savings. The question 
is, Where should the savings go? I mean, basically, the Senator is 
implying there should be savings, and that is very good to hear. I 
think that is a very constructive addition to a part of this dialogue, 
this conversation, that we should take savings because there is waste.
  The Senator's question is, OK, you take the savings, what should we 
do with the savings? That is the basic question.
  The fact is, because of the reforms in Medicare, a couple things are 
happening. No. 1, we are extending the solvency of the trust fund; it 
is another 5 years. The Medicare trust fund will now be extended 5 
years, so that helps seniors.
  I know the Senator didn't mean this at all, but, rhetorically, 
earlier he said: Why does this side want to throw seniors under the 
bus? I know he didn't mean that. I know he knows nobody is trying to 
throw seniors under the bus, nobody wants to do that in the Senate. But 
the fact is, these changes do extend the solvency of the trust fund.
  Then he asked a different question, and it is a very good question. 
It is a judgment call, what should be done with the additional savings? 
This legislation takes those savings to help more people get health 
insurance. One could argue those savings should not be used to help 
those without health insurance get health insurance for them. They 
could go back to the Medicare trust fund, they could reduce the budget 
deficits--there are a lot of different options here. But this is a 
health care reform bill. In this legislation, we are trying to come up 
with a system, if you will, that gets some coherence nationwide in 
health care. We don't have a system today. It is a hodgepodge. It is a 
collection. It is kind of a free-for-all. Docs do their things, 
hospitals do their things, nursing homes do their things; each attempt 
to get health care based on profit motive, but it is kind of 
incoherent. There is no real--anything there.
  We say let's try to look for coherence. We are the only 
industrialized country in the world that does not have some system, 
some way where everybody has health insurance. It seems to me we should 
try to see if we can have some kind of system, some way, where 
everybody has health insurance. I know it is extremely complicated. 
There is no doubt it is complicated. But if people have health 
insurance, that opens up lot of doors for other reform; one is to 
prevent companies, health insurance companies, from denying coverage 
based on preexisting conditions, health care status, and so on and so 
forth, because then what they lose on the margin, they can make up in 
volume because everybody has health insurance. It is the same with the 
hospitals, same with the pharmaceutical industry, same with virtually 
all providers, the whole system. If everybody has health insurance, not 
most everybody--more have health insurance the better the system is.
  That is a judgment call. But I do believe, when people have health 
insurance--those who do not now have it--are going to be more healthy. 
I think that is a good thing. Hospitals will not have to worry near as 
much about uncompensated care, which is a big challenge to hospitals 
these days. The average, I think, is about $1,100, $1,200 a year per 
family, when it comes to uncompensated care that private patients' pay. 
Then, after that, we open up doors to delivery system reform. You get 
the system working a lot better, compensating more on quality outcomes 
rather than quantity, et cetera. I know the Senator knows much about 
all these things.
  But it is a judgment call for those savings. I am glad the Senator 
seems to imply there should be or are savings, but it is a judgment 
call as to where the savings go.
  The 21 percent in docs, we are going to have to take that up after 
this bill. It is going to be difficult because some want to pay for it; 
some want to not pay for it. I grant you, that is going to be a huge 
battle.
  You might ask: Why is that not in this bill?
  Mr. CORKER. I did ask.
  Mr. BAUCUS. My answer to that is, A, it is not part of health reform. 
But, B, on the other hand, it is; they are docs, we care about our docs 
and we are going to have to find a way to pay for them and we will, I 
think, by the end of this year because we have to. Docs--there cannot 
be any reduction.
  Frankly, there is a partial fix in this bill anyway. It is 1 year 
with an update. At least this bill does take care of docs for at least 
1 year and with an increase. That is 1 year. The House wants a 
permanent fix.
  Frankly, I would love to have a permanent fix, but we are having a 
hard time finding the dollars to pay for it all, but this legislation 
does have a 1-year fix for docs.
  I yield to the Senator from Massachusetts.
  The PRESIDING OFFICER. The Senator from Massachusetts is recognized.
  Mr. KERRY. Mr. President, just one moment?
  Mr. BAUCUS. If the Senator will yield, I thank my colleagues for 
staying on the floor. I appreciate that.
  Mr. KERRY. Mr. President, I just was notified--I wish to respond to a 
few of the things here. The Senator from Arkansas has the pending 
amendment. My amendment is apparently not quite ready to be called up. 
What I want to do, if I can make a couple comments so the conversation 
doesn't stay where it is, prior to the Senator from Arkansas and then I 
will yield and then I would like to be able to come back after that 
with my amendment.
  I wish to say to our colleagues on the other side of the aisle, I 
have listened carefully, obviously, for a number of days now. I notice 
most of them have, indeed, disappeared--as the Senator from Montana 
suggested. It is pretty hard to have a legitimate debate in the Senate 
when people speak and then leave the floor and we can't actually test 
the things that have been said.
  One of the things that was said a moment ago by the Senator from Utah 
was, you cannot find any doctors who support this plan. Can you find 
doctors who oppose it? Absolutely. I will give him that. But don't come 
to the floor of the Senate and suggest there are not huge numbers of 
doctors across the country who are desperately waiting for the Senate 
to pass health care reform and, in fact, this plan. In fact, the AMA--
this is what the AMA says. They represent tens of thousands of doctors 
across the country, and they said:

       [We are] working to put the scare tactics to bed once and 
     for all and inform patients about the benefits of health 
     reform.

  We have heard an incredible amount of scare tactics, Senator after 
Senator standing there, jumping up, pounding

[[Page 29533]]

out one sort of misstatement or one distortion or another. The bottom 
line is, they have stood there for the last hour or so, claiming they 
are standing there to protect seniors. It is ironic, when one Senator, 
the Senator from Arizona, who said yesterday and sort of repeated it 
today--this is what he said yesterday:

       I will eagerly look forward to hearing from the authors of 
     this legislation as to how they can possibly add $\1/2\ 
     trillion in cuts without impacting existing Medicare programs 
     negatively and eventually lead to rationing of health care. . 
     . .

  That is the Senator from Arizona today.
  Only a year ago, when he was running for President of the United 
States, this is what the Senator proposed:

       "John McCain would pay for his health plan with major 
     reductions to Medicare and Medicaid,'' a top aid said, ``in a 
     move that independent analysts estimate could result in cuts 
     of $1.13 trillion in 10 years to the government programs.''

  Consistency, obviously, has never constrained anybody in politics. We 
know that. But to stand there, over the last half hour or 45 minutes, 
and say: Seniors are going to get hurt and seniors don't support this 
and we are here to protect seniors--just a few days ago the 
organization that represents 40 million seniors in America, it is the 
largest single representative group of seniors in our country--we all 
know it, it is called AARP. It is the American Association of Retired 
Persons. It represents people from 50 years old on up. There are a 
total of about 90 million of those in the United States of America, so 
they represent about half the seniors in America.
  Their interest, day to day, is making sure those seniors' interests 
are not hurt by what we do here in Washington. Here is what they said, 
on November 20:

       Opponents of health reform won't rest. [They are] using 
     myths and misinformation to distort the truth and wrongly 
     suggest that Medicare will be harmed. After a lifetime of 
     hard work, don't seniors deserve better?

  This is what AARP said a few days before that, on November 18:

       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 
     coverage.

  The Federation of American Hospitals said the following:

       Hospitals always will stand by senior citizens.

  They have no intention of pulling out the support that exists today.
  The American Medical Association:

       [We are] working to put the scare tactics to bed once and 
     for all and inform patients about the benefits of health 
     reform.

  The Catholic Health Association of the United States:

       The possibility that hospitals might pull out of Medicare 
     [is] very, very unfounded. Catholic hospitals would never 
     give up on Medicare patients.

  So everything we have just heard continues the scare tactics, trying 
to gin anger in America that is unfounded, based on the basics of this 
bill. Let me call attention--this is the report this year in March that 
came out from Medicare--it is about Medicare payment policy. It is a 
report to us, the Congress, by MedPAC. As we all know, MedPAC is the 
entity that oversees the administration of Medicare, and its concern is 
maintaining the viability of Medicare, making sure Medicare patients 
are not hurt by a particular program.
  What is in this bill--that Senator Baucus and those of us on the 
Finance committee put in the bill--is precisely what MedPAC told us we 
should do and could do without harming seniors. Let me share, 
specifically, what they said we should do:

       The recommendation is that Congress should eliminate the 
     market basket increase for 2010 and advance the planned 
     reductions for coding adjustments in 2011 to 2010 so that 
     payments in 2010 are reduced by 5.5 percent to 1990 levels.

  They suggested that. They did it because they know it will make the 
program sounder and it will allow them to make payments in other areas 
of Medicare that wind up taking care of Medicare beneficiaries more 
effectively. They said:

       The Congress should direct the Secretary [of health and 
     human services] to rebase rates for home health care services 
     to reflect the average cost of providing care.

  That is precisely what we do here. But the other side jumps up, and 
they will take any change, anything that reflects a shift from one 
place to another--they will exploit shamelessly in an effort to scare 
seniors and pretend it is somehow going to affect them.
  What is interesting--and America ought to take note of this--they 
keep coming to the floor and they keep opposing what is here. They keep 
wanting to strip something out. They keep wanting to send the bill back 
so that ends this process altogether. But they do not come to the floor 
of the Senate and show us how we could fix it more effectively and, in 
fact, serve seniors better, rather than just embracing the status quo. 
Everyone in America knows the status quo is unacceptable. We cannot 
afford it. Medicare will go bankrupt within the next 10 years, and then 
where are we going to be?
  This is the time for responsible action, and every step we have 
offered offers that kind of responsible action without reducing care.
  I will make one last comment and I will yield to the Senator from 
Arkansas and then come back and talk about further ways in which this, 
in fact, serves seniors and others more effectively. But as they have 
talked, for the last moments they have been talking about home care 
cuts.
  I have an amendment that shortly we will talk about that will 
prohibit any reduction in home care, that will guarantee we are clear 
that we are prohibiting any reduction in home care. But I have long 
been an advocate for better home care, more home care capacity. In the 
Finance Committee, I offered amendments to sustain that home care 
quality.
  Nobody worked harder than our late colleague Senator Ted Kennedy, 
with whom I worked for years on this, to try to extend home health 
care, protect home health care patients and augment home health care. 
Here is what the people who represent home health care in America have 
to say. This is from the National Association for Home Care & Hospice, 
a letter they sent to Senator Baucus. It was a letter they sent 
yesterday.

       The National Association for Home Care & Hospice supports 
     making health care available to all Americans. We believe 
     that every-one must be willing to sacrifice to make this 
     happen. [The National Association for Home Care & Hospice] 
     has agreed to do its part by reducing costs and payments in a 
     manner that makes the Medicare home care program more 
     efficient and less susceptible to abuse. We are grateful for 
     the opportunity to make these improvements and at the same 
     time protect the thousands of ethical providers who are 
     participating in this important program. We are pleased to 
     have the opportunity to work with your staff to make this 
     happen. For all these reasons, [the National Association for 
     Home Care & Hospice] supports the provisions of your health 
     care reform legislation as they relate to home health care. 
     We look forward to working with you and your staff . . .
       Thank you for [the] important work [you are doing].

  Who better to speak to the concerns of home health care? The folks 
who have continually been distorting this debate and who continue to 
try to scare people, or an association whose sole existence, whose 
payroll every day is put to the use of protecting the folks they 
represent in home care? I think the answer is self-evident to anybody 
who wants to listen to common sense.
  Mr. BURR. Will the Senator yield for a question?
  Mr. BAUCUS. It will have to be on your time.
  Mr. BURR. I would ask the Senator from Massachusetts, relating to the 
quote from Senator McCain that he showed, is the Senator aware that the 
day after that, factcheck.com said that was false?
  Mr. KERRY. What I am aware of is that the individual who was running 
for President of the United States never stood up and said it was 
false. I don't have any quote of Senator McCain ever refuting it. All I 
can say is that throughout the campaign, that was the operative 
language. It was debated. It was never refuted.
  I yield the floor.

[[Page 29534]]

  The PRESIDING OFFICER. The Senator from Arkansas.
  Mrs. LINCOLN. Mr. President, I am proud to join in this debate on an 
issue that is absolutely critical to all Arkansans and all Americans. I 
compliment Chairman Baucus because, as we talk about this issue in 
terms of health care reform, clearly, our delivery system in health 
care is broken. We have the best hospitals and doctors, research and 
technologies in the world. Yet our delivery system is broken. For the 
last 24 months, the Senate Finance Committee has held hearings and 
roundtables, summits, all kinds of different deliberative efforts 
working in partnership with associations that represent providers, 
advocacy groups on behalf of patients, anybody who would come to the 
table to talk about how we reform this system and make it better for 
the constituents we serve, the patients who are the ultimate recipients 
of the health care system. I applaud him and the work we have done.
  To anyone who says we are jumping in here and moving too fast, I have 
tremendous respect for the minority leader from Kentucky. My husband 
trained at Kentucky, did his subspecialty there. His admiration for one 
of those he trained with is a good friend of Senator McConnell's. But 
the minority leader's comment that we are saying to our constituents, 
sit down and shut up, again, like the comment from the Senator from 
Tennessee that we are throwing seniors under the bus, we are in a body 
that is here to be respectful of one another, respectful of our 
differences, our different approaches, how we come to the ideas we have 
of how we solve these questions.
  The Senator from Massachusetts brings up a great point. Where are the 
suggestions from the other side of how we solve this? Come to the 
table. Are they going to come to the table with ideas of how we do 
something other than just going with the status quo? Clearly, Americans 
understand that we are not throwing them under the bus. We are trying 
to figure out how we preserve a Medicare Program that is going to be 
bankrupt in 2017. How do we make the difference in the delivery system 
so we bring down those long-term costs in health care, so that we can 
actually preserve the programs that work and that are so meaningful to 
people in their lives. As we come to this debate, I hope we will 
continue the age-old attitude in the Senate of being respectful for one 
another's views and one another's efforts in trying to bring about 
something that will make sense and that will be helpful, not throwing 
people under the bus, not telling constituents to sit down and shut up, 
but actually working hard to come up with some solutions.
  Senator McCain was trying to call an awful lot of people in Arkansas. 
My mother was one of those whom he tried to get in touch with to tell 
them that something is wrong up here and that we are not doing what we 
need to do. I certainly visit with my mom an awful lot. I hear about 
her experiences and the concerns she has about Medicare, which is a 
system that is great for her, and I am proud I live in a country that 
provides her with that kind of care. She does believe very strongly in 
some of the things she has seen in her Medicare bill, inefficiencies 
that could be changed, ways that we could make it a better program. I 
hope we will all come to the table here with good ideas and ways that 
we can make a difference.
  I notice that there was an effort or certainly a concern about 
wanting to add people to my amendment. I would welcome Republicans, if 
they wish to offer their own amendment to include other entities, if 
they wish to do that. I have worked on my amendment, and I like my 
amendment the way it is. I think it focuses on an industry with the 
sole purpose to provide health insurance. Their sole purpose is to 
provide health insurance. If they want to add other people----
  Mr. THUNE. Will the Senator yield?
  Mrs. LINCOLN. I will continue visiting for a moment, and then I will 
let the Senator take time on his part. I am directing it solely to 
those businesses whose only purpose is to provide health insurance for 
the people of this country.
  I refer as an example to an article that came out yesterday. It 
references basically one of our large national insurance companies 
working hard, at least I hope they are, to do what is right. I see that 
they are going to be dumping 600,000-plus customers because they don't 
think their profits are big enough. Yet I look at the record, and I 
believe their CEO actually, in 2008, made over $24 million. If they can 
pay their top executive $24 million last year but they are going to 
complain that their profits are not big enough, that they have to dump 
patients, I would ask my colleagues, where do we go to correct this 
imbalance, if it is not to a very plausible amendment? My amendment 
does not restrict what industries, corporations can provide or give 
their executives in pay. It says we are not going to subsidize that 
with tax dollars. The very American taxpayers they are dumping are the 
ones who are subsidizing those incredible executive pay amounts.
  I have to say to my friends over there, those over there who are 
defending the status quo on behalf of the health insurance companies 
and their executives who are receiving these multimillion dollar 
compensation packages, it took nine of them at one time, so it is a 
tough lift to be able to defend these executive compensations for 
insurance company executives; otherwise, nine of them wouldn't have 
been down here trying to shift the conversation to something else.
  The American people do understand that is out of balance. Here we are 
with an opportunity to provide these insurance companies even more 
customers. We just simply want to be reassured that we are not, through 
taxpayers' dollars, subsidizing these enormous executive compensation 
amounts and, more importantly, that the savings that come from that are 
going to go into the Medicare trust fund to shore it up.
  I appreciate everyone's debate and their efforts to come to the floor 
today and talk about a critical issue. I remind my colleagues, current 
law allows all businesses to deduct up to $1 million annually per 
executive as a business expense. That is a million dollar tax break per 
executive per company that is subsidized by the taxpayers. There are 
multiple more ways they can obviously provide greater compensation, and 
there are lots of loopholes in there that allow them to get tax 
subsidies for more compensation for their executives. My amendment 
would limit this amount to $400,000, the very amount the highest public 
official in this land gets paid, the President, a $400,000 salary for 
those health insurance companies that will profit as a result of the 
health insurance reform.
  Our objective is to get more people insured. Working diligently 
through all of these technicalities, trying to get more people insured, 
we are creating a new marketplace for them with more consumers, a 
tremendous amount. This is only in regard to health insurance 
companies. It doesn't dictate what a business can pay an employee. It 
does limit the taxpayer subsidies for compensation. This is a fair 
policy. It is aimed at encouraging health insurance companies to put 
premium dollars toward lower rates and more affordable coverage, not 
into their pocketbooks. They are complaining about profits. Yet they 
are still paying these executives a tremendous amount of money. To be 
sure, there is evidence these companies need the encouragement to do 
the right thing for consumers. Where health insurers spent more than 90 
cents per every dollar on patient care in the early 1990s, that number 
has decreased to just over 80 cents per dollar. For every dollar they 
spend, only 80 cents of it goes back into their efforts to provide 
coverage for consumers. That is in 2007. Those are the numbers we have.
  According to testimony delivered to the Senate Commerce Committee 
earlier this year, this trend has translated into a difference of 
several billion dollars in favor of insurance company shareholders and 
executives at the expense of health care providers and their patients. 
It is imperative that we do what we can to reverse that trend, 
particularly now when millions more Americans will be purchasing their 
health insurance coverage as a result

[[Page 29535]]

of this health reform package. Taxpayers are footing the bill for this 
subsidy, and we must take steps to deter the health insurance companies 
from further enhancing their profit margins at the expense of the 
American people.
  We had a lot of Senators who came to the floor this morning on the 
Republican side to defend the status quo on behalf of the health 
insurance companies and their executives who are receiving these 
multimillion dollar compensation packages. Maybe they don't understand 
that under current law, the American people are already footing the 
bill for this tax windfall for health insurance executive pay. As we 
move forward, it is going to be a greater benefit to those executives 
and the ability for these insurance companies to be able to do that. We 
want to keep those insurance companies in business. We want to make 
sure they are there as providers. It is just a disconnect when they say 
they have to cut 600,000 of their insured under the current system 
because their profits aren't high enough. Yet they are paying their top 
executive a $24 billion compensation package that is subsidized by the 
taxpayers.
  I hope we will work together to figure out what is the right place to 
be here, if what we want to do is to make sure we are reforming health 
care, that we are asking everybody to come to the table and make an 
effort in putting ourselves back on track. Ultimately, we want that 
quality of life that a new, reformed health insurance and health care 
delivery system can provide. We also want to make sure we strengthen 
our economy. Making sure we make good use of every medical dollar, that 
we are getting the biggest bang for that buck is a critical part of 
putting our economy back on track.
  The assumption on the other side has basically been based on the 
current and broken marketplace where insurance companies really do 
bully their customers and monopolize choices. I don't know about their 
phones, but I hear a lot on my phones and from my constituents that 
they can't get insurance.
  They have a neighbor--a hard-working woman who is a single mom--who 
cannot get insurance because of a preexisting condition. I have others 
who have had insurance, and then when they did become ill, they got 
dropped.
  So our hope is we look at this in the context not of the broken 
marketplace that exists today but of what we are trying to create, and 
that is, a more robust marketplace, and one that makes sense both for 
insurance companies and for consumers as well.
  With insurance market reforms we plan to implement, along with more 
consumer choices through the exchange, these insurance companies are 
going to have to work to keep up with the business they have and to be 
able to be there for future customers. That is a healthy marketplace. I 
do not think I will get any disagreement from my colleagues on the 
other side that competition and choice is the way to go in the 
marketplace. That is who we are as Americans. It is to let those who 
have that entrepreneurial spirit--who want to get in the marketplace 
and provide a product at a reasonable cost--to be an active part of the 
marketplace. That is what we are trying to encourage in this 
legislation.
  So the amendment I am offering today would set the deduction cap at 
the same level as the highest paid government official, and that is the 
President. It is estimated to save approximately $650 million over 10 
years, and will place these savings in the Medicare trust fund to 
further strengthen the solvency of that fund and protect our seniors.
  We want desperately to make sure we protect our seniors. We know that 
in many instances there are Medicare Programs out there, unfortunately, 
that are oversubsidized, which means those who are in regular Medicare 
Programs are having to pay for the outrageous subsidies in these other 
Medicare Programs. We want to make sure we bring them to balance and 
create a better system for everybody out there. That means bringing 
down long-term costs. It means making sure we are protecting Medicare 
for all seniors. It means we do it in a deficit-neutral way, which we 
have done in this bill and the other bills we worked on in the Finance 
Committee. It means we work to put our best foot forward and bringing 
about partnerships between States and the Federal Government, as well 
as with providers who understand this delivery system is broken as 
well.
  So in closing, the choice on this vote is very simple: either you 
support these revenues being placed in the Medicare trust fund or you 
support having the IRS write a check and sending it to health insurance 
companies to subsidize the multimillion-dollar salaries they are paying 
in their taxes.
  I urge my colleagues to support this effort on behalf of the American 
taxpayer and on behalf of our seniors, and to vote in favor of this 
amendment that I feel has been structured in a very fair way.
  Mr. President, I yield to the Senator from Montana.
  Mr. BAUCUS. Mr. President, I think we have less than 4 minutes 
remaining on this side. I see someone else who wishes to speak. I 
promised him time, and Senator Durbin as well. I know they are both 
eloquent orators. It is a bit difficult here. So I will split it in 
half, the time remaining, between each of the two.
  Mr. DURBIN. I say to the chairman, I would yield whatever time I 
would have and come around in the next round.
  Mr. BAUCUS. Fine.
  Mr. DURBIN. I yield to Senator Nelson. And I think Senator Kerry 
wanted to lay down an amendment.
  Mr. BAUCUS. Thank you.
  Mr. NELSON of Florida. Mr. President, the Senator from Florida has 4 
minutes?
  The PRESIDING OFFICER. He has 2\1/2\ minutes.
  Mr. NELSON of Florida. Well, let me say, the people of Florida gave 
me one of the toughest jobs I ever had in my life when they elected me 
the insurance commissioner 16 years ago of the State of Florida. I have 
some familiarity with the conduct of the insurance companies, and it 
does not surprise me that the insurance industry is out to kill this 
legislation and is spending millions of dollars running TV ads.
  It does not surprise me that the insurance industry was very 
interested in this legislation to begin with, when we were going to 
expand all of those 46 million people who do not have insurance, to 
bring them into private insurance.
  It does not surprise me that since they have calculated they have to 
do their part, and that this bill will not allow them to cancel 
policies in the middle of somebody getting their health care--and we 
have heard those horror stories: in the middle of chemotherapy, 
suddenly, the woman gets the notice that her insurance is canceled. We 
have heard those horror stories of that little boy who was a year old 
and was heavy in pounds, and the insurance company said: We are not 
going to cover him. We hear the stories that: Oh, no, we can't insure 
you because you have a preexisting condition. And when you look what 
that preexisting condition is, it was a skin rash.
  Did you ever hear of the word cherry-picking? That is the typical 
modus operandi of insurance companies that want to keep their profit. 
They cherry-pick the good risk, the healthy ones, and they deny 
insurance to the ones who need the health insurance.
  So as we come to consider the amendment of the Senator from Arkansas, 
which I support, as we, many times, come to hear all of this extraneous 
argument, come right back to the main function. When you try to--
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. NELSON of Florida. When you try to reform the health care system, 
look who is trying to kill the reform.
  Thank you, Mr. President.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, I yield 5 minutes to Senator Coburn.
  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. COBURN. Mr. President, I thank you. I appreciate it. I sat here 
and listened to my colleagues to hear their input. I find it extremely 
peculiar that the only industry for which you would

[[Page 29536]]

limit their taxes is one that has not struck a deal with the committee. 
The only one. Pharmacists are going to spend $70 million advertising 
for this bill. The other industries are putting up additional moneys to 
advertise for this bill. The only industry that we are going to 
restrict is the industry that is in opposition to what we are doing. It 
is interesting.
  Senator Cornyn made the point with me a moment ago that we are going 
to take $450 billion, and we are going to give it to the very industry 
you are talking about. We are going to take $463 billion from Medicare 
and give it to the same industry you are now criticizing.
  Senator Baucus said--and let me quote--he said: As we tried to work 
this, it was ``rough justice'' to put this agreement together. This is 
democracy.
  It was done behind closed doors. That is not democracy. It was done 
behind closed doors. The Senator from Arkansas asked why we have not 
brought forward something. The Senator from Massachusetts asked. The 
first bill introduced was the Patients' Choice Act.
  I commend to my colleagues a white paper by Thomson Reuters, a very 
well respected firm, talking about the $600 to $850 billion worth of 
waste in the health care system today, entitled ``Where Can $700 
Billion in Waste Be Cut Annually From the U.S. Healthcare System.''
  The reason we are concerned about $465 billion coming out of 
Medicare, to be paid to the very insurance companies you are going 
after right now, is because we are not going where the real waste is. 
The promise of the President was to cut the cost of health care. Right 
here is where it is. This bill does not touch it.
  There is $175 billion a year in fraud in the health insurance 
industry. You all go after $2 billion of it--$2 billion. There is $175 
billion a year in fraud. What is in it? Nothing. We are going to manage 
to pay a private industry, but only the private industry that will not 
play along behind the closed door, rough justice of democracy in this 
country.
  When Senator Corker asked the chairman of the Finance Committee, Why 
are you taking the money from Medicare and using it somewhere else, 
rather than extending the life of Medicare, he did not answer the 
question. The fact is, there is a $44 trillion--according to the latest 
calculation, if you go to the Medicare trustees: $44 trillion--counting 
what has been borrowed--unfunded liability over the next 75 years for 
Medicare. We are going to take $\1/2\ trillion out of that program that 
we all know is going wrong. And I do not doubt the motives of anybody 
here. I just think we are misdirected. And we are going to take that 
and spend it on another program. That is where people ought to be 
concerned.
  It is interesting--I will submit another document for the Record. 
This is a report from the Congressional Research Service, released 
December 1, 2009, at my request.
  I ask unanimous consent that document be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                               Memorandum

                                                 December 1, 2009.
     To: Senator Tom Coburn, Attention: Evan Feinberg.
     From: Thomas L. Hungerford, Specialist in Public Finance, 
         Congressional Research Service.
     Subject: Public and Private Expenditures for Health Care, 
         2007.

       This memorandum responds to your request for information on 
     total national health expenditures for health care and the 
     proportion funded by the federal, state and local 
     governments. In particular you are interested in 
     incorporating tax expenditures into the estimate of the 
     proportion of national health expenditures coming from public 
     sources. It can be argued that some private health 
     expenditures should be attributed to the public sector 
     because of tax subsidies available for health care spending.
       Table 1 reports the breakdown of national health 
     expenditures by source of funds. In 2007, national 
     expenditures amounted to $2.24 trillion, of which 53.8% came 
     from private sources such as private health insurance and 
     46.8% came from public (federal, state, and local government) 
     sources. This breakdown, however, does not take into 
     consideration the tax subsidies for private funding for 
     health care. For example, the exclusion of employer provided 
     health care provides a subsidy for private health insurance, 
     which could be counted as public funds rather than private 
     funds.
       Incorporating tax expenditures into the breakdown of health 
     expenditures into public and private sources will change the 
     results that are reported in Table 1. The intuition behind 
     the analysis is fairly simple. For example, take a dollar an 
     employer pays for a premium for an employee's health 
     insurance. This dollar is part of the employee's 
     compensation, but it is not taxed like other income (at an 
     average federal, state, and local tax rate of 15%); it is 
     excluded from income for income tax purposes. In essence, the 
     employee receives a 15 cent government subsidy for this 
     dollar spent on health insurance--the government pays 15 
     cents and the employee pays 85 cents. This suggests that some 
     funds that are classified as private in Table 1 could 
     arguably be classified as public funds.

      TABLE 1--NATIONAL HEALTH EXPENDITURES BY FUNDING SOURCE, 2007
------------------------------------------------------------------------
                                                                Amount
                      Source of funds                         (billions)
------------------------------------------------------------------------
Total National Expenditures................................     $2,241.2
Private Funds..............................................      1,205.5
    Out-of-pocket payments.................................        268.6
    Private Health Insurance...............................        775.0
    Other Private Funds....................................        162.0
Public Funds...............................................      1,035.7
    Medicare...............................................        431.2
    Medicaid (federal, state and local)....................        329.4
    Other Federal..........................................        137.0
    Other state and local..................................       138.1
------------------------------------------------------------------------
Source: Center for Medicare and Medicaid Services, Office of the
  Actuary, National Health Statistics Group, National Health Expenditure
  Data, table 3, available at http://www.cms.hhs.gov/
NationalHealthExpendData/downloads/tables.pdf.

       Table 2 reports the results of applying this reasoning to 
     total national health expenditures. The table shows the 
     funding sources and public/private breakdown as reported by 
     the Center for Medicare and Medicaid Services (CMS) in the 
     first column. The two columns of numbers show the revised 
     split between public and private funds based on applying the 
     reasoning described above to tax expenditures (the method is 
     described below).

  TABLE 2--REVISED NATIONAL HEALTH EXPENDITURES BY FUNDING SOURCE, 2007
                          [Billions of dollars]
------------------------------------------------------------------------
                 Source of funds                   Private      Public
------------------------------------------------------------------------
Private (CMS definition)........................      894.8       a310.7
    Out-of-pocket payments......................      257.1        a11.5
    Private Health Insurance....................      482.1       a292.9
    Other Private Funds.........................      155.7         a6.3
Public Funds (CMS definition)...................  .........      1,035.7
    Medicare....................................  .........        431.2
    Medicaid....................................  .........        329.4
    Other Federal...............................  .........        137.0
    Other State and local.......................  .........        138.1
                                                 -----------------------
        Total...................................      894.8     1,346.4
------------------------------------------------------------------------
Note: aThe public portion is due to tax expenditures.
Source: CRS analysis of CMS data.

       CMS attributes $268.6 billion of out-of-pocket expenditures 
     to private sources. However, taxpayers are allowed to deduct 
     out-of-pocket medical expenditures exceeding 7.5% of adjusted 
     gross income on their federal and state tax forms. The Joint 
     Committee on Taxation estimates that the federal government 
     lost $8.7 billion in tax revenue in 2007 from this deduction. 
     Other tax expenditures for out-of-pocket expenses amount to 
     $0.3 billion. State and local income tax revenues are about 
     28% of federal income tax revenues; it is assumed that state 
     and local revenue losses from tax expenditures will also be 
     28% of federal revenue loss estimates. Consequently, it is 
     estimated that state and local governments lost $2.5 billion 
     from these tax expenditures. The total tax subsidy for out-
     of-pocket health expenditures is $11.5 billion.
       The Joint Committee on Taxation estimates that federal 
     government forgoes $251.0 billion in income and payroll tax 
     revenue due to the exclusion of employer provided health 
     insurance and other health insurance deductions. State and 
     local government lose $41.9 billion in income tax revenue 
     because of these exclusions and deductions. Consequently, 
     $292.9 billion of the $775.0 billion for health insurance is 
     classified as coming from public funds. Other private funds 
     for health expenditures include charitable contributions to 
     hospitals and other providers. These charitable contributions 
     are deductible and reduce federal, state, and local tax 
     revenues by $6.3 billion. This analysis estimates that $310.7 
     billion of health expenditures that CMS attributes to private 
     funds could be considered public funds.
       The last row of Table 2 reports the revised breakdown of 
     national health care expenditures between private and public 
     sources. It is estimated that public funding sources account 
     for $1,346.4 billion--60% of national health expenditures can 
     be attributed to public sources.

  Mr. COBURN. Here is what it says. I asked them what percentage of 
health care today is run through the government. You might be 
interested to know it is 60 percent. As the Finance chairman responded 
on why we were fixing it, we are going to create 70 new government 
programs in this bill--70 new

[[Page 29537]]

government programs in this bill--and we are fixing the government 
programs we have now. And we wonder why health care costs are out of 
control? They are out of control because the government is running 60 
percent of it now, and there is no competition for that 60 percent.
  Nobody is going to defend outlandish salaries, but it is interesting, 
we are not going after the outlandish salaries of the companies that 
are going to spend $80 million to support this bill, the pharmaceutical 
companies. We are not going to go after the salaries of the people who 
run the hospitals who, on average, make more than $1 million a year. We 
are not going to do any of those. Only the ones who say: Wait a minute. 
Maybe this is not such a good deal.
  Mr. President, I commend to my colleagues a document entitled 
``Impact Of The Patient Protection And Affordable Care Act On Costs In 
The Individual And Small-Employer Health Insurance Markets'' from 
Oliver Wyman and Associates, because what you claim you want to do is 
going to create 11 million young people who are not going to have 
insurance, and for those who remain, their insurance is going to cost 
twice as much.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. COBURN. Mr. President, I thank the chairman for allowing me to 
respond.
  Mr. GRASSLEY. Mr. President, I yield 5 minutes to the Senator from 
Georgia.
  The PRESIDING OFFICER. The Senator from Georgia.
  Mr. CHAMBLISS. Mr. President, I thank the ranking member on the 
Finance Committee for allowing me to speak for a few minutes to simply 
respond to some of the statements, just as Dr. Coburn has done, that 
were made earlier.
  My friend from Massachusetts, whose heart, I know, is in the right 
place, talked about the AMA, as if it were the last word in the medical 
arena, being in support of this bill.
  Well, Dr. Coburn is a practicing physician, and he can speak to this 
maybe even better than I can, but what we know is that the AMA 
represents 10 percent of the practicing physicians in America--10 
percent. That means 90 percent of the docs in America do not belong to 
this group that sent this letter in support of the Senate bill.
  I speak to this with authority because my phones have been ringing 
off the hook since this debate started months ago--the calls coming in 
from docs around the State of Georgia, who are violently opposed to the 
Senate bill--as it was being discussed and as it came out of the 
closed-door session that took place across the hall after the 
leadership in the Finance Committee, after the leadership in the HELP 
Committee could not agree on the direction on which we want to go.
  The Senator from Massachusetts said we are here scaring seniors. 
Well, I hope we are. Seniors ought to be scared. They ought to be 
scared to death of what is going to happen here because we are taking 
almost $500 billion out of Medicare, a program that a bipartisan 
Medicare Commission has said is going broke. And the Senator recognized 
this: It is going broke. We are taking $500 billion out of it. Whether 
you agree or disagree that the cuts in Medicare proposed by the 
Democrats are legitimate, we ought to be taking that money and putting 
it back into Medicare to save that program for the long term.
  The Senator from Tennessee asked the right question to the Senator 
from Montana, and he took 10 minutes responding to the question. And 
Dr. Coburn is right, he did not answer the question. There is a good 
reason why he did not answer the question. Because there is no 
legitimate answer to taking this $500 billion out of Medicare and 
creating an entirely new entitlement program that in and of itself is 
destined to go broke.
  If seniors are not scared by what we are saying, simply go to your 
doctor. Go to your doctor and ask your doctor about this. I know what 
happens to patients, Medicare patients who go to physicians who are 
generally in the range of 45 years or younger. Those physicians are not 
taking additional Medicare patients or any Medicaid patients because 
they can't afford it. The reimbursement rates to the physicians are 
less than the cost of the services they render.
  The Senator from Montana said: Well, we understand that, yes; there 
is $250 billion in reimbursements over the next 10 years that we need 
to take care of. And we are going to take care of. And I appreciate 
that because we need to. But it is in the House bill, and the House 
bill is $1.2 trillion. It is not in this bill, other than the 1-year 
fix the Senator alluded to. That is the reason the House bill is $1.2 
trillion and this bill is about $800 billion. That is the sole 
difference in the two, basically.
  But we are coming back, and in addition to the $800-plus billion 
expenditure in this bill, we still have a hole to be filled to try to 
take care of these docs or there is going to be a wholesale refusal on 
the part of the medical community to see Medicare patients. That should 
scare seniors. So I hope that message is getting out there.
  I wish to close with one other response to my friend from 
Massachusetts who said the National Association for Home Care and 
Hospice is the leading organization in America in dealing with this 
issue, and we ought to listen to them. Let me tell my colleagues what 
they say about what is going on in my State.
  I quote from a letter that has already been introduced dated December 
4 from the Georgia Association for Home Health Agencies. In this letter 
the executive director says:

       According to a study conducted by the National Association 
     for Home Care and Hospice, under Senator Reid's bill, 72 
     percent of home health agencies in Georgia will have negative 
     margins by 2016 in the Senate bill and approximately 68 
     percent of the 100 Medicare Certified home health agencies in 
     Georgia will go out of business and the patients they serve 
     will be rehospitalized or forced to seek alternative more 
     costly care.

  Well, I don't know how it is in the other 49 States, but I want to 
see our patients, our Medicare patients in Georgia, do what they want 
to do, which is stay at home for the most part and receive the good 
home health care they are getting today which, frankly, allows them to 
live a better quality of life and a longer life. It is pretty obvious--
--
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. CHAMBLISS. From this letter that is not going to happen.
  I yield back, and I thank the ranking member.
  Mr. GRASSLEY. I yield to Senator Murkowski for 5 minutes.
  Ms. MURKOWSKI. Thank you, Mr. President, and thank you to my 
colleague from Iowa.
  In this morning's Wall Street Journal there is an article--actually, 
an editorial--and it starts out: ``Another Day, Another Study,'' 
confirming that Obamacare will increase the price of health insurance. 
It goes on to talk about a Blue Cross study. It talks about CBO 
numbers. But the reality is, we have numbers all over. I think we all 
recall the quote from Mark Twain: You've got liars, damn liars, and 
statisticians.
  Well, I think we are caught up in that world now of dueling numbers. 
Our numbers say this is going to increase your premiums. The other 
side's numbers say it is going to decrease your premiums. So the real 
question is, Who is right and whose numbers do you look to?
  Well, I think it is important, as so many of my colleagues have 
mentioned this morning, when we are talking about whether it is the 
home health care statistics in a State they impact, to look to those 
States and what they are saying the impact will be. So I have gone to 
our State's think tank, if you will. The Institute for Social and 
Economic Research at the University of Alaska is the entity that does a 
lot of analysis, not only on health care policy and issues but other 
economic issues. I have asked them, let's sort through some of these 
numbers. Let's sort through some of the statements that have been made 
out there. I think it is important to share this morning some of the 
statements coming out of ISER.
  When we talk about the premiums Alaskans are going to face, instead 
of a

[[Page 29538]]

statement, a very simple statement, that, well, your premiums are going 
to go down, what ISER is saying is, when we look to the CBO estimate of 
the increase in the average premium for the nongroup market, what we 
expect to see is about a 12-percent increase by 2016. For single 
coverage, this is about $1,160 a year, and for family coverage it is 
about $2,900 in 2016.
  ISER is still conducting the analysis to determine the extent of the 
subsidies that may be available for Alaskans that could, in fact, 
reduce those premiums. But I think it is important to make clear that 
we are understanding what we are talking about when we make statements 
such as, well, this is going to increase or this is going to decrease. 
We need to make sure we are looking at all of the numbers.
  CBO has very clearly stated that the average premium per person for 
new nongroup policies is going to be between 10 and 13 percent higher 
in 2016 than the average premium. So we have to say, well, what is the 
difference between that statement and the statement the Democrats have 
made saying that the premiums are going to decrease by 14 to 20 
percent? We have to look behind the screen, behind the curtain.
  Two of the factors, administrative efficiencies and new enrollment, 
will make premiums go down, but these reductions are then overwhelmed 
by a 27- to 30-percent increase in premiums because of the coverage 
requirements that are mandated within the bill. The Democratic analysis 
that is out there omits this 27- to 30-percent increase, fundamentally 
flawing the analysis.
  What are some of the other things ISER has taken a look at as it 
relates to this bill that is before the Senate right now? They have 
stated that because Alaska is a high-cost State, it is highly likely 
health insurance plans in Alaska will become subject to the excise tax 
on health insurance sooner than the U.S. average. The preliminary 
estimate is that roughly 50 percent of health plans in Alaska will be 
subject to the tax by the year 2016 compared to only a 19-percent 
average in the rest of the lower 48. They have also indicated that 
while the uninsured population will be reduced in Alaska, adding 
approximately 65,000 new enrollees to the market, their concern--and 
this is a statement I think is very important--is that the newly 
enrolled Medicaid expansion, and through the new exchange, will create 
a big surge in demand that could easily create what they call a 
``traffic jam'' in the health care system and send the Medicare 
beneficiaries to the back of the line in Alaska due to Medicare's low 
reimbursement rate. This is exceptionally important for us to 
understand.
  On today's front page of the Washington Post there is an article 
about Texas----
  The PRESIDING OFFICER (Mrs. Shaheen). The Senator's time has expired.
  Ms. MURKOWSKI. The only statement we need to remember from this 
article is that even with insurance, you need somewhere to go.
  Thank you, Madam President. I yield the floor.
  Mr. GRASSLEY. Madam President, I yield myself 5 minutes.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. I rise to tell my colleagues why I am going to vote 
against the Lincoln executive compensation amendment. This amendment 
picks out one set of executives in the entire health care arena and 
singles out that one set of executives for limits on compensation. In 
the entire health care sector of the economy, this amendment suggests 
that only one group of executives warrants this sort of special 
treatment, and that happens to be the executives of health insurance 
companies. This amendment then takes that excess compensation that 
apparently Congress knows is the appropriate amount for compensation 
and devotes that excess money to the Medicare trust fund.
  Well, a very commonsense question in this town of nonsense is, why 
not limit compensation for executives in other areas of health care? 
What about the executives of hospitals? Shouldn't their excess 
compensation go to protect Medicare? Why not executives of nursing 
homes then? Why not executives of medical device manufacturers? Why not 
limit compensation on the people who run home health agencies? Why not 
limit compensation for doctors? Why not limit compensation for 
executives at the drug companies?
  Well, let's wait a second on that one. We know the answer to the one 
about why not include drug companies. This amendment can't touch drug 
company executives because their industry cut a secret deal where they 
agreed to some things in this bill, and they are going to get a huge 
payoff in profits once this goes into effect, as long as they don't 
open their big mouth and fight this legislation.
  Of course, this all adds up because if you are watching TV at home, 
or even here on the Hill, big PhRMA is running ads all over the country 
in support of this 2,074-page Reid bill.
  If the idea is for Congress to set the precedent of limiting 
compensation to protect the Medicare trust fund, then shouldn't we 
branch out even beyond the health care industry? We could get a lot of 
compensation--or we could get a lot of income into the Medicare trust 
fund by limiting compensation beyond health care to say, for instance, 
executives of trade associations or union leaders or trial lawyers or 
baseball players or movie stars. But, no; this amendment focuses on one 
specific group of executives who weren't going to be bought off by this 
bill. So let's just call this amendment out for the brazen political 
stunt it is, and if we do that, vote it down.
  I wish to remind everyone in closing that I asked the sponsor to 
include drug company executives in her amendment but was turned down.
  I yield the floor and yield 5 minutes to Senator Brownback.
  The PRESIDING OFFICER. The Senator from Kansas.
  Mr. BROWNBACK. Madam President, I wish to thank the ranking member 
from Iowa for his comments on the amendment.
  I wish to speak on the Johanns motion and its effect on the State of 
Kansas and the underlying bill in particular. Cuts to home health 
agencies of $42 billion have a huge impact in my State, and I wish to 
urge my colleagues to support the Johanns amendment and restore that 
amount of money to the home health care agencies.
  Years ago I did some work with the home health care agencies, and 
anybody who has been around them knows these groups don't operate on 
much of a profit margin. They are frequently not highly capitalized. 
They are high on people and people skills. They take care of folks in 
their homes. They do a great job of it. They take care of people where 
they want to be taken care of, which is in their homes and not in 
hospitals or extended stay facilities.
  Home health care and hospice frequently work with people in some of 
the most difficult times in their lives, when they are facing those 
difficult, often final, illnesses and they want to do it at home. They 
don't want to be in the hospital. They want to be at home with family 
and friends around comfortable surroundings. In this underlying base 
bill, home health care is cut $42 billion from the people who need it 
the most and from agencies that need it the most and are in dire 
straits.
  I have a chart up here which shows the impact on my State, 
particularly on home health care agencies. Roughly $240 million in cuts 
to home health care agencies in the State of Kansas will take place 
under this base bill. In this base bill, 64 percent of the home health 
agencies in Kansas will go broke by 2016, 64 percent by 2016. So just 
at the point in time where you have a lot of uptake and need for home 
health care for some people who are aging at that point in time, you 
are going to cut and you are going to cut this much, $240 million in my 
State, 64 percent of them go broke, and for what?
  Supposedly, it is to save a bunch of money, right? Well, on top of 
this, the CMS Office of the Actuary recently pointed out that the 
drastic cut to home health care will not produce savings to the 
Medicare Program. According to OACT, the savings from permanent annual 
productivity adjustments are unrealistic.

[[Page 29539]]

  Again, that just stands to reason; if you are going to force people 
out of their homes into a hospital for extended care because you are 
cutting home health care, you are not going to save money in that 
system. You are going to spend more money in that system. This is not 
going to work. It is going to hurt people overall, and it is going to 
be at a point in their lives when they would rather be at home than in 
the hospital.
  I think these are cruel cuts. I think it is at a terrible time. That 
is just for home health care, that alone, and then with the hospice. I 
have a letter from the Kansas Home Care Association that I wish to ask 
unanimous consent of the Presiding Officer to have printed in the 
Record at the end of my statement.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (See exhibit 1.)
  Mr. BROWNBACK. They say in this sentence, among other things:

       This will cause an increase in patients seeking care in 
     more expensive institutions which will only cause more of a 
     drain on State and Federal budgets.
       It is projected that over 58 percent of Kansas home health 
     agencies will operate at a negative margin in 2010. . . .

  I noted to you the number that is going to go broke by 2016. This 
isn't a far-off prospect. This is even next year, under the current 
setting. Then they are going to cut another $240 million from the 
Kansas ones that will cause even more of them to have great difficulty 
and financial trouble at this point in time.
  I ask my colleagues to revisit this issue. Vote for the Johanns 
motion that supports home health care agencies. The Johanns motion is 
simple. It says: Look, restore this piece. Don't take these moneys from 
home health care agencies. For a number of us who represent a number of 
rural States, home health care is key. It can be expensive in a rural 
setting. They need the resources to be able to meet the needs of the 
seniors we have.
  On top of that, in the overall cuts that are taking place are key and 
major cuts to Medicare Advantage programs. Referring to the chart, 
there will be a 63.7-percent cut to Medicare Advantage benefits that 
will affect more than 1 in 10 Kansas Medicare beneficiaries. A $1.5 
billion cut to Kansas hospitals is taking place and an 11.8-percent cut 
in hospice payments. Home health care agencies often do hospice care as 
well. So this is a double cut for them.
  Again, this is at a point in time in life where it is the most 
difficult. There is $124 million in cuts of skilled nursing facilities 
as well. This will force more people into that setting.

                               Exhibit 1


                                 Kansas Home Care Association,

                                     Topeka, KS, December 4, 2009.
     Hon. Pat Roberts,
     Senator from Kansas.
       Dear Senator Roberts: On behalf of the Home Health Care and 
     Hospice agencies of Kansas, we would like to support the 
     Republican Senators motions to commit back to the Senate 
     Finance Committee the HCR bill with changes that do not 
     include cuts in payments to both home health and hospice 
     agencies.
       This bill includes cuts to home health agencies that total 
     $42.1 billion and cuts to hospice agencies of $7.7 billion. 
     In Kansas a number of our member agencies service both home 
     care patients and hospice patients, so they would be hit 
     twice with monstrous cuts.
       It is projected that over 58 percent of Kansas home health 
     agencies will operate at a negative margin in 2010 and that 
     number increases significantly in years to follow. Hospice 
     agencies have already sustained cuts that have limited access 
     to the Hospice benefit, particularly in rural areas, which of 
     course is much of Kansas.
       Last week Governor Mark Parkinson announced a 10 percent 
     cut to Medicaid providers in order to balance the state 
     budget. Agencies that provide services to Medicaid clients 
     cannot sustain such drastic cuts and access will be severely 
     limited. This will cause an increase in patients seeking care 
     in more expensive institutions which will only cause more of 
     a drain on state and federal budgets.
       On behalf of the Kansas Home Care Association members, we 
     applaud your efforts to block cuts to home health care and 
     hospice benefits that the citizens of Kansas and the United 
     States need and deserve.
           Sincerely yours,
                                                       Jane Kelly,
                                               Executive Director.

  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Iowa is recognized.
  Mr. GRASSLEY. Madam President, I yield 10 minutes to the Senator from 
Texas.
  Mr. CORNYN. Madam President, I want to talk about the breathtaking 
audacity of this bill, in a takeover of yet another important sector of 
our economy, at a time when our economy is in recession--and the 
President was wondering at his job summit just on Thursday, how come 
the private sector seems to be on the sidelines when they should be 
back in the game creating jobs. This bill is exactly one of the reasons 
for that outcome.
  This bill is chock-full of avenues that lead to more and more 
Washington control over our health care system and our economy. The 
amendment of the Senator from Arkansas would give Washington control 
over how much money health care executives would make. But we know as a 
practical matter, in terms of limiting executive compensation, section 
162(m) has been a disaster.
  Actually, in the past, when Congress has attempted to do this, it has 
exacerbated the problem by encouraging companies to come up with 
different ways of compensating their executives that would not be 
subject to those limitations. This is ineffective in accomplishing the 
goal the Senator claims she wants.
  This amendment also adds to the complexity--it adds mud to the 
already muddy waters--by imposing complex limitations on just one 
industry, as has been described.
  I listened this morning--amazed--when there were offers to include 
other organizations such as AARP, which has reaped hundreds of billions 
of dollars of income from insurance sales, and executives at Walmart in 
the Senator's home State, who are also involved in the health care 
industry. Of course, those were rejected. Our favorite game around here 
is to try to demonize certain parts of the private sector and, of 
course, if the private sector is not involved in creating jobs, all 
that leaves is the government.
  In health care, all that will do--once there is no private health 
insurance available because of draconian mandates, taxes, and 
limitations on compensation--is eventually leave the government as a 
single-payer provider of health care in this country. I suspect that 
may be the ultimate goal.
  We already know the Reid bill will force millions of seniors to 
purchase so-called Medicare gap products which, by coincidence, are 
sold by AARP. We have heard Senators come to the floor and quote AARP 
as if it was holy writ, and somehow they represent all seniors. We know 
they have a blatant conflict of interest in supporting this bill, 
particularly as to stripping out Medicare Advantage benefits so they 
can sell more of our seniors Medigap coverage, which Medicare Advantage 
eliminates the need for.
  We also know this bill provides more power to Washington and is 
taking it away from individuals in other ways by limiting individuals 
to only four different options for what kinds of health coverage they 
can get. There is no room for innovation or flexibility. We know, 
ultimately, that drives up the cost for people who have insurance now--
their health insurance premiums.
  We ought at least be as good to the American people as we are to 
ourselves as Members of Congress. We have almost 300 different health 
care plan options under the Federal employees health care benefits. Why 
should the American people accept less choices when it comes to their 
health care than Members of Congress? They should not.
  These health insurance market reforms are designed to give Washington 
more power. More and more studies have said new controls by Washington 
will do nothing but drive up the cost of insurance. The Congressional 
Budget Office said they will go up by $2,100 for American families. A 
new study came out yesterday saying that, in Texas, premiums would go 
up for 61 percent of individuals purchasing their insurance in the 
individual market.

[[Page 29540]]

  The President of the United States said his goal for health care 
reform was to lower the cost of health insurance for the average 
American family by $2,500. By that test, this bill fails to deliver on 
the President's promise.
  Then there is, of course, the expansion of other government programs 
that, while they promise coverage, limit access to care by the way they 
are structured. This bill purports to give 94 percent of the American 
people health care coverage but does so by putting 15 million more 
Americans on the Medicaid Program. Of the 31 million newly insured 
under the Reid bill, the only choice of 15 million would be Medicaid. 
Of course, we know Medicaid--for example, in Dallas, TX, only 38 
percent of doctors will see a new Medicaid patient because 
reimbursement rates are so low that a doctor cannot see Medicaid 
patients and leave his or her door open to see other patients. We, in 
essence, condemn low-income persons to a health care gulag, where they 
are offered coverage but have no access to health care. For 60 million 
Americans, Medicaid would be their only choice.
  The $120 billion cuts to Medicare Advantage that we talked about 
earlier gives more power to Washington and takes it away from the 
individual. By cutting the private part of Medicare under Medicare 
Advantage, it would result in seniors having no choice but Medicare fee 
for service. Medicare fee for service compensates doctors at about 80 
percent of what private insurance does. That is why, in Texas, 42 
percent of the doctors will not see a new Medicare patient under the 
Medicare fee-for-service payment formula. Frankly, it pays so low that 
they cannot afford to see new Medicare patients.
  That means, again, this fraud is perpetrated on the American people--
our seniors--saying we are going to keep our promise to them by 
providing coverage by effectively denying access to care because the 
reimbursement rates are so low.
  This bill gives the government more power over people, and it takes 
it away from individuals in a number of other ways. While advocates 
describe it as a way to create competition and choice, the reality is 
it would drive out competition from the market and ultimately become 
the only choice for millions of American people. The so-called public 
option, which sounds relatively innocuous until people realize the 
effect of that, and the pay-or-play mandate on small businesses, which 
kills jobs, creates a rational decisionmaking process, and employers 
that will drop employees from the current private coverage, only to be 
left on a government-run plan, the so-called government option, which 
will end up, in the end, being anything but optional--denying power to 
the individual to make their own decisions in consultation with their 
doctor and family, and giving Washington more power over their lives.
  There are good reasons the vast majority of Americans don't trust 
Washington with running our health care system--an issue that so 
intimately affects all 300 million of us in America. We know Washington 
has a lousy record at managing spending. We have a $12 trillion 
national debt and, before the end of this month, the administration and 
the majority leader will come to Members of Congress and say: Would you 
please lift the statutory debt limit because we maxed out our credit 
card and we need to lift the statutory debt limit.
  Our entitlement programs are out of control, with Medicare running an 
unfunded liability of $38 trillion. The majority wants to take $\1/2\ 
trillion from Medicare and use it not to fix Medicare but to create a 
new entitlement program. Washington running health care means the 
personal health care decisions will be impacted by lobbyists and 
special interests rather than the interests of the American people. 
That is the reason the insurance industry has been supportive of health 
care up until now. There is $450 billion in tax dollars that will flow 
directly to the insurance industry under this bill in the form of tax 
credits.
  The hospital associations cut a deal so they would not be subject to 
the axe of the so-called ``independent'' Medicare advisory board.
  Everyone has heard about the deal that the pharmaceutical industry 
cut, in which it would result in them running ads supporting Members of 
Congress who support this bill because they want to protect their 
special deal cut behind closed doors. We heard Senator McCain talk 
about the special deal cut in this bill for Medicare Advantage 
beneficiaries in Florida--another special political deal in order to 
secure a vote to support this bad deal--but it left out seniors in 
Pennsylvania and California.
  I believe if there is any special deal to be cut, every senior who is 
a beneficiary under Medicare Advantage ought to have the same deal, not 
any more of these behind-closed-doors special deals in order to secure 
votes.
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. CORNYN. There is just one job-killing policy after another in 
this bill, and this is the latest.
  Mr. GRASSLEY. Madam President, I yield the remaining time to the 
Senator from Wyoming.
  Mr. BARRASSO. Madam President, how much time remains?
  The PRESIDING OFFICER. There is 4\1/2\ minutes remaining.
  Mr. BARRASSO. Madam President, you know as well as I that the 
President promised the American seniors that if they liked the care 
they had, they could keep it. Nothing could be further from the truth.
  Looking through this bill we are debating, there is an incredible 
amount of cuts to Medicare, which is a program seniors rely upon for 
their health care: $120 billion of cuts to Medicare Advantage. One in 
four people in America who depend on Medicare for their health care--11 
million Americans--are on Medicare Advantage. The reason they chose it 
is because it is an advantage. It helps with coordinated care and 
preventive care. Having practiced medicine for 25 years, I know the 
people at home get it. That is why they chose that program. It also 
cuts $135 billion from hospitals and $115 billion from nursing homes.
  I want to focus a little bit on the $42 billion cut from our home 
health agencies. I don't know how anybody on the other side of the 
aisle can say with a straight face that the legislation before us 
doesn't cut Medicare and doesn't hurt our seniors because it does.
  I will tell you, having taken care of people in hospitals, the 
services that are provided through home health care is what helps get 
people out of the hospital sooner, gets them home faster, gets them out 
of nursing homes, and helps keep down their costs. These services 
include skilled nursing care, physical therapy, occupational therapy, 
speech and language therapy, and medical social services.
  I have a letter from the director of home health services of Wyoming, 
the Home Health Care Alliance.
  I ask unanimous consent that it be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                                 December 5, 2009.
     Senator Michael B. Enzi,
     Ranking Member, Committee on Health, Education, Labor, and 
         Pensions, Hart Senate Office Building, Washington, DC.
       Dear Senator Enzi: Over the past ten years the Medicare 
     home health benefit has taken a larger hit in spending 
     reductions than any other benefit. As home health has become 
     an increasingly important part of our health care system with 
     highly skilled and often technically complex services that 
     enable millions of senior citizens and disabled Americans to 
     avoid being hospitalized or admitted to nursing homes, these 
     home health services save Medicare millions of dollars each 
     year.
       I believe that further reduction in home health payments 
     would place the quality and availability of home health 
     services at risk. I urge you to oppose the cut in Medicare 
     dollars for home health agencies through out our nation.
           Sincerely,

                                                  Mari Irelan,

                                                        President,
                             Home Health Care Alliance of Wyoming.

  Mr. BARRASSO. This letter talks about the devastating impact of the 
cuts proposed in this bill we are considering today. There are 43 home 
health agencies in Wyoming and a number of

[[Page 29541]]

them are in communities--the occupant of the chair is from a State 
where there are a lot of rural areas. A number of our agencies are in 
communities that don't even have hospitals. So it helps people stay in 
their homes, in their home communities, stay out of the hospital, out 
of the nursing home, and it gives them the dignity and the opportunity 
and the independence they need to stay at home.
  Yet this bill, according to the folks in Wyoming and the folks 
nationally, is going to make it that much harder for our seniors to 
stay at home.
  Taking $42 billion from home health care, raiding that program to 
start another program, to spend it on a new government program is going 
to absolutely impact the ability of home health care providers in this 
country to offer services. These nurses, therapists, and home care 
aides all drive hundreds of miles on a daily basis in Wyoming, going 
from ranch to farm, to help care for people and to help them stay at 
home. It is all around the country.
  There is a front-page story in the New York Times today, a wonderful 
story of a delightful 94-year-old lady, Bertha Milliard. She lives in 
Maine. There is a picture of her with her nurse during a home health 
care visit. Bertha is very worried that they are going to lose this 
service, which is the service that keeps her out of the hospital.
  It just seems, as we look at this, that there is no way home health 
care agencies around the country are going to be able to sustain these 
kinds of cuts and continue to remain available to the Medicare patients 
who depend on home health care.
  Even the National Association for Home Care & Hospice said that in a 
few short years, Medicare will be paying home health agencies less than 
it costs to even provide the services. We are talking about less than 
the gas in the cars and the salaries of the folks who drive around. We 
are not talking about profit. We are talking just about keeping doors 
open.
  As I think about the patients in Wyoming whom I have taken care of 
over the years who have benefited from home health services, who have 
been able to receive care from nurses, therapists, home care aides and 
allow them to stay at home, to be more independent--not totally 
independent but more independent--I think anything that cuts into this 
is not good for America.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. BARRASSO. I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Madam President, I ask unanimous consent that we continue 
with debate, and debate only, as under the previous order, for an 
additional hour, with Senators permitted to speak for up to 10 minutes 
each.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BAUCUS. Madam President, I yield to the Senator from Michigan, 
Ms. Stabenow, 5 minutes.
  The PRESIDING OFFICER. The Senator from Michigan.
  Ms. STABENOW. Madam President, I thank the distinguished Senator from 
Montana, who has been here morning, noon, and night counteracting 
falsehoods and scare tactics on the floor and putting forward what is 
really in this legislation that is so important to millions of people 
around the country. Everyone benefits, in one way or the other, by 
either costs coming down or by direct access to more affordable 
insurance. I thank our distinguished leader from Montana.
  We have talked so much about Medicare and Medicare Advantage, but I 
do have to take a moment to respond to what has been said over and over 
on the floor. It is very difficult for me--and I know for others around 
the country--to listen to our friends from the other side of the aisle 
lamenting that they want to protect Medicare, when it was a Democratic 
Congress and a Democratic President who created Medicare, over the same 
objections, by the way. You can take a look at the objections in 1965, 
the debate: The world was going to come to an end if, in fact, we 
passed Medicare. Of course, Medicare has become a great American 
success story for tens of millions of seniors and people with 
disabilities.
  Our friends now talk about how they are going to protect Medicare, at 
the same time that just a couple weeks ago, on the House side, 80 
percent of Republicans voted to do away with Medicare as we know it 
today and make it a voucher system and put insurance companies back in 
control.
  One of the frustrations for me is to hear the unfortunate negative 
comments that have been made about a very distinguished organization 
that represents senior citizens across the country, the American 
Association of Retired Persons, that I might add, when we were doing 
the prescription drug bill, my colleagues on the other side of the 
aisle used in every single speech because they were supporting them at 
that time. Now they are supporting our position. They disagree with 
them. They have said:

       Most importantly, the legislation does not reduce any 
     guaranteed Medicare benefits.

  Now we are hearing how horrible they are, which I think is a real 
disservice to a very important national organization. I think it is 
important, in the name of truth and in the name of fairness, to look at 
quotes that have been made about AARP that are different from what we 
have heard on the floor today and since this debate began.
  Our distinguished colleague from Arizona, who sponsored an amendment 
related to Medicare Advantage and has been on the floor numerous times, 
including today, disparaging AARP, said at an AARP convention:

       I say God bless AARP--

  This is the senior Senator from Arizona.

       I say God bless AARP for everything they are doing, not 
     only for the present generations of Americans, but for future 
     generations. That's your duty, that's your strength, and 
     that's why I love to see you at every town hall meeting.

  The unfortunate thing is now our colleagues on the other side of the 
aisle don't want to see AARP at every townhall meeting because they are 
not saying what they want them to say.
  I also have to express concern that we had 6 years of our colleagues 
in full control of the Federal Government--the Presidency, House, and 
Senate--and we did not get legislation to bring down health care costs 
or legislation to make sure every American, small business, and family 
could afford insurance as we are doing today. So it is a little 
difficult, even though we have come together on other issues on health 
care, on this particular one it is difficult now to hear all the 
criticisms that are flying and all the things we should be doing, but 
they were not brought forward a number of years ago, when they actually 
were in charge and could have done something about it. That is 
concerning to me.
  This legislation is about saving lives, it is about saving money, and 
it is about saving Medicare.
  I wish to share one story because not too long ago--it seems like a 
long time since we have been working so diligently this week--it was 
just Thanksgiving, and families all across America came together to 
reminisce around the dinner table, to watch football, and share a 
family meal. Even in tough times we stop, reflect, and give thanks for 
our many blessings. I know that is true for my family, and I am sure 
all our families.
  This year, there were 45,000 empty place settings at tables across 
the country for men and women whose lives were cut short because they 
did not have health insurance. I wish to share one story.
  The PRESIDING OFFICER. The Senator's time has expired.
  Ms. STABENOW. I ask for an additional minute.
  Mr. BAUCUS. I yield 1 minute.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Ms. STABENOW. One of those place settings was for a young man named 
Dr. Joe Hines, from Okemos, MI. He was a recent graduate of dental 
school. He had just completed his residency and had lined up a job in 
private practice in Detroit. He did not have health insurance. He 
became ill. He called his mom who urged him to go to a doctor, but he 
did not have insurance. He waited too long, figuring it would pass and

[[Page 29542]]

it did not pass. It got worse. He died at age 27.
  This legislation is about Joe Hines. It is about his family. It is 
about every one of the 45,000 families who lost loved ones this year. 
It is about the 14,000 people who got up this morning--today--on a 
Saturday, with insurance and will go to bed without it. Saving lives, 
saving money, saving Medicare, that is what we are fighting to do.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Madam President, I yield to the Senator from Alabama 10 
minutes.
  The PRESIDING OFFICER. The Senator from Alabama.
  Mr. SESSIONS. Madam President, I thank Senator Grassley, and I 
appreciate his leadership on this very important issue.
  As I have reviewed the legislation and looked at the analysis, the 
financial accounting that has gone into it, I have been astounded, 
beyond my ability to express it, by the errors and fictitious promises 
that have been made by the bill's supporters.
  My colleagues and people listening to or reading these words may 
think what I am saying cannot be true, that this is an exaggeration or 
has absolutely another side to the issue. But the statements I am 
making, I believe, are accurate, and if I am in error, I am glad to 
stand corrected.
  The numbers are so huge they cannot, in reality, be hidden. The 
numbers simply do not add up. President Obama had a grand concept in 
his mind. He was following, I think, a great chimera of reform that he 
believed he could accomplish. He was able to express it on the campaign 
trail with cadence, passion, and skill. People liked those promises. As 
so often is the case with many of us, he came to believe his own 
rhetoric, his own words, and those words took on a reality of their 
own.
  But once one takes office, words cease to be reality. Facts then 
dominate. Promises easily made in the Iowa spring or the New Hampshire 
winter, if not carefully constructed when made, become unreachable when 
a candidate takes office. Realities, I have to say, have risen to 
defeat his vision. They are not compatible.
  One, the basic promises he has made financially under this bill 
cannot be met. The numbers do not add up. They do not work.
  Two, the present debt crisis we are in, a crisis that will lead to 
doubling of the national debt in 5 years, the debt accumulated from the 
founding of the Republic, will double in 5 years and triple in 10, 
according to our own Congressional Budget Office. That does not include 
any money spent on this legislation because it is not current law. It 
will only make it worse. The financial crisis we are facing makes it 
even more important that we act with care and caution before we move 
forward.
  I also note that many people today are happy with the quality of the 
health care they receive. They are nurses, they are doctors, the 
quality of the diagnostic equipment, the hospitals they have to 
utilize. They do not have any desire, whatsoever, for the Federal 
Government to take that over.
  What they have been concerned about--and rightly so--are the rising 
costs. But the promises in this bill to reduce costs for the average 
American have not been achieved. Costs will continue to go up for 
average Americans.
  There are many flaws, many fictions in the legislation. Its promises 
sound good, but reality, in fact, is interfering. I will point out a 
number of promises that have been made and the facts that dispute 
those. I will then point out what I think are the real facts. I will 
ask and evaluate this bill on how well it meets the promises that have 
been made for it. From this analysis, it becomes clear to me that it is 
an offer we can and an offer we must refuse.
  Fiction No. 1: The allegation has been made and statements have been 
made from the beginning that the bill would cost $848 billion.
  The facts are, when the new programs created by this bill are fully 
implemented, the bill will cost $2.5 trillion. I think the sponsors of 
the bill acknowledge that.
  No. 1, is the cost $848 billion as promised? The answer is, no, it is 
much more than that. In fact, $2.5 trillion--2,500 billion dollars.
  How can we be that far apart? The bill's new benefits programs, the 
expenditures the bill calls for are not phased in until 2014, the fifth 
year of the 2010-2019 period, during which the cost of this bill is 
scored by the Congressional Budget Office.
  For example, the insurance subsidies funded by the Federal Government 
do not begin until 2014. Also, according to the bill, Medicaid will be 
expanded up to 133 percent of Federal poverty level, but that does not 
happen until 2014. It is disingenuous at best--just not accurate, some 
would say dishonest--for promoters of this legislation to claim the 
costs of the bill are only $848 billion, when they don't begin to pay 
out the new benefits in the 10-year period until 5 years from now. So 
shouldn't you score the bill from the time the benefits start and then 
for 10 years to get a 10-year honest score of the legislation?
  The Reid bill that is on the floor today, that was written basically 
in secret and added to this unrelated piece of legislation to get it to 
the floor, this piece of legislation begins to collect fees from 
insurers, medical device companies, and others--they are collecting 
money in increased fees and taxes--as soon as 2010. But when the true 
10-year score, when the expenditures start from 2014 to 2023--the first 
10 years of real implementation of the bill--that is when the cost of 
the program is $2.5 trillion. I don't think that is disputable in any 
significant way. Maybe a little here or there. I am just explaining 
what the facts are.
  Overall, costs rise too. They do not go down. The Congressional 
Budget Office states that, ``Under the legislation, Federal Government 
outlays for health care would increase during the 2010-2019 period, as 
would the Federal budgetary commitment to health care.'' So the Federal 
Government spending on health care, far from going down, is increased 
under this legislation.
  We currently spend one-sixth of our total gross domestic product--
one-sixth of the productivity of our economy--on health care. How much 
more can we afford to pay? And wasn't it the original intent of the 
bill to rein in health care spending to reduce the percentage of GDP 
going to health care? Wasn't that one of the concerns our business 
community has had--that too much of America's wealth is going to health 
care? They would like to see something that would reduce that.
  I suppose the fact that it utterly fails in that regard and, in fact, 
increases the national health care expenditures from 17 percent of GDP 
now--more than any other country--to 21 percent is the reason groups 
such as the U.S. Chamber of Commerce have said this bill must be 
defeated and have aggressively opposed it. They do not always get 
engaged in these issues, but on this question they are engaged, and 
they have said it will not do and not meet the concerns President Obama 
reflected upon. He talked about the need to reduce the percentage of 
GDP on health care, but it is going up under this legislation, 
according to the scoring of the CBO.
  One more question. If the benefits don't start until after 5 years 
from today, why is it so important to pass this monstrous bill today? 
Why can't we slow down a little bit? Why can't we do exactly as we are 
asking and go step by step and find out the things we know can work and 
do those things--particularly those things we can do now--that don't 
cost money but can actually help increase the quality of health care 
and maybe even bring costs down? Why don't we do those things?
  Fiction No. 2: The President said in his State of the Union Address 
to the Congress, the joint session of Congress, that not one dime would 
be added to the Nation's surging debt.
  Now, is that true or not? If it is not true, then I think people--
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. SESSIONS. Madam President, I appreciate the opportunity to speak. 
I will talk about the other points as the time avails itself and we 
have the time to do so.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.

[[Page 29543]]


  Mr. BAUCUS. Madam President, I ask unanimous consent that Senator 
Rockefeller be added as cosponsor to the Lincoln amendment, No. 2905.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BAUCUS. Madam President, may I ask how much time remains on each 
side?
  The PRESIDING OFFICER. The minority has 19 minutes 40 seconds 
remaining; the majority has 23\1/2\ minutes.
  Mr. BAUCUS. I thank the Chair. I yield 10 minutes to the Senator from 
Illinois.
  The PRESIDING OFFICER. The Senator from Illinois.
  Mr. DURBIN. I thank the chairman.
  Madam President, the Senator from Alabama has just said to the 
Senate: Slow down; you are going too fast on health care reform here.
  Today, across America, 14,000 Americans will lose their health 
insurance. Tomorrow, 14,000 Americans will lose their health insurance. 
Monday, the same, and every day of the week.
  Are we going too fast? The first time this issue came before us was 
over 100 years ago. Theodore Roosevelt, a Republican, said: We need to 
talk about health care for all Americans. It was a cause that was 
repeated by Franklin Roosevelt, certainly by Harry Truman and Lyndon 
Johnson. For 100 years now, there have always been voices in the Senate 
who have said: Slow down, you are going too fast.
  This year, 45,000 Americans will die because they do not have health 
insurance. We are the only civilized country in the world--the only 
Western industrialized, developed country in the world--where a person 
can die because they do not have health insurance. That is a fact of 
life.
  Slow down, they say on the other side of the aisle; you are going too 
fast. Well, we are here on a Saturday. It is a rare occurrence for the 
Senate to meet on Saturday, but I am glad we are here. If there were 
ever a time we should be here, it is right now. And we are here to 
discuss this bill--a 2,000-page bill. You know what went into this 
bill? Two committees: the Senate Finance Committee, under the 
leadership of the Senate Finance Committee chairman, Max Baucus of 
Montana, and the HELP Committee, now chaired by Senator Dodd of 
Connecticut. They spent days and weeks preparing this bill. Why did it 
take that long? Because health care represents $1 out of every $6 spent 
in America--one-sixth of our economy. It is that big a deal. And we 
produced this bill, this 2,075-page bill, after the considered effort 
of Democrats and Republicans writing it over the course of 1 year. Yet 
the other side says: Slow down.
  You know what, the American people ought to ask our Republican 
friends: Where is your bill? Why haven't you prepared a bill? You have 
had a year to do it. You knew this was coming. I know you have many 
ideas because we have heard them in speeches, we have seen them in 
charts, and we have seen them in press releases. But we don't see a 
bill. Nothing. It leads you to two conclusions--one of two. This is too 
hard to do, so they didn't do it, too difficult to write a bill, so 
they didn't do it, or they really don't believe we need to change the 
current system. Well, they are wrong.
  Today, health protection for Americans is not affordable. The cost of 
health insurance is going up so fast--faster than wages, faster than 
businesses can keep up with it--and people are being tossed aside, one 
after the other. Fourteen thousand Americans a day are losing health 
insurance because they lost their job or the business they work for 
says: We just can't pay the premiums anymore. That is the reality.
  This bill makes health insurance more affordable, No. 1 and, No. 2, 
this bill, at the end of the day, means that 94 percent of the people 
living in America will have health insurance. We have never in our 
history ever reached that level of protection--94 percent. I wish it 
were 100 percent, but it is 94 percent. Have the Republicans produced a 
bill that adds health insurance protection for anyone in America? No. 
Nothing.
  There is something else this bill does, and it took a lot of hard 
work to achieve it. This bill not only tackles health reform, but it 
reduces our deficit, and we should. This is a debt our kids are 
carrying. So Senator Baucus and the Finance Committee worked with 
Senator Reid of Nevada. This bill, by the Congressional Budget Office 
estimates, will reduce the deficit by $130 billion in the first 10 
years, $650 billion in the next 10. How does it do that? Well, if the 
cost of health care goes down, the cost of government goes down for the 
same health care--real savings. Have the Republicans, who stand here 
day after day saying we have to do something about the deficit, 
produced a health care reform bill that reduces it? No. Nothing. They 
have nothing to bring to us.
  Let me talk about one other aspect of this bill that is critically 
important. This bill gives to the American families and consumers, for 
the first time in a long time, a fighting chance against the health 
insurance companies. Do you know what they do to you? Do you know what 
happens when you get sick? You not only have to battle your illness, 
you have to battle your insurance company. Your doctor says you need 
this prescription, your doctor says you need this surgery, and then the 
doctor calls some clerk in some office in the middle of nowhere who 
says: Not covered. We are not paying for it. And do you know what 
happens next? The battle rages. It isn't just you against the disease; 
it is you against your insurance company. Do you know what they do? 
They turn you down. They say: We looked at your application for 
insurance, and you forgot to mention a preexisting condition, such as 
acne, when you were a teenager. I am not making that up. You didn't 
take into consideration that there is a limit on how much we will pay, 
and when you get really sick, we just stop paying. You didn't realize 
that you thought your child was covered by your family health insurance 
company, but your young son just reached the age of 24 and he is not 
covered anymore. He is on his own.
  Well, we take care of every one of those things in this bill. We give 
families, for the first time in history, a fighting chance to take on 
these insurance companies--real reform. I have yet to hear the first 
Republican come to the floor and endorse that concept. Why? Because the 
health insurance companies hate it. This is how they make money.
  Did you see what Aetna just announced? Aetna is one of the biggest 
health insurers. Their CEO makes a very modest $24 million a year in 
salary--$24 million. They had their most profitable quarter ever, and 
they announced they need more. So in order to add to their profits next 
year and add to the payments to their CEO and their shareholders, they 
are going to take 650,000 people out of coverage at Aetna. They are 
going to drop the people they think may just get sick someday. So they 
try to cherry-pick the healthiest people to keep their profits high. 
What is going to happen to those 650,000 people? Do you think they are 
going to join in the chorus from the other side that says slow down 
when it comes to health insurance for everybody in this country? Of 
course not.
  Senator Lincoln has an amendment that challenges the CEOs of these 
health insurance companies and says: Enough is enough. We will let you 
deduct from your taxes, we will give you a subsidy for $400,000 in 
income for a CEO of a health insurance company--that is how much the 
President gets paid, incidentally--but beyond that, we will not let you 
deduct it. We won't subsidize these obscene bonuses and payments to the 
health insurance executives. That is part of this as well.
  I also think it is great to hear our colleagues on the other side of 
the aisle with their newfound belief in Medicare. They come before us 
and say: You know, we are standing here to fight for Medicare. That is 
what this battle is really all about. Historically, that party has not 
stood to fight for Medicare; they have stood to fight Medicare. They 
opposed it when it was created, they have tried to privatize it, and 
they have basically ridiculed it as a government health insurance 
program. But for 45 million Americans, it

[[Page 29544]]

is a lifeline to insurance when they retire so that their savings don't 
melt away and disappear because of high health care bills.
  Most of our colleagues have ignored a vote they just cast 2 days ago. 
One of the most important votes we have had on the floor--in addition 
to Senator Mikulski's amendment which helped the women of America get 
preventive health services--was the amendment of Senator Michael Bennet 
of Colorado. He offered an amendment that basically said any of the 
savings that come forward out of this Medicare change in this bill have 
to be put into giving sound financial footing to Medicare, more 
services for the elderly, and making certain we protect the services 
that are already guaranteed. That passed 100 to 0. My friends on the 
other side of the aisle know that. They all voted for it.
  So we are protecting Medicare. We are going to put it on sound 
financial footing. And for the 45 million people currently receiving it 
and those who look forward to it in the future, this bill will make 
Medicare stronger.
  Slow down? No, we are not slowing down. This time, we are going to 
pass health care reform. This time, we are going to make America a 
healthier country with quality, affordable health care for everybody.
  Madam President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa is recognized.
  Mr. GRASSLEY. Madam President, I yield myself such time as I might 
consume on this side.
  I listened to the distinguished majority whip. I don't know how many 
times we on this side have to tell him that if they want to read 
Republican bills here is an opportunity to come and read them. They do 
exist and they have existed for a long time, going back to some of 
their entries into the Senate in the spring.
  Another thing I heard was that Republicans have no ideas, taking on 
the insurance companies. I would refer him to the Coburn-Burr bill that 
does away with the discrimination, that insurance companies cannot deny 
health insurance because of preexisting conditions.
  I heard him say we are newfound supporters of Medicare. Let me 
suggest to him that when we learned from the complaints of his party 4 
years ago, when they were berating the fact that we wanted to take $10 
billion out of Medicare and how that was ruining Medicare--we are faced 
now with $464 billion out of Medicare and we think they have talked out 
of both sides of their mouth, in the sense that 4 years ago, if 
Medicare would be hurt if $10 billion were taken out, surely if $464 
billion were taken out, it is hurting Medicare.
  I rise not to take on the Senate majority whip at this point but I 
rise because we keep hearing from the other side about how premiums are 
going to go down. I referred in previous remarks in this past week to a 
letter sent to Senator Bayh that provides a very comprehensive analysis 
of what health insurance premiums will look like as a result of this 
Reid bill now before us.
  That reminds me of one other thing the Senate majority whip said, 
that we want to delay action on this bill. What we want to have is 99 
Senators have the time to consider what is in this 2,074-page bill, 
when you have to remember that in the secrecy of the Senate leader's 
office, Senator Reid's office, from October 2 until about the Saturday 
before Thanksgiving, it took that long in secrecy to put two bills 
together out of two separate committees. That is one Senator putting 
together the 2,074-page bill we have before us. Don't you think that 99 
other Senators ought to have at least that same period of time to 
consider what is in this bill? I think so.
  Anyway, getting back to the increase in premiums and Senator Bayh's 
letter from the Congressional Budget Office saying that premiums are 
going to go up, I wonder if anyone has actually read that letter. I 
hear a lot of people saying this letter proves that premiums would go 
down under the Reid bill, even though that is not what that letter 
says. So I am here to tell people what the letter says. The letter 
makes it very clear that premiums will increase on average 10 to 13 
percent for people buying coverage in the individual market. I think 
you saw a specific figure given by the Senator from Texas, that in his 
State for a large percentage of the individual market premiums would go 
up, just for people in the State of Texas.
  I have a chart here in case you missed what this letter actually 
says. The people who keep saying premiums are going to go down 
conveniently forget to mention this 10 to 13-percent increase that is 
going to happen for the individual market. No, they would prefer to 
talk about 57 percent of Americans in the individual market who are 
going to get subsidies. Yes, it is true. The Government is spending 
$500 billion of hard-earned taxpayers' dollars in addition to the cuts 
they are having in home health care that is a pending amendment before 
the Senate. These cuts and these tax increases cover up the fact that 
this bill drives up premiums faster than current law.
  I repeat, premiums will go up faster under this bill. Supporters of 
this bill are covering up this increase in costs by then handing out 
these subsidies. But if you are 1 of the 14 million people who does not 
get a subsidy--well, what? You are out of luck. You are stuck with the 
fact that this is 10 to 13 percent more expensive and, coupled with it, 
an unprecedented new Federal law that mandates that you buy and 
purchase insurance.
  Some may say this is the individual market, it only accounts for a 
small portion of the total market. Again, if you are comfortable, as 
the other side seems to be, with 14 million people paying more under 
this bill than they would under current law.
  I wish to also have you look at the employer-based market. The 
Congressional Budget Office analysis says this bill maintains the 
status quo in the small group and large group insurance market. Is this 
something we ought to be celebrating, maintaining the status quo? Are 
expectations so low at this point that Democrats are celebrating that 
this bill will increase premiums for some 14 million people and 
maintain the status quo for everybody else?
  I am being generous in using the phrase status quo, because this bill 
actually makes things worse for millions of people. This bill is so bad 
that Democrats are trying to convince the American people that this is 
more of the same when even that is not the case.
  What happened to bending the growth curve? In other words, the 
inflation we have historically had in health care costs, going up three 
or four times the rate of inflation, going up now 8 or 9 percent even 
when we have deflation in the economy at large? What about the 
President's promise that everyone will save $2,500? According to CBO, 
almost every small business will pay between 1 percent more or 2 
percent less for health insurance. That means compared to what 
businesses would have paid under current law, this bill will raise 
premiums 1 percent or maybe decrease them by a whopping 2 percent. That 
doesn't sound like this bill is providing real relief, and $2,500 in 
savings for every American, as President Obama pledged repeatedly 
during the campaign, is not going to happen.
  The larger businesses will pay the same or up to 3 percent less for 
health insurance. Once again, that doesn't sound like relief, it sounds 
like more of the same. In fact, the Congressional Budget Office has 
confirmed that between now and the year 2016, premiums will continue to 
grow at twice the rate of inflation.
  I thought Congress was considering health reform to put an end to the 
unsustainable premium increases. This bill cuts Medicare by $500 
billion, raises taxes by $500 billion, restructures 17 percent of our 
economy, spends $2.5 trillion, and some of my colleagues on the other 
side of the aisle are celebrating that they have achieved the status 
quo when in fact the situation will be worse. I thought the status quo 
was not something that was acceptable to most Members of this body.
  Our constituents want to lower costs. That is their main concern. 
That is what our constituents begged for, lower costs. But this bill 
fails to address that concern. It raises premiums

[[Page 29545]]

and, despite offering new ideas throughout the committee process and on 
the floor, Republicans are being accused of supporting the status quo 
when our bills are right here for anybody to look at if they think 
there are not any ideas we would put forth.
  The Congressional Budget Office has spoken and it is pretty clear my 
colleagues across the aisle are not only OK with the status quo, they 
are OK with making things worse--higher taxes, higher premiums, 
increased deficits and less Medicare. Just think, we are approaching 
the Christmas holiday season and a Christmas gift coming from this 
Senate, with a 2,074-page bill: higher taxes, higher premiums, 
increased deficits, $464 billion cuts in Medicare and not doing 
anything about inflation in health care costs. They are celebrating 
that they spend $2.5 trillion to raise premiums for 14 million people, 
not bending this growth curve, not cutting costs.
  Don't take my word for it. You have to read this letter from the 
Congressional Budget Office. It is there in black and white as 
evidenced by the chart I have here.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Massachusetts is recognized.
  Mr. KERRY. Madam President, I will yield myself such time as I will 
use.
  There have been times during this debate that I have listened with 
astonishment to the minority. They agree with the diagnosis--that our 
health care system is in need of treatment. But they offer no remedy, 
no prescription, no cure.
  We don't need a second opinion on what the problems are with our 
health care system. Our country leads the world in the advancement of 
medical science. We have the best doctors, the best technology and the 
best hospitals in the world. It is no surprise to see kings and queens 
come to the United States for medical treatment.
  But for all that, the system is dysfunctional, wasteful and abusive. 
It rewards quantity over quality. And it delivers profits more than 
care. It is a system in which too many American families are just one 
illness or one injury away from financial ruin.
  I would like to thank Majority Leader Reid, Chairman Baucus, Chairman 
Dodd and Chairman Harkin for getting us to this important point in our 
long march toward a health care system that is affordable and available 
to all Americans. Their efforts have presented us an opportunity to 
cast a vote that will make life better for every single American. It 
isn't often that we get a chance to do that. But we have that chance 
now.
  I know the majority leader, the Senate Finance Committee, and the 
Health, Education, Labor, and Pensions Committees have each tirelessly 
worked on the provisions in this bill and have taken great care to 
ensure that Medicare beneficiaries will maintain access to their 
guaranteed benefits and will receive additional preventive benefits and 
expanded prescription drug coverage.
  The amendment offered Senator Johanns is very similar to the McCain 
amendment we debated over the last few days. Once again, the opponents 
of this bill are endorsing the status quo that leaves Medicare on the 
brink of going bankrupt and seniors facing higher costs. My amendment 
simply ensures that no beneficiary would receive a reduction in their 
guaranteed Medicare home health benefit.
  Let me remind my colleagues again what will happen if we stick with 
the status quo. The status quo means Medicare will be broke in 
approximately 8 years. The status quo means seniors will continue 
paying higher and higher premiums and cost-sharing due to wasteful 
overpayments to providers. The status quo means that each year billions 
of Medicare dollars will continue to be wasted on lining the pockets of 
private insurance companies. And the status quo means that seniors will 
continue struggling to pay for prescription drugs.
  The stakes for seniors and for the Medicare Program have never been 
higher. Senators have a choice: Endorse the status quo or strengthen 
Medicare. Regarding Medicare changes for home health providers, let me 
describe what is in the Senate bill.
  As most of my colleagues would agree, home health care is an 
important benefit in the Medicare Program. Today more than 3 million 
Medicare beneficiaries receive home health services across the 
country--including those with acute illnesses and injuries and those 
afflicted with numerous chronic conditions.
  Across the country, more than 9,800 home health agencies provide care 
to seniors in their homes. This care helps seniors get better and avoid 
expensive rehospitalizations. Home health providers make a real 
difference in improving seniors' health. We should support their 
efforts.
  While I have great respect for the services of home health providers, 
we also have a responsibility to protect the Medicare Program. As part 
of this, we must make sure Medicare is paying appropriately--and not 
overpaying--for Medicare services. We must also take action to root out 
fraud and abuse in the Medicare Program. I believe the policies in the 
Senate bill achieve both goals.
  First, the Senate bill would ``rebase'' home health payments to 
ensure payments reflect actual costs of providing care. These changes 
are based on MedPAC recommendations, which is the nonpartisan group 
that advises Congress on Medicare.
  When the current home health payments were set, seniors received an 
average of 31 visits per episode. Today, they only receive 22 visits. 
The Senate bill directs CMS to ``rebase'' payments to reflect this 
change. That is common sense.
  The Senate bill also roots out fraud in the system by revising how 
Medicare pays for ``outlier'' cases. Medicare provides an extra payment 
today for providers who treat sicker or ``outlier'' patients. 
Unfortunately, the GAO found that some providers were gaming the system 
and getting more outlier payments than they deserve.
  For example, GAO found that in one Florida County, providers were 
receiving 60 percent of all total outlier payments--even though the 
county had less than 1 percent of the total Medicare population. 
Clearly, something was going on there that needs to be changed.
  The Senate bill addresses this problem by placing a cap on the amount 
any individual provider can receive in outlier payments. In addition, 
it establishes a productivity adjustment for home health providers 
beginning in 2015. These changes ask home health providers--like all 
other providers--to offer more efficient and higher quality care over 
time.
  I believe the Senate policies are fair and reasonable. In making 
these changes, we worked closely with the home health industry to 
ensure these changes were reasonable and fair. On the rebasing policy, 
MedPAC recommended we fully implement these changes in 2011. To ensure 
providers could adapt to the new payment rates, the Senate bill phases-
in the changes over 4 years. The home health providers support this 
phase-in.
  The outlier policy and fraud changes were actually suggested by the 
home health industry. The home health industry fully supports these 
changes. For the productivity changes, the Senate bill holds off on 
applying these reductions while the rebasing policy is taking effect.
  This will give providers extra time to adapt to the payment changes 
and is much less aggressive than the proposals put forth by MedPAC, the 
House bill and the administration, which require all of these payment 
changes to be implemented at the same time.
  Finally, the Senate bill includes special protections for rural home 
health providers. From 2010--2015, rural providers will receive a 3 
percent extra payment each year. This payment will ensure that rural 
providers are protected as we reform the broader home health system. In 
total, the Medicare delivery reforms in the Senate bill strike a fair 
balance between ensuring seniors have access to care, while also 
rooting out inappropriate payments from the system.
  The opponents of these Medicare changes do not have a plan to protect 
seniors and strengthen the Medicare

[[Page 29546]]

Program. They advocate doing nothing. The opponents of health reform 
are now claiming that Medicare beneficiaries will be harmed by this 
bill. And here is what AARP--for example--has said about these claims:
  AARP:

       Opponents of health reform won't rest. [They are] using 
     myths and misinformation to distort the truth and wrongly 
     suggesting that Medicare will be harmed. After a lifetime of 
     hard work, don't seniors deserve better?

  I would like to remind my colleagues of the positive changes in the 
bill. It improves the solvency of the Medicare Program by 5 years. It 
puts $30 billion back into the pockets of seniors in the form of lower 
Medicare premiums. It makes prescription drugs more affordable. It 
guarantees that seniors can continue to see the doctor of their 
choosing. It provides free wellness and prevention benefits to Medicare 
beneficiaries. And it also includes fair and appropriate changes for 
home health that protect access to care.
  The truth is the Johanns amendment is harming seniors, harming the 
Medicare Program, and harming taxpayers. For this reason, I urge my 
colleagues to oppose the amendment by Senator Johanns and to support my 
home health amendment which ensures that no beneficiary would receive a 
reduction in their guaranteed Medicare home health benefit.
  I just listened to my friend, Senator Grassley. He and I have a good 
relationship; we work together here; we both serve on the Finance 
Committee. I have enjoyed a lot of the things we do together. Clearly, 
whatever I am saying is going to be substantive, but there is nothing 
personal in it. I have to say there is a lack of reality here in a lot 
of the comments we are hearing from our friends on the other side of 
the aisle, and a persistance in perpetuating a myth.
  A lot have seen the politics of this country where, if you say 
something over and over, no matter how true it is, it can have an 
impact. I know that personally. But let me tell you, I heard the 
Senator from Iowa say--I am going to quote him; I wrote it down:

       Certainly if $450 billion is being taken out of Medicare, 
     it is hurting Medicare.

  That is what he said. Let me review what is happening here. I want to 
go back to the comments of the Republican nominee for President last 
year. This is a quote. John McCain, from an article in the Wall Street 
Journal:

       John McCain would pay for his health care plan with major 
     reductions to Medicare and Medicaid, a top aide said, in a 
     move that independent analysts estimate could result in cuts 
     of $1.3 trillion.

  After I said that on the floor, the Senator from North Carolina, 
Senator Burr, stood up and said:

       Have you seen factcheck.org?

  I said I haven't read the specific article but we didn't see that 
corrected in the course of the campaign.
  Now I have seen the article. I wanted to know what the Senator from 
North Carolina was referring to, so I went and got factcheck.org. 
Factcheck.org went through the Obama campaign ads and their ads and 
fact checked what was being said. The McCain adviser is a fellow named 
Holtz-Eakin. In a conference call with reporters after the ad was 
released, what he said was:

       No service is being reduced. Every beneficiary will in the 
     future receive exactly the benefits that they have been 
     promised from the beginning.

  That is the same thing as we are doing. No benefit is being cut. But 
he didn't say he was not going to reduce the overall amount of money. 
What he said subsequently, and I am quoting from factcheck.org--here it 
is as late as October 17, about 2 weeks before the election--Mr. Holtz-
Eakin said in a telephone conference call with reporters, representing 
the campaign for the Republican party:

       Any shortfall in McCain's health care plan will be covered 
     without cutting benefits by such measures as Medicare fraud 
     and abuse reduction, employing a new generation of treatment 
     models for expensive chronic diseases, speeding adoption of 
     low-cost generic drugs, and expanding the use of information 
     technology in medicine.

  That is exactly some of which is happening right here--some of which 
is happening right here.
  Let's get this conversation into a place of reality. Here is what 
happened in arriving at the reductions in overall Medicare 
expenditures, which does not reduce any benefit to any senior citizen, 
which is why AARP, that represents 40 million senior citizens, is 
supporting the Democratic legislation. They have written that to us as 
late as yesterday.
  Madam President, $120 billion comes from reducing overpayments in 
Medicare. Someone on the other side of the aisle has to explain to me 
how you hurt Medicare by stopping the charging of a $90 overprice of 
premium to seniors, which is what happens. Do you know how the 
overpayments are paid for? Every senior couple, in a traditional 
Medicare plan, pays an additional $90 per year in order to finance the 
overpayments. What they are suggesting is, we shouldn't cut 
overpayments. What they are suggesting is, Medicare is OK, paying 
seniors in a certain group an overpayment that doesn't even go to the 
seniors. Guess whom it goes to. It goes to the insurance company. Are 
you telling me we ought to go to the taxpayers and say: Hey, folks, we 
know we are paying a 14-percent overpayment for the service compared to 
what we pay for everybody else and we are going to keep on paying it. 
That is exactly what our friends on the other side of the aisle are 
saying.
  What we are saying is: No, we think we ought to reduce that payment, 
and that is the $120 billion. That doesn't cut one benefit for a 
senior, but it makes the program more effective.
  Let me go further. Here are the people who have come together in a 
series of meetings to say: Yes, we can live with a reduction in our 
overall Medicare payment because we can be more efficient. The 
hospitals came to the White House and said: We are willing to reduce 
the payments we are receiving by $150 billion. Guess what. We are not 
even doing that. We are only asking them to reduce their payments by 
$106 billion. That is what is in this bill. The hospitals have agreed. 
I represent hospitals in Massachusetts. We have one of the best 
hospital systems in America in the network of hospitals we have. People 
come from all over the world to come to our hospitals. I see the 
Senator from Minnesota. They come from all over the world to go to some 
of the hospitals Minnesota has. The fact is, those hospitals agree we 
can do this more efficiently, and we can reduce the overall payments 
under Medicare. We have worked very hard to protect the way we do that 
so it doesn't do injury.
  The insurers have come to the table. Home health care came to the 
table. I read the letter earlier from home health care services. It is 
from the President of the National Association for Home Care & Hospice. 
He writes: We support the provisions of your health care reform 
legislation as they relate to home health care. That is what we are 
debating on the floor. They do support it.
  The fact is, the Senator from Georgia, who stood and said: In our 
State, we have a letter that says--well, first of all, that is based on 
an earlier assumption. Secondly, we have no idea what the assumptions 
are in the analysis they made. Thirdly, it is based primarily on the 
House bill, which has $13 billion more in reductions than we have. So 
before we get stuck there, we ought to listen to the national 
association that is working with us on a daily basis, where we agree on 
what the reductions ought to be.
  The skilled nursing facilities, the rehab facilities, the long-term 
acute care hospitals have all come to the table and said: We can do 
this. Is that their preference? Do they love it? Nobody wants their 
budget to be tightened, where they have to make changes to try to be 
more effective. But the bottom line is, every single one of them has 
agreed with what we are doing on this side of the aisle. 
Notwithstanding that, our friends on the other side of the aisle keep 
coming back and keep trying to stand for grandma or stand for some 
senior citizen who is being falsely scared into believing their benefit 
is going to be cut or that Medicare is somehow going to be less 
available to them.
  My amendment, which we will ultimately vote on, will guarantee that 
no

[[Page 29547]]

benefit is going to be cut for any senior under this plan. That is what 
we are going to do.
  In addition to that, let me remind my colleagues and people listening 
what this bill does. This bill actually improves the solvency of 
Medicare. We have heard any number of people say Medicare is going to 
go bankrupt by 2017. Indeed, it is. We stretch that out. We improve 
that so we can then take the improvements in the health care system----
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. KERRY. I yield myself an additional couple of minutes.
  It improves the solvency of the Medicare program by 5 years. It puts 
$30 billion back into the pockets of seniors in the form of lower 
Medicare premiums. It makes prescription drugs more affordable. It 
guarantees that seniors can continue to see the doctor of their choice. 
It provides free wellness and prevention benefits to Medicare 
beneficiaries. They are busy talking about the cuts, when this actually 
improves what Medicare beneficiaries are going to get. They don't have 
wellness and prevention benefits today. It provides for them.
  It guarantees they will see the doctor of their choice. It actually 
puts $30 billion back into their pockets, and it also includes fair and 
appropriate changes for home health that actually protects access to 
health care.
  The truth is, the Johanns amendment is the amendment that actually 
would wind up hurting seniors. This amendment provides additional 
benefits. We all understand the importance of this. The Senate bill 
releases home health care payments so those payments actually reflect 
the real cost of providing care. We do that not in a partisan way. We 
do that based on the nonpartisan MedPAC commission recommendations to 
us of how you can improve Medicare.
  Our colleagues have a long way to go on the other side to begin to 
talk about real health care change. This bill roots out fraud from the 
system, revises how Medicare pays for the outlier cases; that is, the 
cases that treat the sicker or what we call outlier patients. 
Unfortunately, GAO found some providers were gaming the system and 
getting more outlier payments than they deserve. Do they want us to 
continue to overpay people, providing service that people either don't 
need or charging more for the service that they do need but could have 
gotten at a lower price? Those are the changes we make. The American 
people will be proud of it.
  Let me give an example. The GAO found that in a Florida county, 
providers were receiving 60 percent of all the other outlier payments, 
even though the county had less than 1 percent of the total Medicare 
population. That is absurd. What we do is fix those kinds of 
absurdities that make Americans so angry about the administration of 
their tax dollars in Washington.
  I believe the Senate bill addresses a number of these problems in a 
thoughtful way.
  We need to have a debate about what is in this bill and what the real 
impacts are and what the negative impacts are of not doing these 
things. Our colleagues stand for the status quo. This is going to be 
historic when we pass it because it is going to benefit people in so 
many different ways, getting rid of preexisting condition restraints, 
not having people kicked off insurance they thought they had but when 
they get sick, they find it is gone. We end that. We get 31 billion 
more people covered in a way that spreads the risk of being sick in a 
sensible way and reduces the costs for other Americans. That is common 
sense. I am proud of what we are doing.
  The PRESIDING OFFICER. The Senator from Arizona.
  Mr. McCAIN. Madam President, as much as I would like to put the last 
Presidential campaign behind me, we seem to be continuing to dredge it 
up in a totally false manner, time after time.
  I ask unanimous consent that my campaign position paper on a specific 
plan of action lowering health care costs be printed in the Record.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

         A Specific Plan of Action: Lowering Health Care Costs

       John McCain Proposes a Number of Initiatives That Can Lower 
     Health Care Costs. If we act today, we can lower health care 
     costs for families through common-sense initiatives. Within a 
     decade, health spending will comprise twenty percent of our 
     economy. This is taking an increasing toll on America's 
     families and small businesses. Even Senators Clinton and 
     Obama recognize the pressure skyrocketing health costs place 
     on small business when they exempt small businesses from 
     their employer mandate plans.
       Cheaper Drugs: Lowering Drug Prices. John McCain will look 
     to bring greater competition to our drug markets through safe 
     re-importation of drugs and faster introduction of generic 
     drugs.
       Chronic Disease: Providing Quality, Cheaper Care For 
     Chronic Disease. Chronic conditions account for three-
     quarters of the nation's annual health care bill. By 
     emphasizing prevention, early intervention, healthy habits, 
     new treatment models, new public health infrastructure and 
     the use of information technology, we can reduce health care 
     costs. We should dedicate more federal research to caring and 
     curing chronic disease.
       Coordinated Care: Promoting Coordinated Care. Coordinated 
     care--with providers collaborating to produce the best health 
     care--offers better outcomes at lower cost. We should pay a 
     single bill for high-quality disease care which will make 
     every single provider accountable and responsive to the 
     patients' needs.
       Greater Access and Convenience: Expanding Access To Health 
     Care. Families place a high value on quickly getting simple 
     care. Government should promote greater access through walk-
     in clinics in retail outlets.
       Information Technology: Greater Use Of Information 
     Technology To Reduce Costs. We should promote the rapid 
     deployment of 21st century information systems and technology 
     that allows doctors to practice across state lines.
       Medicaid and Medicare: Reforming the Payment System To Cut 
     Costs. We must reform the payment systems in Medicaid and 
     Medicare to compensate providers for diagnosis, prevention 
     and care coordination. Medicaid and Medicare should not pay 
     for preventable medical errors or mismanagement. Medicare 
     should lead the way in health care reforms that improve 
     quality and lower costs. We need to change the way providers 
     are paid to move away from fragmented care and focus their 
     attention on prevention and coordinated care, especially for 
     those with chronic conditions. This is the utmost important 
     step in effectively caring for an aging population. We must 
     work in a bipartisan manner to reform the physician payment 
     system, focus efforts on eliminating fraud and move Medicare 
     into a new generation of coordinated, quality care.
       Smoking: Promoting the Availability of Cessation Programs. 
     Most smokers would love to quit but find it hard to do so. 
     Working with business and insurance companies to promote 
     availability, we can improve lives and reduce chronic disease 
     through smoking cessation programs.
       State Flexibility: Encouraging States To Lower Costs. 
     States should have the flexibility to experiment with 
     alternative forms of access, coordinated payments per episode 
     covered under Medicaid, use of private insurance in Medicaid, 
     alternative insurance policies and different licensing 
     schemes for providers.
       Tort Reform: Passing Medical Liability Reform. We must pass 
     medical liability reform that eliminates lawsuits directed at 
     doctors who follow clinical guidelines and adhere to safety 
     protocols. Every patient should have access to legal remedies 
     in cases of bad medical practice but that should not be an 
     invitation to endless, frivolous lawsuits.
       Transparency: Bringing Transparency To Health Care Costs. 
     We must make public more information on treatment options and 
     doctor records, and require transparency regarding medical 
     outcomes, quality of care, costs and prices. We must also 
     facilitate the development of national standards for 
     measuring and recording treatments and outcomes.

                Confronting the Long-Term Care Challenge

       John McCain Will Develop A Strategy For Meeting The 
     Challenge Of A Population Needing Greater Long-Term Care. 
     There have been a variety of state-based experiments such as 
     Cash and Counseling or The Program of All-Inclusive Care for 
     the Elderly (PACE) that are pioneering approaches for 
     delivering care to people in a home setting. Seniors are 
     given a monthly stipend which they can use to: hire workers 
     and purchase care-related services and goods. They can get 
     help managing their care by designating representatives, such 
     as relatives or friends, to help make decisions. It also 
     offers counseling and bookkeeping services to assist 
     consumers in handling their programmatic responsibilities.

[[Page 29548]]



     Setting the Record Straight: Covering Those With Pre-Existing 
                               Conditions

       Myth: Some claim that under John McCain's plan, those with 
     pre-existing conditions would be denied insurance.
       Fact: John McCain Supported The Health Insurance 
     Portability And Accountability Act In 1996 That Took The 
     Important Step Of Providing Some Protection Against Exclusion 
     Of Pre-Existing Conditions.
       Fact: Nothing In John McCain's Plan Changes The Fact That 
     If You Are Employed And Insured You Will Build Protection 
     Against The Cost Of Any Pre-Existing Condition.
       Fact: As President, John McCain Would Work With Governors 
     To Find The Solutions Necessary To Ensure Those With Pre-
     Existing Conditions Are Able To Easily Access Care.

  Mr. McCAIN. Then I ask unanimous consent to have printed in the 
Record a statement from FactCheck.org, of October 20, 2008, that says: 
``Obama's False Medicare Claim,'' which were the attacks on me which 
were not based on fact. I quote from FactCheck.org:

       These claims are false, and based on a single newspaper 
     report that says no such thing. McCain's policy director 
     states unequivocally that no benefit cuts are envisioned. 
     McCain does propose substantial ``savings'' . . .

  I did propose savings, and we can make savings. Nowhere in my wildest 
imagination did I ever believe we were going to cut benefits in order 
to create a $2.5 trillion new entitlement program when the system is 
already going broke. I will have those put in the Record.
  Mr. KERRY. Reserving the right to object----
  Mr. McCAIN. The Senator from Massachusetts wants to distort my 
record, and that is fine. But it gets a little----
  The PRESIDING OFFICER. Is there objection to having the document 
printed in the Record?
  Mr. McCAIN. As Ronald Reagan once said: Facts are stubborn things.
  Mr. KERRY. Madam President, I am not going to object to putting 
something important in, but I would like my colleague to stay for a 
moment because this is very important.
  Mr. GRASSLEY. Regular order.
  The PRESIDING OFFICER. The majority's time has expired.
  The Senator from Iowa.
  Mr. GRASSLEY. I yield the remaining time on our side to Senator 
Thune.
  Mr. KERRY. I have objected to a statement being put in unless I have 
a chance to explain it.
  The PRESIDING OFFICER. Objection is heard.
  Mr. McCAIN. I ask unanimous consent that the Senator from 
Massachusetts be allowed 3 additional minutes and I be allowed 2 
additional minutes.
  The PRESIDING OFFICER. Is there objection?
  The Senator from Massachusetts.
  Mr. KERRY. I thank my friend from Arizona because this is the way the 
Senate ought to work. I totally agree with what the Senator said. I 
want the Senator to know I agree with him. He is correct that the 
statement in FactCheck.org calls the Obama campaign to account for a 
misstatement about his proposal. I agree. It did that. It did not 
recommend a reduction in benefits. But that is not what I suggested 
that it did. What I am talking about is, the Senator said--and his 
staff insisted--he could get the savings for his reductions that would 
benefit Medicare from waste, fraud, and abuse from new treatment 
models, from expanding the use of information technology and that there 
is a complete similarity between what we are doing in order to achieve 
these savings and what he was doing. I am trying to point out the 
similarity, not the difference. I am not here to debate the campaign 
ad. I think it didn't accurately reflect the Senator's position. But do 
I believe, if you read the whole article, which is why I will not 
object to it being put in there, you will see it clearly says he is 
supportive of savings in Medicare, so you can do it without cutting 
benefits, which is exactly what we are doing.
  I yield the floor and thank my colleague for his courtesy.
  The PRESIDING OFFICER. The Senator from Arizona.
  Mr. McCAIN. Madam President, I thank the Senator from Massachusetts. 
This has been a vigorous debate. I see my prime adversary, the Senator 
from Illinois, on the floor, whom I look forward to doing battle with 
additionally, as well as my friend from Massachusetts. The fundamental 
point, I would say to my friend from Massachusetts, is that I never 
envisioned, nor do I believe the American people ever envisioned, we 
would be ``cutting'' benefits or, as the Senator says, making savings 
in order to transfer that to a brand new entitlement program. That is 
what the debate is about, whether we are going to take a failing system 
that in 7 years is going bankrupt, according to the Medicare trustees, 
and then take all this money, no matter how these savings are made--and 
I believe they are cuts of huge magnitude--and then fund a brandnew 
entitlement program.
  That is what this real debate is about.
  I thank my friend from Massachusetts for his courtesy. I look forward 
to the rebuttal from the Senator from Illinois, as well as the Senator 
from Montana. Thank you.
  I yield the floor.
  Several Senators addressed the Chair.
  The PRESIDING OFFICER. The Chair is in doubt.
  Mr. BAUCUS. Madam President, I suggest the Senator from Iowa be 
recognized.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Madam President, I yield the remainder of the time to 
the Senator from South Dakota.
  The PRESIDING OFFICER. The Senator from South Dakota.
  Mr. THUNE. Madam President, this is a great discussion. I have to say 
the fundamental point in this discussion should not be lost on anybody 
in this Chamber or on the American people; that is, whatever was said 
during the course of the campaign last year was said in the context of 
protecting and preserving and prolonging the lifespan of Medicare.
  Senator McCain is very accurate in the way he describes his position. 
But the American people need to understand what the other side is 
proposing: a $2.5 trillion expansion of the Federal Government, 
financed with $\1/2\ trillion in Medicare cuts in the first 10 years 
and, as the Senator from New Hampshire said, $3 trillion in the first 
two decades of this program--which does nothing to extend the lifespan 
of Medicare by 1 day, nothing. What it does is it creates an entirely 
new entitlement program that is going to be paid for by future 
generations of Americans.
  So Medicare, which is destined to be bankrupt by 2017--is sitting out 
there floundering with this huge unfunded liability. It is going 
bankrupt. What we are talking about doing is piling a $2.5 trillion new 
entitlement program on top of that. That is what this debate is about.
  They can say these Medicare cuts are not real. But we have 11 million 
people in this country who get Medicare Advantage benefits, and if 
there is going to be $118 billion cut, somebody is going to feel some 
pain. Surely, you jest when you say these cuts are not going to hurt 
anybody. Hospitals, home health agencies--$15 billion out of nursing 
homes.
  In the State of South Dakota, home health care agencies, like they do 
in Montana, provide services to people in rural areas. Some home care 
specialists have to travel 50 or 60 miles to serve a patient in their 
home. What we are talking about doing is cutting, in my State, $35 
million out of home health care. These cuts are $\1/2\ trillion. Of 
course, somebody gets hurt by that.
  But what is probably most troubling of all, I guess, about the whole 
proposal the other side has made is, after all that--cutting Medicare, 
raising taxes--at the end of the day 90 percent of the people in this 
country either have their health insurance premiums stay the same or go 
up--over 6 percent if you are in the small-employer market, 5 percent 
if you are in the large-
employer market--double the rate of inflation. That does not change 
anything.
  If you are a family today, and you are paying $13,000 for health care 
insurance--this is according to the Congressional Budget Office--in 
2016 you will be paying over $20,000 a year for health insurance. That 
is a $7,000 increase. Now, tell me how that reforms or helps anybody in 
this country?

[[Page 29549]]

  I want to show you how far we have come because the President said, 
in 2007, when he was campaigning: When I become President, we will have 
a health care reform bill that reduces premiums for people in this 
country by $2,500 per family and covers everybody. We all know this 
bill leaves 24 million people uncovered, according to the Congressional 
Budget Office. It raises premiums by 10 to 13 percent for everybody who 
buys in the individual marketplace. It keeps them the same--and when I 
say ``the same,'' there will be yearly increases of 5 to 6 percent year 
over year for this foreseeable future--for everybody else.
  The best you can hope for, America--90 percent of America--is the 
status quo. That is the best you can hope for under this bill. How does 
that change the status quo? How is that reform? You can call this an 
overhaul. You can call this a takeover. You can call it lots of things. 
But it is not reform because when the American people think about 
reform, they are thinking about something that drives their health care 
costs down not up.
  The Congressional Budget Office has said that under this bill, health 
care costs in this country will go up by $160 billion over the first 10 
years, not down. If you are 90 percent of Americans, you stay the same 
or your premiums--at worst--go up by 10 to 13 percent. That is 
according to the Congressional Budget Office.
  So I want to point out how far this debate has evolved from what the 
goals were in the first place. I have some comments some of my 
colleagues have made. Senator Stabenow said:

       High health care costs are causing cuts in benefits and 
     increases in premiums, adding to the ranks of the uninsured 
     at alarming rates. But the impact of this problem goes beyond 
     individual families. Skyrocketing health care costs make our 
     businesses less competitive in the global marketplace and 
     cost us good-paying jobs.

  This is about jobs, and this proposal does nothing to help small 
businesses create jobs. It kills jobs. That is why the National 
Federation of Independent Business, the Chamber of Commerce, the 
National Association of Wholesalers and Distributors--all the major 
business organizations--are opposed to this legislation. They know the 
impact it will have on jobs.
  I want to read one final quote. This does not come from a business 
organization. This comes from the dean of the Harvard Medical School. 
This was in an op-ed just recently in the Wall Street Journal:

       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. . . . 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.

  That is from the dean of the Harvard Medical School. He goes on to 
say:

       This will make an eventual solution even more difficult.

  So these Medicare cuts are real. They are $\1/2\ trillion in the 
first 10 years. As the Senator from New Hampshire has said, $3 trillion 
over the first two decades. It cuts Medicare Advantage. There are 11 
million seniors in this country who get Medicare Advantage. So do not 
say they are not going to get hurt. Their benefits are going to go 
down. Of course they are going to get hurt.
  Home health agencies, nursing homes, hospices--as I said, in my State 
of South Dakota, home health care delivery will feel an impact of $35 
million in an area of the country where we have vast distances in 
geography and where we already have home health agencies closing up 
shop because the reimbursements do not keep up with the costs, 
particularly when you have to travel the distances we have to in our 
States. If you have to put them in the hospital, the costs go up by 
multiples. It is so much more efficient to have somebody served in a 
home health setting rather than have them stay overnight in a hospital 
or staying successive nights in a hospital.
  So this is not reform. This actually keeps costs the same or drives 
them up for 90 percent of Americans. It does nothing to preserve the 
lifespan----
  The PRESIDING OFFICER. The minority's time has expired.
  Mr. THUNE. I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Madam President, I ask unanimous consent that 10 more 
minutes of debate be allowed, evenly divided.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BAUCUS. Hearing no objection?
  The PRESIDING OFFICER. Yes, without objection, it is so ordered.
  Mr. BAUCUS. Madam President, I would just like to state as clearly as 
I possibly can, so people understand, the Medicare savings are being 
used for Medicare. There is a strong implication by many Senators that 
the savings are not going to be used for Medicare, that it will go 
someplace else. That is not true. The Medicare savings are going to be 
used for Medicare.
  What are the savings? I think all Senators would like to reduce 
waste. All Senators agree there is too much waste in the current 
system. It makes good sense to try to attack that waste, root out that 
waste, and where there are overexpenditures, to try to get the levels 
down to a reasonable level. Everybody knows we have spent too many 
dollars on Medicare Advantage. Everybody knows that. That is why we are 
bringing that cost down.
  There is also waste and fraud--I know my good friend from South 
Dakota understands this--in home health care agencies. In the State of 
Florida, for example, the Government Accountability Office showed that 
in Florida 60 percent of the outlier payments--the extra money that 
goes for sicker patients--were in one county. That county has 1 percent 
of seniors. It had 60 percent of the outlier payments, according to the 
Government Accountability Office. That is fraud. They rooted out a lot 
of fraud in home health.
  Home health is very good. My mother is in home health right now. It 
works really well. I am very proud of the home health caretaker there 
who takes care of my mother. But we are reducing some of the 
overpayments. We are getting the waste out. And guess what. Those 
savings, where do they go? They go back into Medicare. I repeat that. 
They go back into Medicare. I do not know if any Senator wants to open 
up his ears or her ears and hear that. They go back into Medicare. 
Guess what. That is why the solvency of the Medicare trust fund is 
extended.
  If these so-called cuts, which we hear about on the other side, were 
really cuts, as implied by the other side, you would think that would 
hurt Medicare. You would think that might reduce the period in which 
the trust fund would be solvent; that it would go insolvent at an 
earlier time, if we were really cutting Medicare. No, it is the 
opposite. These are savings in Medicare which extend the life of 
Medicare.
  Please, please--I see my friend from Iowa. I think he understands, 
these Medicare savings go into Medicare for extending the solvency of 
the Medicare trust fund. I see my friend from South Dakota. I think he 
understands--he is sitting there and grinning at me now-- I think he 
understands those savings go back into Medicare and extend the solvency 
of the trust fund. So let's make that very clear.
  Second, we are using some of the money to reduce Part B premiums. 
That helps seniors. If Part B premiums are reduced, that helps seniors. 
By how much? Madam President, $30 billion over 10 years. That will 
reduce seniors' Part B premiums. That helps seniors. We are not taking 
money away from seniors; we are helping seniors, giving more dollars to 
seniors in this legislation.
  In addition, there are additional benefits for seniors in this 
legislation. We are starting to close the doughnut hole--that is 
something seniors talk about--in prescription drug benefits. They want 
that doughnut hole closed.
  I might add to that, there are other benefits: new preventive 
benefits under Medicare for mammograms, preventive screenings, 
colonoscopies, annual wellness visits--all new benefits.
  So I want to make it very clear that it is not true when some 
Senators say

[[Page 29550]]

we are taking money away from Medicare and creating a whole new 
entitlement program. We are not taking money away from Medicare and 
hurting seniors. We are reforming how dollars are paid, taking the 
waste out, and extra, excessive payments, and putting the money back 
into Medicare, back for seniors, back for beneficiaries.
  Also, not one penny of guaranteed benefits will be cut. Not one penny 
can be cut. So please, people, understand that the savings go to help 
seniors, with more benefits, extending the solvency of the trust fund. 
That is what we are doing. If we keep that firm point in mind, then 
maybe we can go address some of the next steps that are in this bill. 
But that is very important.
  Madam President, I do not know how much time I have.
  The PRESIDING OFFICER. The Senator has 16 seconds.
  Mr. BAUCUS. Madam President, he can probably extend a little bit. I 
see the Senator from Minnesota anxiously sitting over there in the 
corner. Maybe we could give him a couple----
  Mr. FRANKEN. Madam President, I will just take the 16 seconds.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. FRANKEN. I do have the microphone, and I thank you for the 16 
seconds.
  I would like to now--oh, I have used it up.
  I yield my time.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. ENZI. Madam President, first, I ask unanimous consent that an 
article that was discussed earlier and had some objection to it--but 
that objection has been resolved now--from FactCheck.org be printed in 
the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                      Obama's False Medicare Claim

                          (By Brooks Jackson)


                                Summary

       In a TV ad and in speeches, Obama is making bogus claims 
     that McCain plans to cut $880 billion from Medicare spending 
     and to reduce benefits.
       A TV spot says McCain's plan requires ``cuts in benefits, 
     eligibility or both.''
       Obama said in a speech that McCain plans ``cuts'' that 
     would force seniors to ``pay more for your drugs, receive 
     fewer services, and get lower quality care.''
       Update, Oct. 21: A second Obama ad claims that McCain's 
     plan would bring about a 22 percent cut in benefits, ``higher 
     premiums and co-pays,'' and more expensive prescription 
     drugs.
       These claims are false, and based on a single newspaper 
     report that says no such thing. McCain's policy director 
     states unequivocally that no benefit cuts are envisioned. 
     McCain does propose substantial ``savings'' through such 
     means as cutting fraud, increased use of information 
     technology in medicine and better handling of expensive 
     chronic diseases. Obama himself proposes some of the same 
     cost-saving measures. We're skeptical that either candidate 
     can deliver the savings they promise, but that's no basis for 
     Obama to accuse McCain of planning huge benefit cuts.


                                Analysis

       The Obama campaign began the Medicare assault with a 30-
     second TV ad released Oct. 17, which it said would run 
     ``across the country in key states.''
       Announcer. John McCain's health care plan . . . first we 
     learned he's going to tax health care benefits to pay for 
     part of it.
       Now the Wall Street Journal reports John McCain would pay 
     for the rest of his health care plan ``with major reductions 
     to Medicare and Medicaid.''
       Eight hundred and eighty-two billion from Medicare alone. 
     ``Requiring cuts in benefits, eligibility, or both.''
       John McCain . . . Taxing Health Benefits . . . Cutting 
     Medicare. We Can't Afford John McCain.
       Obama. I'm Barack Obama and I approved this message. The ad 
     quotes the Wall Street Journal as saying McCain would pay for 
     his health care plan with ``major reductions to Medicare and 
     Medicaid,'' which the ad says would total $882 billion from 
     Medicare alone, ``requiring cuts in benefits, eligibility, or 
     both.''
       Obama elaborated on the theme Oct. 18 in a stump speech in 
     St. Louis, Mo., claiming flatly that seniors would face major 
     medical hardships under McCain: ``Obama, Oct. 18: But it 
     turns out, Senator McCain would pay for part of his plan by 
     making drastic cuts in Medicare--$882 billion worth. Under 
     his plan, if you count on Medicare, you would have fewer 
     places to get care, and less freedom to choose your doctors. 
     You'll pay more for your drugs, receive fewer services, and 
     get lower quality care.''
       Update, Oct. 21: A second and even more misleading Obama ad 
     begins: ``How will your golden years turn out?'' It states 
     flatly that McCain's plan would mean a 22 percent cut in 
     benefits, higher premiums, higher co-pays, and more expensive 
     prescription drugs, and claims that both nursing home care 
     and a patient's choice of doctor could be affected.
       As the narrator says that McCain's plan ``means a 22 
     percent cut in benefits,'' the ad displays a footnote citing 
     an Oct. 6 Wall Street Journal story as its authority.
       But, in fact, the Journal story makes no mention of any 22 
     percent reduction, or any reduction at all. To the contrary, 
     the story's only mention of what might happen to benefits is 
     a quote from McCain adviser Douglas Holtz-Eakin promising to 
     maintain ``the benefit package that has been promised.'' The 
     story quotes him as saying ``savings'' would come from 
     eliminating Medicare fraud and by reforming payment policies 
     to lower the overall cost of care.


                    Obama-Biden Ad: ``Golden Years''

       Obama. I'm Barack Obama and I approve this message.
       Announcer. How would your golden years turn out under John 
     McCain? His health care plan would cut Medicare by $800 
     billion. That means a 22% cut in benefits. Higher premiums 
     and co-pays. More expensive prescription drugs. Nursing home 
     care could suffer and so could your choice of doctor. After a 
     lifetime of work, seniors' health care shouldn't be a gamble. 
     John McCain's plan, it's not the change we need.
       The fact is that McCain has never proposed to cut Medicare 
     benefits, or Medicaid benefits either. Obama's claim is based 
     on a false reading of a single Wall Street Journal story, 
     amplified by a one-sided, partisan analysis that piles 
     speculation atop misinterpretation. The Journal story in turn 
     was based on an interview with McCain adviser Holtz-Eakin. He 
     said flatly in a conference call with reporters after the ad 
     was released, ``No service is being reduced. Every 
     beneficiary will in the future receive exactly the benefits 
     that they have been promised from the beginning.''


                    Twisting Facts to Scare Seniors

       Here's how Democrats cooked up their bogus $882 billion 
     claim.
       On Oct. 6, the Journal ran a story saying that McCain 
     planned to pay for his health care plan ``in part'' through 
     reduced Medicare and Medicaid spending, quoting Holtz-Eakin 
     as its authority. The Journal characterizes these reductions 
     as both ``cuts'' and ``savings.'' Importantly, Holtz-Eakin 
     did not say that any benefits would be cut, and the one 
     direct quote from him in the article makes clear that he's 
     talking about economies: ``Wall Street Journal, Oct. 6: Mr. 
     Holtz-Eakin said the Medicare and Medicaid changes would 
     improve the programs and eliminate fraud, but he didn't 
     detail where the cuts would come from. ``It's about giving 
     them the benefit package that has been promised to them by 
     law at lower cost,'' he said.''
       Holtz-Eakin complains that the Journal story was ``a 
     terrible characterization'' of McCain's intentions, but even 
     so it clearly quoted him as saying McCain planned on ``giving 
     [Medicare and Medicaid beneficiaries] the benefit package 
     that has been promised.''
       Nevertheless, a Democratic-leaning group quickly twisted 
     his quotes into a report with a headline stating that the 
     McCain plan ``requires deep benefit and eligibility cuts in 
     Medicare and Medicaid''--the opposite of what the Journal 
     quoted Holtz-Eakin as saying. The report was issued by the 
     Center for American Progress Action Fund, headed by John D. 
     Podesta, former chief of staff to Democratic President Bill 
     Clinton. The report's authors are a former Clinton 
     administration official, a former aid to Democratic Sen. Bob 
     Kerrey and a former aid to Democratic Sen. Barbara Mikulski.
       The first sentence said--quite incorrectly--that McCain 
     ``disclosed this week that he would cut $1.3 trillion from 
     Medicare and Medicaid to pay for his health care plan.'' 
     McCain said no such thing, and neither did Holtz-Eakin. The 
     Journal reporter cited a $1.3 trillion estimate of the amount 
     McCain would need to produce, over 10 years, to make his 
     health care plan ``budget neutral,'' as he promises to do. 
     The estimate comes not from McCain, but from the Urban-
     Brookings Tax Policy Center. McCain and Holtz- Eakin haven't 
     disputed that figure, but they haven't endorsed it either.
       Nevertheless, the report assumes McCain would divide $1.3 
     trillion in ``cuts'' proportionately between the two 
     programs, and comes up with this: ``The McCain plan will cut 
     $882 billion from the Medicare program, roughly 13 percent of 
     Medicare's projected spending over a 10-year period.'' And 
     with such a cut, the report concludes, Medicare spending 
     ``will not keep pace with inflation and enrollment growth--
     thereby requiring cuts in benefits, eligibility, or both.''


                        ``Savings'' vs. ``Cuts''

       For the record, Holtz-Eakin said in a telephone conference 
     call with reporters Oct. 17, after the ad was released, that 
     any shortfall in McCain's health care plan could be covered, 
     without cutting benefits, by such measures as reducing 
     ``Medicare fraud and

[[Page 29551]]

     abuse,'' employing ``a new generation of treatment models'' 
     for expensive chronic diseases, speeding adoption of low-cost 
     generic drugs, and expanding the use of information 
     technology in medicine.
       Interestingly, Obama proposes to pay for his own health 
     care plan in part through some of the same measures, 
     particularly expanded use of I.T. and better handling of 
     chronic disease. Whether either candidate can achieve the 
     huge savings they are promising is dubious at best. As 
     regular readers of FactCheck.org are aware, we're skeptical 
     of Obama's claim that he can achieve his promised $2,500 
     reduction in average health insurance premiums, for example.
       But achievable or not, ``savings'' are what McCain is 
     proposing. It's a rank distortion for Obama's ad to twist 
     that into a plan for ``cuts in benefits, eligibility or 
     both,'' and for Obama to claim in a speech that seniors will 
     ``receive fewer services, and get lower quality care.''
       Update, Oct. 21: The Center for American Progress Action 
     Fund issued a rebuttal to this article, claiming our analysis 
     is ``flawed,'' that this article ``relies solely on the 
     denials of McCain senior policy adviser Douglas Holtz-Eakin'' 
     and that we failed to conduct a ``thorough analysis of the 
     implications'' of McCain's health care proposals.
       We disagree. Our criticism of both Obama and American 
     Progress is that they themselves misinterpret and 
     misrepresent what Holtz-Eakin said to the Wall Street Journal 
     in the first place. He was quoted in the Journal, and stated 
     again to reporters in a conference call, that what McCain is 
     proposing is to reduce the costs borne by Medicare and 
     Medicaid, and that benefits will not be reduced. American 
     Progress simply ignores that clear statement in its analysis, 
     and the Obama ads take the extra step of telling seniors that 
     McCain plans to cut benefits, when McCain says the opposite.
       The American Progress argument rests on the idea that 
     because McCain has also promised to make his health care plan 
     budget neutral--neither raising nor cutting total federal 
     spending--and that because American Progress' analysis 
     concludes that he cannot achieve the savings that he claims, 
     that McCain therefore must be forced to break his promise not 
     to cut benefits.
       We are also skeptical that McCain can achieve such savings, 
     and we said so at the outset of our article. And we've twice 
     called into question the campaign's claim that its plan is 
     budget neutral. But it is false logic to conclude that 
     Medicare benefit cuts would be McCain's only option should 
     his promised savings fail to materialize. McCain could simply 
     run up the deficit. Or he could choose to water down his 
     health care plan to make it less expensive.
       It is certainly possible that McCain will break his promise 
     not to cut benefits, just as it is possible that Obama will 
     break his promise to raise taxes only on families making over 
     $250,000 a year. We have no crystal ball, and we don't 
     pretend we can predict the future. But for Obama or American 
     Progress to state as a matter of fact that McCain will be 
     forced to cut benefits, or that he is proposing any such 
     thing, is simply a falsehood designed to frighten elderly 
     voters.

  Mr. ENZI. Madam President, I yield 5 minutes to the Senator from 
Maine.
  The PRESIDING OFFICER. The Senator from Maine.
  Ms. COLLINS. Madam President, I thank the manager of the bill.
  I rise in support of the motion offered by my colleague from Nebraska 
to commit this bill in order to strike the more than $42 billion in 
cuts in the Medicare home health benefit.
  Madam President, you, too, come from a pretty rural State, so I know 
you understand just how important home health care is to the seniors in 
our States. Home health care has become an increasingly important part 
of our health care system. The highly skilled services and 
compassionate care that our Nation's home health agencies provide have 
helped to keep families together. They have enabled millions of our 
most frail and vulnerable senior citizens to avoid hospitals and 
nursing homes and, instead, to receive care just where they want to be, 
in the privacy, comfort, and security of their own homes.
  Moreover, by helping these individuals to avoid more costly 
institutional care, home health saves Medicare millions of dollars each 
year. That is why I find it so frustrating and so ironic that once 
again the Medicare home health benefit is under attack.
  The bill before us would cut payments to home health providers by 
more than $42 billion over the next 10 years. Moreover, these cuts are 
a double whammy because they come in addition to $7.5 billion worth of 
cuts that have been imposed by the Centers for Medicare and Medicaid 
Services through regulation.
  These cuts are particularly unfair and disproportionate for a program 
that costs Medicare less than $16 billion a year. That is simply not 
right, and it is certainly not in the interests of our Nation's seniors 
who rely on home health care in order to keep out of more expensive 
hospitals, nursing homes, and other institutions.
  The Medicare home health benefit has already taken a larger hit in 
spending over the past 10 years than any other Medicare benefit. In 
fact, home health as a share of Medicare spending has dropped from 8.7 
percent in 1997 to only 3.6 percent today.
  There was an excellent article in today's New York Times talking 
about the disproportionate impact this bill would have on home health 
care. As the reporter points out, under this legislation, home care 
would absorb a disproportionate share of the cuts. It currently 
accounts for 3.7 percent of the Medicare budget but would be required 
to absorb 10.2 percent of the savings from Medicare under the House 
bill and 9.4 percent of savings under the Senate bill. That does not 
make sense.
  Home health care has consistently proven to be a compassionate and 
cost-effective alternative to institutional care. In rural States where 
home health providers have to travel long distances to deliver care, 
the impact of these cuts will ultimately fall on our seniors because 
home health agencies simply will not be able to afford to serve seniors 
who are living in smaller communities off rural roads in isolated parts 
of our States.
  These deep cuts are completely counterproductive to our efforts to 
control overall health care costs. They also place the quality of home 
health services at risk, particularly given ever-rising staffing, 
transportation, and technology cuts.
  As our Nation faces the continuing challenges of caring for an aging 
population, now is not the time to be making such deep cuts in the 
Medicare home health benefit. I urge support for the motion to commit 
introduced by my friend and colleague from Nebraska.
  Thank you, Madam President.
  Mr. ENZI. Madam President, how much time do we have?
  The PRESIDING OFFICER. The minority time has expired.
  The Senator from Montana.
  Mr. BAUCUS. Madam President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. ENZI. I ask unanimous consent that the order for the quorum call 
be rescinded.
  The PRESIDING OFFICER. Is there objection?
  Mr. BAUCUS. As long as it is equally divided between the two sides.
  Mr. ENZI. That would be fine with me, and I would even allow the 
Senator from Minnesota to go first. I would use the same amount of time 
he uses.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. FRANKEN. How much time do I have? Two minutes.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. FRANKEN. Madam President, let me use the 16 seconds I had but use 
it in a better way, so maybe it won't be 2 minutes. I was going to talk 
about Senator Lincoln's amendment to limit tax benefits health 
insurance companies receive on salaries for CEOs, but let me just talk 
about the nature of this debate.
  My esteemed colleague from Arizona, Senator McCain, quoted Ronald 
Reagan saying facts are stubborn things. We just had my distinguished 
colleague from South Dakota say that this bill does not extend for 1 
day the solvency of Medicare. Well, according to the Office of the 
Actuary for the Centers for Medicare and Medicaid Services, it extends 
it for 5 years. Now, facts are either stubborn things or they aren't. 
The Actuary for CMS is either the Actuary for CMS or not. You can't 
have a debate such as this and throw things around. Facts are stubborn 
things. We are entitled to our own opinions. We are not entitled to our 
own facts. You cannot stand up here

[[Page 29552]]

and wave your arms and say this doesn't extend Medicare 1 minute, 1 
day, when the Actuary for Medicare says the bill extends it for 5 
years.
  I yield the floor.
  Mr. ENZI. Madam President, how much time do I have?
  The PRESIDING OFFICER. The Senator has no time.
  Mr. ENZI. Madam President, the agreement was that whatever time he 
took, our side would get.
  The PRESIDING OFFICER. The Senator would then have 2 minutes.
  Mr. ENZI. Thank you.
  Madam President, the first thing I wish to do is mention that some of 
these things are facts, particularly if you go to specific situations. 
In Wyoming, our home health care is a specific situation, and we have 
had letters pouring in. I have one here from the Home Health Care 
Alliance of Wyoming, and I ask unanimous consent that it be printed in 
the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                                  Home Health Care


                                          Alliance of Wyoming,

                                  Wheatland, WY, December 5, 2009.
     Senator Michael B. Enzi,
     Ranking Member, Committee on Health, Education, Labor & 
         Pensions, Hart Senate Office Building, Washington, DC.
       Dear Senator Enzi: Over the past ten years the Medicare 
     home health benefit has taken a larger hit in spending 
     reductions than any other benefit. As home health has become 
     an increasingly important part of our health care system with 
     highly skilled and often technically complex services that 
     enable millions of senior citizens and disabled Americans to 
     avoid being hospitalized or admitted to nursing homes, these 
     home health services save Medicare millions of dollars each 
     year.
       I believe that further reduction in home health payments 
     would place the quality and availability of home health 
     services at risk. I urge you to oppose the cut in Medicare 
     dollars for home health agencies throughout our nation.
           Sincerely,
                                                      Mari Irelan,
                                                        President.

  Mr. ENZI. Madam President, the letter says:

       Over the past 10 years the Medicare home health benefit has 
     taken a larger hit in spending reductions than any other 
     benefit. As home health has become an increasingly important 
     part of our health system with highly skilled and often 
     technically complex services that enable millions of senior 
     citizens and disabled Americans to avoid being hospitalized 
     or admitted to nursing homes, these home health services save 
     Medicare millions of dollars each year.
       I believe that further reduction in home health payments 
     will place the quality and availability of home health 
     services at risk. I urge you to oppose the cut in Medicare 
     dollars for home health agencies throughout our Nation.

  The New York Times today pointed out that in the Reid bill:

       Home care would absorb a disproportionate share of cuts. It 
     currently accounts for 3.7 percent of the Medicare budget, 
     but would account for 9.4 percent of the cuts in the Senate 
     bill according to the Congressional Budget Office.

  That is from the New York Times.
  The last time Congress made similar cuts was in the Balanced Budget 
Act in 1997 when about 15 percent of home health agencies ended their 
participation in Medicare. So there is a history on this that shows 
that if we do what we are talking about doing here, we will put people 
out of business and we will put an end to services to seniors and the 
more rural----
  Mr. BAUCUS. Madam President, if my good friend would allow me to 
interrupt to propound a unanimous consent agreement so Senators know 
when votes are going to come up, and then continue.
  Mr. ENZI. Sure.
  Mr. BAUCUS. Madam President, I ask unanimous consent that once this 
agreement is entered, it be in order for Senator Kerry or his designee 
to be recognized to offer the majority side-by-side to the Johanns 
motion; that the Senate proceed to vote in relation to the Kerry 
amendment; and that upon disposition of the Kerry amendment, the Senate 
then proceed to vote in relation to the Johanns motion; that no 
amendments be in order to the Kerry amendment or the Johanns motion; 
further, that upon disposition of the above-referenced amendment and 
motion, the Republican leader's designee be recognized to call up an 
amendment related to the Lincoln amendment No. 2905; further, that on 
Sunday, December 6, after the Senate has resumed consideration of H.R. 
3590, the time until 3:15 p.m. be for debate with respect to the 
Lincoln amendment No. 2905, and the Republican amendment identified 
above; with the time on Sunday equally divided and controlled, with 
Senators permitted to speak for up to 10 minutes each; that at 3:15 
p.m., the Senate proceed to vote in relation to the Lincoln amendment 
No. 2905; that upon disposition of amendment No. 2905, the Senate then 
proceed to vote in relation to the Republican amendment related to the 
Lincoln amendment; that all of the amendments and motions covered in 
this agreement be subject to an affirmative 60-vote threshold and that 
if any achieve it, then they be agreed to and the motion to reconsider 
be laid upon the table; that if they do not achieve that threshold, 
then they be withdrawn; that prior to the second votes covered in this 
agreement, there be 2 minutes of debate; that after the first vote, 
each succeeding vote covered here be limited to 10 minutes each; 
provided further that no other motion be in order, except a motion to 
reconsider a vote with respect to the above-referenced amendments and 
motion.
  The PRESIDING OFFICER. Is there objection?
  The Republican leader.
  Mr. McCONNELL. Reserving the right to object, and I will not be 
objecting, I also wish to make clear that the majority leader and I 
have an understanding that we will actually have four votes tomorrow--
not just two, four. Bearing that in mind, I do not object.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BAUCUS. Madam President, I might say, that is our understanding 
on this side as well.


                Amendment No. 2926 to Amendment No. 2786

  Mr. BAUCUS. Madam President, I call up the Kerry amendment which is 
at the desk and ask for the yeas and nays.
  The PRESIDING OFFICER. The clerk will report the amendment.
  The legislative clerk read as follows:

       The Senator from Montana [Mr. Baucus], for Mr. Kerry, 
     proposes an amendment numbered 2926.

  The amendment is as follows:

               (Purpose: To protect home health benefits)

       On page 869, between lines 14 and 15, insert the following:

     SEC. 3143. PROTECTING HOME HEALTH BENEFITS.

       Nothing in the provisions of, or amendments made by, this 
     Act shall result in the reduction of guaranteed home health 
     benefits under title XVIII of the Social Security Act.

  The PRESIDING OFFICER. The question is on agreeing to the amendment.
  The yeas and nays have been requested. Is there a sufficient second? 
There appears to be.
  The clerk will call the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. Byrd) 
is necessarily absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Kentucky (Mr. Bunning), the Senator from Oklahoma (Mr. Inhofe), 
and the Senator from South Carolina (Mr. Graham).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``yea.''
  The result was announced--yeas 96, nays 0, as follows:

                      [Rollcall Vote No. 363 Leg.]

                                YEAS--96

     Akaka
     Alexander
     Barrasso
     Baucus
     Bayh
     Begich
     Bennet
     Bennett
     Bingaman
     Bond
     Boxer
     Brown
     Brownback
     Burr
     Burris
     Cantwell
     Cardin
     Carper
     Casey
     Chambliss
     Coburn
     Cochran
     Collins
     Conrad
     Corker
     Cornyn
     Crapo
     DeMint
     Dodd
     Dorgan
     Durbin
     Ensign
     Enzi
     Feingold
     Feinstein
     Franken
     Gillibrand
     Grassley
     Gregg
     Hagan
     Harkin
     Hatch
     Hutchison
     Inouye
     Isakson
     Johanns
     Johnson
     Kaufman
     Kerry
     Kirk
     Klobuchar
     Kohl
     Kyl
     Landrieu
     Lautenberg
     Leahy
     LeMieux

[[Page 29553]]


     Levin
     Lieberman
     Lincoln
     Lugar
     McCain
     McCaskill
     McConnell
     Menendez
     Merkley
     Mikulski
     Murkowski
     Murray
     Nelson (NE)
     Nelson (FL)
     Pryor
     Reed
     Reid
     Risch
     Roberts
     Rockefeller
     Sanders
     Schumer
     Sessions
     Shaheen
     Shelby
     Snowe
     Specter
     Stabenow
     Tester
     Thune
     Udall (CO)
     Udall (NM)
     Vitter
     Voinovich
     Warner
     Webb
     Whitehouse
     Wicker
     Wyden

                             NOT VOTING--4

     Bunning
     Byrd
     Graham
     Inhofe
  The PRESIDING OFFICER. On this vote, the yeas are 96, the nays are 0. 
Under the previous order requiring 60 votes for the adoption of this 
amendment, the amendment is agreed to.
  Mr. LAUTENBERG. Mr. President, I move to reconsider the vote.
  Mr. BEGICH. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                            Motion to Commit

  The PRESIDING OFFICER. There will now be 2 minutes of debate equally 
divided on the Johanns motion to commit.
  The Senator from Montana.
  Mr. BAUCUS. Madam President, this is very simple. A vote for the 
Johanns amendment is a vote for the status quo. What does that mean? It 
means seniors will continue to pay higher and higher premiums, higher 
cost sharing due to wasteful overpayments. A vote against Johanns means 
we can extend the solvency of the Medicare trust fund that helps 
benefits.
  I think we are for seniors in this body. I urge a vote against 
Johanns.
  The PRESIDING OFFICER. The Senator from Maine.
  Ms. COLLINS. Madam President, home health care is the compassionate, 
cost-effective alternative to institutional care. It allows our seniors 
to receive care just where they want to be--in their own homes. Under 
this bill, home health care would take a disproportionate cut.
  Let me quote a home health care director in my State who sums up what 
the approach will be, what will happen if this motion is agreed to. She 
says:

       Our staff is scared, but it is our patients who will pay 
     the price if Congress makes cuts in home care.

  I urge support for the motion to commit offered by the Senator from 
Nebraska.
  Ms. COLLINS. I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. DURBIN. I announce that the Senator from West Virginia (Mr. 
Byrd), the Senator from Vermont (Mr. Leahy), and the Senator from 
Vermont (Mr. Sanders) are necessarily absent.
  Mr. KYL. The following Senators are necessarily absent: the Senator 
from Kentucky (Mr. Bunning), the Senator from Oklahoma (Mr. Inhofe), 
and the Senator from South Carolina (Mr. Graham).
  Further, if present and voting, the Senator from Kentucky (Mr. 
Bunning) would have voted ``yea.''
  The ACTING PRESIDENT pro tempore. Are there any other Senators in the 
Chamber desiring to vote?
  The result was announced--yeas 41, nays 53, as follows:

                      [Rollcall Vote No. 364 Leg.]

                                YEAS--41

     Alexander
     Barrasso
     Bayh
     Bennett
     Bond
     Brownback
     Burr
     Chambliss
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     DeMint
     Ensign
     Enzi
     Grassley
     Gregg
     Hatch
     Hutchison
     Isakson
     Johanns
     Kyl
     LeMieux
     Lincoln
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Risch
     Roberts
     Sessions
     Shelby
     Snowe
     Thune
     Vitter
     Voinovich
     Webb
     Wicker

                                NAYS--53

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

                             NOT VOTING--6

     Bunning
     Byrd
     Graham
     Inhofe
     Leahy
     Sanders
  The ACTING PRESIDENT pro tempore. On this vote, the yeas are 41, the 
nays are 53. Under the previous order requiring 60 votes for the 
adoption of this motion, the motion is withdrawn.
  Mr. DORGAN. Mr. President, I move to reconsider the vote and to lay 
that motion on the table.
  The motion to lay on the table was agreed to.
  The ACTING PRESIDENT pro tempore. The Senator from Nevada.


                Amendment No. 2927 to Amendment No. 2786

  Mr. ENSIGN. Mr. President, I have an amendment at the desk.
  The ACTING PRESIDENT pro tempore. The clerk will report the 
amendment.
  The bill clerk read as follows:

       The Senator from Nevada [Mr. Ensign] proposes an amendment 
     numbered 2927 to amendment No. 2786.

  Mr. ENSIGN. Mr. President, I ask unanimous consent to waive the 
reading of the amendment.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  The amendment is as follows:

       At the appropriate place, insert the following:

     SEC. _. LIMITATION ON AMOUNT OF ATTORNEY'S CONTINGENCY FEES.

       (a) In General.--An attorney who represents, on a 
     contingency fee basis, a plaintiff in a medical malpractice 
     liability action may not charge, demand, receive, or collect 
     for services rendered in connection with such action 
     (including the resolution of the claim that is the subject of 
     the action under any alternative dispute resolution system) 
     in excess of--
       (1) 33\1/3\ percent of the first $150,000 of the total 
     amount recovered by judgment or settlement in such action; 
     plus
       (2) 25 percent of any amount recovered in excess of the 
     first $150,000 recovered by such judgment or settlement,
     unless otherwise determined under State law. Such amount 
     shall be computed after deductions are made for all the 
     expenses associated with the claim other than those 
     attributable to the normal operating expenses of the 
     attorney.
       (b) Calculation of Periodic Payments.--In the event that a 
     judgment or settlement includes periodic or future payments 
     of damages, the amount recovered for purposes of calculating 
     the limitation on the contingency fee under subsection (a) 
     may, in the discretion of the court, be based on the cost of 
     the annuity or trust established to make the payments. In any 
     case in which an annuity or trust is not established to make 
     such payments, such amount shall be based on the present 
     value of the payments.
       (c) Definitions.--In this section:
       (1) Contingency fee.--The term ``contingency fee'' means 
     any fee for professional legal services which is, in whole or 
     in part, contingent upon the recovery of any amount of 
     damages, whether through judgment or settlement.
       (2) Health care professional.--The term ``health care 
     professional'' means any individual who provides health care 
     services in a State and who is required by the laws or 
     regulations of the State to be licensed or certified by the 
     State to provide such services in the State.
       (3) Health care provider.--The term ``health care 
     provider'' means any organization or institution that is 
     engaged in the delivery of health care services in a State 
     and that is required by the laws or regulations of the State 
     to be licensed or certified by the State to engage in the 
     delivery of such services in the State.
       (4) Medical malpractice liability action.--The term 
     ``medical malpractice liability action'' means a cause of 
     action brought in State or Federal court against a health 
     care provider or health care professional by which the 
     plaintiff alleges a medical malpractice claim.

  Mr. ENSIGN. Mr. President, the amendment I am offering is an 
amendment on medical liability reform. I believe meaningful medical 
liability reform should be included in any overall health care 
legislation that we do this year. I have a separate bill from this 
amendment, a complete comprehensive medical liability reform bill, 
which I introduced earlier, known as S. 45. In an effort to find a 
compromise, however, I am offering this amendment today.

[[Page 29554]]

  This amendment was originally offered by Senator Edward Kennedy back 
in 1995. While many Members of the Senate, including myself, were not 
here in 1995, 21 Members from the other side of the aisle were here at 
that time, and they supported this amendment. Those Members included: 
Senator Akaka, Senator Baucus, Senator Bingaman, Senator Boxer, Senator 
Byrd, Senator Conrad, Senator Dodd, Senator Dorgan, Senator Feingold, 
Senator Feinstein, Senator Harkin, Senator Inouye, Senator Kerry, 
Senator Kohl, Senator Lautenberg, Senator Leahy, Senator Levin, Senator 
Mikulski, Senator Murray, Senator Reid, and Senator Specter. I would 
hope these Members will today continue to support Senator Kennedy's 
amendment from 1995.
  Clearly, the issue of medical liability reform is even more pressing 
today than it was back in 1995. We, as Americans, spend more money on 
lawsuits than any other country in the world and more than twice as 
much as all but one other country. According to a recent nonpartisan 
study, the direct cost of health care lawsuits is around $30 billion a 
year. That is the direct cost to our health care system--around $30 
billion a year. These costs are multiplied by indirect costs, 
especially doctors ordering costly tests out of fear of being sued.
  Estimates of wasted money spent on unneeded tests range from over 
$100 billion a year annually to $250 billion a year annually. Let me 
repeat those numbers. The estimates range from $100 billion to $250 
billion annually in unnecessary tests conducted by doctors due to fear 
of lawsuits.
  In 2006, an article in the New England Journal of Medicine suggested 
that as much as 40 percent of medical liability lawsuits are without 
merit. Medical liability insurance premiums are threatening the 
stability of our Nation's health care system. These rates are forcing 
many physicians, hospitals, and other health care providers to move out 
of high-liability States, limit the scope of their practices, and even 
to close their doors permanently. This crisis is affecting more and 
more patients and is threatening access to reliable, quality health 
care services.
  I have a good friend in southern Nevada who practices obstetrics. In 
his practice, he specializes in high-risk pregnancies. Because of the 
medical liability problems we have seen in the past several years, his 
insurance company limits the number of high-risk pregnancies in which 
he can assist. So you have one of the best doctors practicing 
obstetrics who--because of fear of lawsuits by his insurance company--
is limited as to the number of high-risk pregnancies in which he can 
assist.
  If you are a woman with a high-risk pregnancy, it would seem to me 
you would want the best doctors to take care of you. That only makes 
sense. Because of the medical liability crisis we are facing in this 
country, however, the best of the best are limited to the number of 
cases they can handle. Because of unaffordable medical liability 
insurance premiums, it is now common for obstetricians to not even 
deliver babies and it is also common for other specialists to no longer 
provide emergency calls or to provide certain high-risk procedures.
  Ask yourself this question: What if you were in need of an emergency 
procedure; what if you were the woman who had a high-risk pregnancy and 
could not find a specialist to provide you with the care you needed?
  The medical liability crisis is threatening patient access to 
reliable quality health care services all over America. Additionally, 
costly medical liability insurance premiums have forced some emergency 
departments to shut down temporarily in recent years.
  In my home State of Nevada, our level I trauma center closed for 10 
days in 2002. This closure left every patient within a 10,000 square 
mile area unserved by a level I trauma center.
  Unfortunately, Jim Lawson was one of those in need of the trauma unit 
at that time. Jim lived in Las Vegas, and was just 1 month shy of his 
60th birthday. He had recently returned from visiting his daughter in 
California. When he returned, he was injured in a severe car accident.
  Jim should have been taken to University Medical Center's level I 
trauma center, but it was closed. Instead, Jim was taken to another 
emergency room, where he was to be stabilized and then transferred to 
Salt Lake City's trauma center. Tragically, Jim never made it that far. 
He died that day due to cardiac arrest caused by blunt force from 
physical trauma.
  Why was Nevada's only level I trauma center closed? Due to a simple 
fact: the doctors could not afford medical liability premiums, and 
there were not enough doctors to provide care. Ultimately, the State 
had to step in and take over the liability to reopen the trauma center.
  More than 35 percent of neurosurgeons have altered their emergency or 
trauma call coverage because of the medical liability crisis. This 
means that patients with head injuries or those who are in need of 
neurosurgical services must be transferred to other facilities, 
delaying much needed care.
  Dr. Alamo of Henderson, NV, brought another example of this problem 
to my attention. Dr. Alamo was presented with a teenager suffering from 
myasthenia gravis. She was in a crisis and in need of immediate medical 
treatment. Because of the medical liability situation, there was no 
emergency neurologist on call to assist this young woman.
  Dr. Alamo called several in the area, and none of them wanted to take 
her case because of the medical liability situation. So Dr. Alamo had 
the young woman transported to California by helicopter to receive the 
medical care she needed. Just imagine if that was your daughter or some 
close friend or relative. How would you feel?
  These kinds of situations should not happen and should not be forced 
to happen because of the medical liability crisis we have in America 
today. Stories such as these are all too common across our country.
  To address the growing medical liability crisis in my State of 
Nevada, the State enacted legislation that includes a cap on 
noneconomic damages and a cap on total damages for trauma care. Several 
other States have enacted similar reforms.
  This should not be a Republican or Democratic issue; this is 
fundamentally a patient issue. Simply put, the current medical 
liability crisis means patients cannot find access to care when they 
need it most in many areas.
  Without Federal legislation, the exodus of providers from the 
practice of medicine will continue, and patients will find it 
increasingly difficult to obtain needed care.
  As we work on a comprehensive healthcare reform bill, one of our 
primary goals must be to enact meaningful medical liability reform to 
help ensure patients access to care. As you know, President Obama 
addressed the entire Congress on health reform in September. During his 
speech, he said, ``I don't believe malpractice reform is a silver 
bullet, but I have talked to enough doctors to know that defensive 
medicine may be contributing to unnecessary costs.'' I think that is 
quite an understatement. Talk to health care providers. It drastically 
contributes to unnecessary costs, not just maybe contributes.
  The President went on to say that he has asked Secretary Sebelius to 
move forward on demonstration projects in individual States to test 
ways to put patient safety first and let doctors focus on practicing 
medicine.
  Let's face reality. There is no doubt that defensive medicine occurs 
every day and that the costs to the health care system are staggering. 
As I mentioned earlier, tens if not hundreds of billions of dollars are 
wasted every year due to the practice of defensive medicine, largely in 
an attempt to avoid frivolous, junk lawsuits.
  Just think of how many uninsured patients we could take care of with 
that money or how much cheaper premiums would be for those who have 
insurance. We must stop playing games and start doing something real to 
address this important healthcare issue.
  Unfortunately, the underlying bill does not meaningfully address 
medical liability reform--it only contains a toothless sense of the 
Senate. The Sense of the Senate notes that Congress should consider 
establishing a

[[Page 29555]]

State demonstration program to evaluate alternatives to the current 
civil litigation system.
  Let's be honest with ourselves. This is just windowdressing. The 
Sense of the Senate is just fluff. It ignores the substantial progress 
that many States have already made with medical liability reform. 
Capping noneconomic damage awards has been highly successful in a 
number of States, such as Texas and is something that should be part of 
health care reform.
  But, if we cannot reach a consensus on this, then we should at least 
follow Senator Kennedy's example and limit the amount of attorneys' 
contingency fees as an important first step.
  Let's do the right thing. Let's enact real medical liability reform.
  The amendment that I am proposing today would place reasonable limits 
on attorney's contingency fees in medical malpractice cases. The limit 
would be 33\1/3\ percent of the first $150,000 of the total amount 
recovered by the judgment or settlement. There would be a further limit 
of 25 percent of any amount recovered in excess of the first $150,000 
recovered by the judgment or settlement.
  While helping to reign in the cost of frivolous medical malpractice 
lawsuits, this amendment also ensures that States' rights are 
protected. This amendment explicitly allows States that have different 
fee limitations to keep them in place instead of these caps. This 
amendment ensures appropriate State flexibility while at the same time 
helping to improve access to care and reduce health care costs. Let me 
repeat. Back in 1995 when Senator Edward Kennedy offered this 
amendment, these 21 Senators, part of the Democratic majority, all 
voted for the Kennedy amendment.
  To be clear, my Medical Care Access Protection Act contains more 
detailed limitations on contingency fees than those contained in the 
amendment I am proposing today. But in the interest of finding a 
starting point on medical liability reform, I am willing to start off 
the debate by enacting Senator Kennedy's limitations first.
  By the way, the other side is going to say that the trial lawyers 
need this money to be able to take these cases. Let's face it, the 
trial lawyers are mostly the ones who get the money out of these cases. 
We want to make sure that money goes mostly to the patient. So when you 
see pictures put up by the other side, you will notice that my 
amendment would actually help those very patients who are in the 
pictures that those on the other side will put up.
  Medical liability reform works, and it is already turning the tide 
against frivolous lawsuits and outrageous jury awards in some States. 
We have seen it in California, in Texas and in my home State of Nevada, 
where the number of medical malpractice lawsuits has decreased 
drastically. It has been a crisis driving doctors out of business for 
too long. It is time to protect patients across the country and ensure 
access to quality health care.
  To illustrate my point, I would like to tell you about the success of 
medical liability reform in several States. First, take the example of 
Texas that passed medical liability reform in 2003.
  To begin with, access to health care has improved, with 18,252 new 
physicians coming to Texas. The number of high-risk medical specialists 
in Texas is growing. Since 2003, Texas has added 768 emergency medicine 
doctors, 481 heart doctors, 218 obstetricians, 212 orthopedic surgeons, 
and 48 neurosurgeons. These additions are not limited to metro Texas. 
The ranks of rural obstetricians have grown by 27 percent; 22 rural 
counties have added an obstetrician and ten counties have added their 
first OB; 23 rural counties have added at least one emergency medicine 
physician and 18 counties added their first ER doctor.
  In addition to improvements in access to health care, charity care 
has also greatly expanded due to medical liability reform. Today, Texas 
hospitals are rendering $594 million more in charity care annually than 
they were just 6 years ago. That is a 24 percent increase in charity 
care, which is due to liability savings.
  Liability savings in States across the country have allowed hospitals 
to: upgrade medical equipment; expand the emergency room; expand 
outpatient services; staff ER rooms 24/7 with high-risk specialists; 
improve salaries for nurses; and launch patient safety programs.
  Without reforms and the attendant savings, these healthy developments 
would not have been possible. Lawsuit reform has been a magnet for 
attracting doctors and the funding mechanism to improve access to care 
and enhance patient safety.
  Physicians have seen a decrease in their medical liability premiums. 
Since 2003, physicians in Texas have saved a collective $574 million on 
their liability premiums. Today, most Texas doctors are paying lower 
liability premiums than they were in 2001. All major physician 
liability carriers in Texas have cut their rates since the passage of 
the reforms, most by double digits. Texas physicians have seen their 
liability rates cut, on average, 27.6 percent. Eighty-five percent of 
Texas doctors have seen their rates slashed 30 percent or more. More 
than 43 percent of Texas doctors have seen their liability premiums 
reduced in half. Twenty-five rate cuts have occurred since the passage 
of the 2003 landmark reforms.
  In my home State of Nevada, limitations on noneconomic damages has 
helped to stabilize the medical liability climate and allowed the 
Independent Nevada Doctors Insurance Exchange to keep rates steady in 
2008, following a 20 percent decline in 2007. And rates stayed steady 
after years of increasing dramatically.
  In Mississippi reform in 2004 created a hard $500,000 limit on non-
economic damages. Since that law took effect, the number of medical 
malpractice lawsuits has fallen nearly 90 percent, which in turn has 
cut malpractice insurance costs by 30 percent to 45 percent, depending 
on the county.
  Ohio and West Virginia have also seen sizable reductions in frivolous 
lawsuits and as a result less costly medical liability insurance.
  These examples prove that lawsuit reform can improve access to care, 
expand the number of doctors and types of care that hospitals are able 
to offer, and help reduce medical costs.
  According to a conservative estimate by the Congressional Budget 
Office, if Congress adopted my full Medical Care Access Protection Act, 
the deficit would decrease by $54 billion over 10 years.
  It would also, according to the CBO, save the private sector about 
the same amount of money. So over $100 billion in savings that now goes 
to propping up a lot of frivolous lawsuits across the country.
  By the way, think about it. If you had medical malpractice committed 
against you, I believe you should have access to the courts. I believe 
you should be able to sue. I believe you should be able to get just 
compensation. The problem is now, because our courts are so clogged 
with all these frivolous lawsuits, it takes years if not up to a decade 
to be able to get through the court system. For many of these patients 
who were severely hurt--many of them die before the case is ever 
settled. That is another reason we need medical liability reform and we 
need it now.
  Let me tell you why I believe medical liability reform has been left 
out of this bill. Actually, I don't want to tell you why. Let me let 
Howard Dean tell you why. Howard Dean, obviously, is the former 
chairman of the Democratic National Committee. I am going to quote from 
him.

       [T]he reason why tort reform is not in the bill is because 
     the people who wrote it did not want to take on the trial 
     lawyers in addition to everybody else they were taking on, 
     and that is the plain and simple truth. Now, that's the 
     truth.

  That is a direct quote from Howard Dean, the former chairman of the 
Democratic National Committee.
  I hope as this debate unfolds many of my colleagues on the other side 
of the aisle will change their minds about enacting serious medical 
liability reform. I hope that at least these 21 Senators who voted for 
this amendment before will vote for it again when it comes to a vote 
tomorrow. This isn't a battle between the right and the left; it is a 
battle between right and wrong.

[[Page 29556]]

  This amendment is a helpful prescription for patients. I know many on 
the other side of the aisle would like to cap salaries of people who 
work in the health insurance industry. I hope these same Members would 
support this simple amendment to limit trial lawyers' contingency fees 
in a responsible manner.
  I urge adoption of the amendment and yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Illinois.
  Mr. DURBIN. Mr. President, I ask unanimous consent that upon the 
conclusion of the remarks of Senator Ensign, I be recognized for a 
period of time equal to that utilized by Senator Ensign; further, that 
upon the conclusion of my remarks, Members be recognized in an 
alternating fashion and that they be permitted to speak for up to 10 
minutes each; further, if any extensions of time are requested, the 
other side be accorded the same addition; further, that the Democratic 
speakers following me be as follows: Senators Franken, Lautenberg, 
Stabenow, Dodd, and Kaufman.
  The ACTING PRESIDENT pro tempore. Is there objection?
  Mr. ENZI. Reserving the right to object, and I will not, I wish to 
make a clarification that you wouldn't object to a couple of people 
without alternating so that we can have a couple of people who also go 
without alternating. Hopefully, we can make some arrangements on the 
time. I would like a provision that if one goes longer, the other side 
can go longer too. With that provision, I have no objection.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. DURBIN. Will the Chair inform me how much time the Senator from 
Nevada used?
  The ACTING PRESIDENT pro tempore. Twenty-one and a half minutes.
  Mr. DURBIN. I thank the Chair.
  Mr. President, this issue is very personal and very important. I know 
a little bit about this because many years ago, before coming to 
Congress, I was a trial lawyer. I spent many years defending doctors 
when they were sued for medical malpractice, and I spent as many years 
representing plaintiffs who claimed to be victims of medical 
malpractice. I have literally been at both tables in the courtroom. At 
least in a previous life, I knew a little bit about this field of legal 
practice.
  What the Senator from Nevada is trying to do is to reduce the 
contingency fee that can be paid to a lawyer who represents a 
plaintiff.
  Here is how it works. If you believe you or a member of your family 
has been a victim of medical malpractice, where you have either been 
hurt or someone in your family has died, you will go to a lawyer and 
say: I don't think I was treated right.
  The lawyer will say to you: If I think you have a good case we can 
prove in court, I will represent you. But I know you don't have enough 
money to pay me my legal fee. I will take your case, accept your case 
on a contingency, which means if you win, I get paid, and if you lose, 
I don't get paid.
  That is what a contingency fee is. For most Americans who are not 
wealthy, this is the only way they can get a good attorney to go into 
court, is to pay a percentage if they win, a contingency fee. That is 
one side, one table in the courtroom.
  There is another table in the courtroom. At that table sits the 
doctor or hospital and an attorney. That attorney isn't paid on a 
contingency fee; that attorney is paid by the hour, by the insurance 
company. No matter how many hours that attorney puts into the case, 
that attorney is confident at the end of the day he will be paid, win 
or lose.
  The Senator from Nevada comes here and says: We think it would be 
just to limit how much victims' attorneys can get paid. I waited 
patiently and listened, hoping that at some point he would say: And in 
all fairness, we think defense attorneys should be limited in what they 
are paid too. But I didn't hear that because what it gets down to is 
really not about attorneys. If we are about making it fair and equal 
for both tables in the courtroom, we would limit both attorneys' fees. 
No. What this is all about is to discourage attorneys from representing 
victims, limit the amount of money a plaintiff's attorney can receive 
as a contingency fee.
  There has been a lot said about frivolous lawsuits for medical 
malpractice. I want to tell you, as a person who did this for a living, 
the last thing in the world I would ever consider doing is taking a 
frivolous lawsuit. It costs a fortune. At the end of the day, you are 
likely to lose. You can't keep the doors open and the lights on in a 
law practice taking lawsuits that are going to lose, taking on 
frivolous cases. You carefully weigh the cases you take because you, as 
a plaintiff's attorney representing a victim, have to make a massive 
time-and-dollar commitment to bring that case to trial, realizing that 
at the end of the day, if there is a ``not guilty,'' you are 
emptyhanded. You have nothing to show for all of that effort and all of 
that money spent. That is what is behind contingency fee cases.
  That is why the Senator from Nevada has focused on only one table in 
the courtroom--the victims' table--saying we want to discourage lawyers 
from taking on victims' medical malpractice cases, we want to 
discourage them by paying them less. Defense lawyers--no limit 
whatsoever on how much the insurance company can pay them. That is the 
Ensign amendment in summary.
  I am sorry in a way that Senator Ensign has invoked Senator Kennedy's 
name to support his effort. I am sorry that Senator Kennedy is not here 
because I think I know what Ted Kennedy, sitting right back here, would 
be saying at this very moment. He would explain to the Senator from 
Nevada that the amendment he is referring to was part of the Gingrich 
revolution, which some may recall, which was an attempt to change tort 
reform laws across America with some onerous provisions--removing, for 
example, the right of people to recover punitive damages in a lawsuit, 
all sorts of limitations or bars against filing lawsuits. It was an 
onerous law which Senator Kennedy offered his amendment to in the hopes 
of slowing it down. Senator Kennedy was not successful. At the end of 
the day, this bill passed, this Gingrich revolution bill passed. It was 
sent to President Clinton, who vetoed it. So to suggest this was 
Senator Kennedy's life's work--it was his attempt to slow down a 
steaming locomotive coming through the Senate. It didn't work. To 
invoke his name at this point is to at least not tell the whole story 
behind the amendment.
  If you are going to tell the whole story about this amendment, you 
need to get beyond lawyers and start talking about victims going into 
courtrooms.
  For the longest time, the argument on the other side of the aisle has 
been, if you go into a courtroom saying you are the victim of medical 
malpractice and prove that you are, they want to limit the amount of 
money a jury can give you for your injury. They used to call it caps. 
Right now, if you are a victim of medical malpractice and you are 
successful in a courtroom, you are likely to recover your medical bills 
and your lost income and some money for what they call noneconomic 
damages. Those would be scarring, disfigurement, pain and suffering. So 
what most of the effort has been on the other side is to limit the 
amount you can recover for these noneconomic losses--scarring, 
disfigurement, pain and suffering. For people who have proven they were 
the victims of malpractice, they have tried to limit the amount they 
can take from a jury. In over half the States in the Nation, those 
limitations or caps have been put in place.
  What is the scope of this problem? The Institute of Medicine tells 
us--at least this was a finding they made back in 1999--that there are 
up to 98,000 deaths in America each year, preventable deaths, because 
of medical malpractice--98,000. When you look across the board at the 
number of paid malpractice claims each year against doctors in America, 
it is about 11,000. One in 10 of the deaths and injuries--frankly, a 
much smaller number than 1 in 10--actually ends up in a lawsuit. So the 
vast majority of victims of medical

[[Page 29557]]

malpractice don't bring a lawsuit. Either they don't know they were 
victims or they decide it is not something they want to do. A very 
small percentage do.
  What the Senator from Nevada did not tell us is that since 2003, when 
this issue has been addressed by so many States, the number of medical 
malpractice lawsuits each year has gone down and continues to go down. 
The premiums for medical malpractice insurance have started to come 
down as well. So there is a positive trend here because of State reform 
and other circumstances which have led to fewer medical malpractice 
lawsuits.
  But make no mistake, there are still victims and there still will be. 
We have to be honest about what those victims face and what the Ensign 
amendment will mean. What the Ensign amendment means is that many of 
them won't be able to find a lawyer. Some of them should. Let me tell 
you some real-life stories of victims of medical malpractice and what 
happened to them.
  This beautiful couple, Molly Akers of New Lenox, IL, and her husband 
tell a story that is heartbreaking. Molly had a swelling in her breast, 
and her doctor performed a biopsy and determined she had breast cancer. 
She had several mammograms which found no evidence of a tumor. The 
doctors decided, however, that it must have been some rare form of 
breast cancer, and they said that Molly, to be safe, needed a 
mastectomy. They removed her right breast. After the operation, the 
doctor called her into the office and revealed that they discovered she 
never had breast cancer. Instead, the radiologist who reviewed her 
slides accidentally switched Molly's slides with those of another 
woman. Molly was permanently disfigured because of this mistake, this 
negligence.
  She said:

       I never thought something like this could happen to me, but 
     I now know that medical malpractice can ruin your life.

  By the way, the other woman, whose slides were switched with Molly's, 
was told she was cancer free. That was a medical error that ended up 
injuring two people, not just one.
  Is she entitled to her day in court? Is she entitled to be 
compensated for what she went through? Is she entitled to have at least 
those responsible pay for her medical bills, her lost wages, pain and 
suffering, scars and disfigurement? By most standards of justice, the 
answer would be yes. But if she isn't rich enough to pay an attorney's 
fee, she walks in and says: The best I can do is tell you that if I 
win, you win. It will be a contingency fee basis to the lawyer. What 
the Senator from Nevada wants to do is to reduce the likelihood that 
she will find a lawyer to represent her.
  This is another story of another person from Illinois. Glenn 
Steinberg is shown here. In 2004, Glenn went for surgery in Chicago to 
remove a tumor from his abdomen. Ten days after surgery, while he was 
still in the hospital, he was having pain and problems. They did an 
xray of his abdomen and they found a 4-inch metal retractor lodged 
against his intestine that had been left in his body after the surgery. 
A second surgery was performed to remove this metal instrument, during 
which time Glenn's lungs aspirated and he died. Glenn's wife Mary lost 
her husband. She said:

       Not a day goes by that I don't miss Glenn's companionship 
     and the joy he brought to our home. Because of gross 
     negligence, he was not here to support me when my son went 
     off to serve our country in Iraq.

  A real-life story. This man did nothing wrong--an innocent victim 
who, in our system of justice, is entitled to compensation. But if his 
widow didn't have enough money to pay the attorney's fees and went in 
for a contingency fee, she might be limited because of the amendment 
offered by the Senator from Nevada.
  This next case in Illinois involves children. I have met the little 
fellow we are going to talk about, Martin Hartnett. He is the second 
boy from the right. When Martin's mother, Donna, arrived at the 
hospital to deliver him, her labor was not progressing. Her doctor 
broke her water and found it was abnormal. Rather than considering a C-
section, Donna's doctor tried administering a drug to help induce 
contractions. Six hours later, Donna still hadn't delivered, but her 
son's fetal-monitoring system began indicating he was in severe 
respiratory distress. The doctor finally decided it was time to perform 
an emergency C-section but waited another hour before she was taken to 
the operating room. During that time, the doctor failed to administer 
oxygen or take other immediate steps to help Martin breathe.
  After Martin was born, he was in intensive care for 3 weeks. Later, 
Donna learned that Martin had substantial brain damage and cerebral 
palsy--a direct result of the doctor's failure to respond to 
indications of serious oxygen deprivation and to deliver in a timely 
manner.
  Donna's doctor told her not to have any more children because he said 
there was a serious problem with her DNA which could result in similar 
disabilities in the future.
  Well, that turned out not to be true. Donna has given birth since to 
three perfectly healthy sons who are shown in this photo as well. Donna 
sued the doctor responsible for Martin's delivery and received a 
settlement in the case. Here she is, a young mother who is being told 
the problem was her problem, and it turned out it was a problem in the 
way she was treated when she went to the hospital.
  Again, the Senator from Nevada would reduce the likelihood that 
Donna--the mother of this child who is going to face a lifetime of 
challenges--would have the attorney to come to court for reasonable 
compensation.
  These are real-life examples. I know the other side--the Senator from 
Nevada said specifically: Oh, you are going to hear about the victims, 
but this is really about lawyers.
  These victims would not have their day in court, would not have a 
chance to recover from medical malpractice that was eventually admitted 
or proven if it were not for an attorney to bring them to court. It 
does take a long time. I will concede, the Senator from Nevada said it 
takes a long time on these cases. Well, I have been there, and I know 
why. The attorneys representing the other side try to drag it out as 
long as they possibly can, filing motions and requiring discovery. It 
can go on and on. So an attorney who takes up one of these cases better 
not take up a frivolous case because it will be a lifetime of futility 
if you take that approach.
  I took a look and asked my staff: Well, if Senator Ensign's amendment 
is dealing with victims' attorneys, are they really getting paid a lot 
more compared to the defense attorneys? Well, we went and looked at the 
information. We found that in a recent year, there was around $1.3 
billion paid to victims' attorneys who filed medical malpractice cases 
in America--$1.3 billion. At the same time, $2.1 billion was paid to 
defense attorneys.
  So to argue we just want to reduce the plaintiffs' or the victims' 
attorneys' fees and ignore the defense attorneys' fees is to ignore a 
mismatch already. The defense attorneys in America are being paid 
substantially more--50 percent more--than those who represent the 
victims.
  In 2008, in Texas, medical malpractice insurers earned $369 million 
in premiums. They paid out $17 million in losses. If one-third of that, 
say $5.5 million, went to victims' attorneys, how much went to defense 
attorneys in medical malpractice cases in Texas? Mr. President, $41 
million. So $5.5 million for plaintiffs' attorneys, $41 million for 
defense attorneys.
  This amendment does not even address the cost of defense attorneys.
  In Tennessee, in 2008 malpractice insurers paid $79 million in losses 
to victims, so perhaps $26 million went to victims' attorneys' fees, 
and $83 million was paid in defense attorney fees.
  There is no similar outrage on the other side of the aisle when it 
comes to how much money the defense attorneys are being paid.
  In the State of Mississippi in 2008 they paid out $874,000 in losses, 
and paid $4.1 million in defense attorneys' fees.
  So it just goes on and on. The evidence is clear. Overwhelmingly, in 
the

[[Page 29558]]

courtroom, the race goes to the swift, and the swiftest are the ones 
with the most resources--the most attorneys, the most discovery, the 
most expert witnesses, and they all cost money. Time and again, 
plaintiffs' attorneys come into many courtrooms at a distinct 
disadvantage to the insurance companies that would be benefited by 
this.
  Now, what are we going to do about this issue? And it is an issue. 
Well, I think the President is on the right track. First, we know it is 
a State issue when it comes to medical malpractice. Historically, the 
States set the standards, and the States initiate the reforms. A 
majority of States have already done that, limiting recoveries, even 
limiting fees in some cases. They have done it. Why would we come in at 
the Federal level and preempt that?
  Secondly, the President said: Let's encourage some positive thinking 
about ways to end this. How can you reduce the number of medical 
malpractice lawsuits? There is one simple way, and many States have 
discovered it. It is when a doctor walks in and says to a patient: I 
made a mistake, and I am sorry. It sounds simple, doesn't it?
  It happened in my family recently. One of the members of my family 
went for back surgery and had complications afterwards. It went on for 
weeks. He went in, and the doctor said: I am sorry. When I did your 
back surgery, I should have cauterized you right then and there rather 
than waiting through 2 miserable weeks until we finally did it. It was 
my mistake.
  Well, my relative did not file a lawsuit. That doctor was honest. We 
know doctors are human. They make mistakes. Some States have protected 
the doctors' right to say: I am sorry. Many times that is all that is 
needed. There are other cases where States have put together panels to 
review lawsuits before they are filed. They do it successfully. There 
are other cases where they have to file an affidavit from a doctor that 
says this is a lawsuit with a real possibility of medical malpractice 
being proven.
  All of these things are working, and we want to encourage them. But, 
please, do not close the door of the courtroom to victims and their 
attorneys. Do not benefit the defense attorneys, the insurance 
attorneys, at the expense of the victims' attorneys.
  Mr. BROWN. Mr. President, will the Senator yield?
  Mr. DURBIN. I am happy to.
  Mr. BROWN. I say thank you to Senator Durbin.
  My understanding is, some States have stricter licensing requirements 
for doctors, and that typically very few doctors, relatively, commit 
significant, repeated mistakes as they are practicing medicine. But 
some small number of doctors are responsible for the large number of 
medical errors and negligence and malpractice.
  How important is it that the States strengthen their licensing 
requirements so those doctors--the small minority of doctors--who 
really do seem guilty of the most malpractice are disciplined either by 
losing their license or by being disciplined in other ways so they are 
not inflicting this on their patients?
  Mr. DURBIN. I think the Senator from Ohio has put his finger on a 
part of the problem. It turns out, the vast majority of lawsuits 
involve a very small percentage of doctors, many of whom are making 
errors repeatedly. I would recommend to my friend from Ohio a book to 
read, and I know he reads them. It is called ``Complications.'' It is 
by Dr. Atul Gawande, who is a Boston surgeon with whom we are familiar. 
I read it, and it was an eye opener about what a surgeon learns and 
goes through. But he spends a whole chapter in there about doctors and 
nurses of practicing doctors who are not up to skill anymore because of 
age, alcoholism, and drug addiction, and they are afraid to speak out.
  That is not common. It is rare. But it should not happen at all. 
Those doctors who consistently make mistakes, consistently get sued, or 
have these problems should be identified and removed from the practice 
until they can be rehabilitated or go off to another job.
  Mr. BROWN. If the Senator will yield for a moment, again, don't the 
State licensing boards have the ability to do disciplinary action? I 
know in my State, in Columbus, they do. Are they not doing that enough? 
Is there a way to strengthen that?
  Mr. DURBIN. The point Dr. Gawande makes is there is this conspiracy 
of silence, this fear of outing a doctor.
  Mr. BROWN. Nurses are not willing to speak up?
  Mr. DURBIN. Nurses are not willing to speak up, other colleagues are 
not willing to speak up, and they should for the sake of their own 
profession, but certainly for the sake of the patients.
  Mr. BROWN. So the Senator is arguing that if there was a mechanism or 
an environment where nurses and doctors would be willing to speak up, 
if there was a doctor, a surgeon who had a problem with alcohol, this 
issue would not go away certainly, but this issue would be much less 
serious, the issue of malpractice, the medical errors, the deaths, the 
injuries that come from some kind of medical error? Medical malpractice 
would be much alleviated?
  Mr. DURBIN. I am.
  I see my time is over. I thank the Senator from Ohio, and I would say 
this is one part of the answer. But denying victims a day in court I do 
not think brings justice to this country or fairness, and I know 
Senator Kennedy would be saying the same thing if he were here today.
  I yield the floor.
  The PRESIDING OFFICER (Ms. Stabenow). The Senator from Wyoming.
  Mr. ENZI. Madam President, I yield time to the Senator from Nevada.
  The PRESIDING OFFICER. The Senator from Nevada.
  Mr. ENSIGN. Madam President, there is an urban myth that people like 
to talk about when they are discussing health care reform. It is like 
one of those rumors that runs rampant on the Internet. Nobody knows 
where it started, but you are sure it must be true.
  The story is about Canadian health care: everyone there is covered, 
and they have a progressive health care system that we should somehow 
copy.
  Well, it is time to bust this myth and tell the American people what 
a government-run health care system like Canada's would mean for us in 
the United States.
  Canada and Great Britain offer what is typically referred to as 
universal coverage. Universal coverage, however, does not mean 
unlimited access to care or readily available care. Let me tell you 
why.
  Let's talk about spending first. The U.S. spends about 16 percent of 
its gross domestic product on health care, while Canada spends about 10 
percent. I know some Members of this body have been asking: If Canada 
can spend less money on health care, why can't we?
  Well, there is a right way to reduce spending with technology, 
healthier behaviors, common sense, medical liability reform, other 
things I have talked about; and there is a wrong way.
  In Canada, the government spends 10 percent on health care by setting 
a global budget. When the demand for health care exceeds that amount, 
the Canadian Government does not increase funding. Instead, medical 
care is often delayed and/or denied. Some estimate that about 750,000 
Canadians are currently on a waiting list for medical procedures or 
referrals to specialists.
  Madam President, can you imagine waiting up to 6 months for a hip 
replacement or up to 6 months for cardiac bypass surgery? What if you 
had to wait up to 4 months to get an MRI.
  People who live in countries that have government-forced health care 
systems often wait, and then wait some more, for medical care. This 
chart shows typical patient wait times in Canada. The blue bar shows 
median clinically reasonable wait times. The red bar shows actual wait 
times. So this, in the blue, is what a reasonable patient wait time 
should be and what is shown in red is what patients actually 
experience.
  If you look at this chart and study the wait times, you can see that 
in every single one of these cases whether it is general surgery, 
gynecology, internal medicine, neurosurgery, or ophthalmology, the 
actual wait times are

[[Page 29559]]

always much longer than what a clinically reasonable wait time should 
be in Canada.
  For example, the median clinically reasonable wait time for 
neurosurgery is 5.8 weeks. But, as we see from this chart, the actual 
wait time is 31.7 weeks. That is for neurosurgery. That is shown on 
this part of the chart. Can you imagine having to wait that long for 
neurosurgery?
  For orthopedic surgery, the clinically reasonable wait time is 11 
weeks. The median actual wait time is 36.7 weeks. This is hard to 
fathom.
  In Canada, the wait time depends on many factors. Getting in to see a 
doctor depends on the province in which you live, whether you are an 
urban or rural resident, the urgency of your medical condition, and 
your age.
  I want to encourage all Americans not to take my word for it on these 
wait times. You can go to this Web site, http://ontariowaittimes.com, 
and it will actually tell you what the wait times are for various 
procedures.
  As a matter of fact, my assistant who is on the Senate floor with me 
today broke her arm several months ago. Interestingly, she went to this 
Web site to find out how long her wait time would be for surgery in 
Ontario. By the time she would have got in to see a doctor in Canada to 
have the necessary procedure conducted, her arm would have already 
healed. It would have healed incorrectly, but it would have already 
healed.
  That is unacceptable, but that is typical of what happens in 
countries where there is government rationing, and where the government 
sets a global budget.
  Think about how frustrated you would be if you had to wait that 
length of time. Some Canadians get tired of this waiting. They leave 
the queue and catch planes, trains, and automobiles to the United 
States to get medical care when they need it most.
  The Mayo Clinic, for example, sees about 2,000 Canadian patients each 
year. The Henry Ford Clinic in Michigan saw 191 hospital patients from 
Canada and had about 1,400 outpatient visits from Canada last year 
alone.
  Those numbers have increased steadily over the past 3 years. In fact, 
revenue from Canadian patients has increased by $7.5 million at the 
Henry Ford Clinic in the last 3 years. Although these major medical 
clinics do not track why some Canadian patients come to the United 
States for medical care, I believe the significant wait times in Canada 
are one of the primary reasons they choose to cross the border.
  I also believe that Canadian patients come to the United States to 
reap the benefit of America's research and development and to access 
new breakthroughs in medical technologies.
  Many of my colleagues have heard the story of Shona Holmes. Shona, a 
Canadian citizen, was experiencing numerous conditions, including 
headaches, fatigue, and severe vision problems. Her primary care doctor 
in Canada ordered an MRI and the results suggested a brain tumor. Shona 
would have to wait 4 months to see a neurologist or 6 months to see an 
endocrinologist in Canada. She couldn't wait that long. Since it would 
be illegal for her to see a doctor outside the government-run health 
care system in her own country, she traveled 2,000 miles to the Mayo 
Clinic to Scottsdale, AZ, and paid for the visit herself. Doctors at 
the Mayo Clinic diagnosed Shona with Rathke's cleft cyst.
  Shona returned to Canada with her diagnosis and attempted to have 
surgery under Canada's government-run health care plan. The Canadian 
Government wasn't able to do the necessary surgery within a 6-month 
time period. Since Shona's vision was rapidly declining, waiting more 
than 6 weeks for surgery was completely unacceptable. So her husband 
got a second job, took out a second mortgage on their home, and 
borrowed money from family and friends for surgery at the Mayo Clinic. 
Incidentally, the Mayo Clinic recommended a second surgery to remove 
her adrenal gland. So Shona went back to Canada and got in line. It 
took 3 years for her to get her second surgery in Canada--3 years.
  In written testimony before the House Energy and Commerce Committee, 
Shona said:

       If I had relied on my own government-run health care system 
     in Canada, I would not be sitting before you today. At the 
     very best I would be blind and at the very worst I would be 
     dead.

  Shona isn't the only Canadian citizen who has come to the United 
States for access to timely medical care. A private company called 
Timely Medical Alternatives was created in 2003 to help Canadian 
citizens obtain medical care in the United States. Over the years, the 
company has sent more than 500 Canadians to the United States for 
timely medical care. Richard Baker, the founder of Timely Medical 
Alternatives said:

       The Canada Health Act is responsible for more pain, more 
     suffering, and more death than any other piece of domestic 
     legislation in Canadian history.

  I am concerned that the inclusion of a government-run health plan in 
the Democrats' health reform bill will destroy the American health care 
system as we know it today.
  Section 1323 of this bill establishes the community health insurance 
option. Don't let the name fool you; it is a government-run plan. 
States can opt out of the government-run plan if they enact a law 
prohibiting the offering of the government-run plan in the exchange, 
but I honestly expect that few States will take this course of action. 
Regardless of the language indicating that people won't be forced to 
participate in a public health insurance program and won't be penalized 
for not participating, I still believe that some individuals will be 
forced into this government-run plan. I also believe this is just the 
first step toward a complete government-run plan.
  Under the bill, the Secretary of Health and Human Services will be 
required to negotiate provider reimbursement rates. The government 
typically doesn't negotiate with doctors and hospitals. The government 
would likely resort to price-setting based on Medicare or Medicaid or 
use existing government programs as leverage for negotiations, creating 
similar effects. Remember, Medicare and Medicaid currently reimburse at 
much lower rates than the private sector.
  Madam President, I ask for an additional 3 minutes.
  The PRESIDING OFFICER. Is there objection? Without objection, it is 
so ordered.
  Mr. ENSIGN. Madam President, Democrats claim that they will not be 
putting private health insurance companies out of business, but it 
seems to me that they are doing everything possible to make it harder 
for these companies to stay in business. I also question whether 
Members of Congress will be required to participate in this government-
run program. We should be required to do so. If we decide that a 
government-run plan is good enough for the American people, then I 
believe that Members of Congress should subject themselves to the same 
type of care. I know there will be an amendment to do just that.
  I want to tell a story about how federal government officials don't 
always think that they should be subject to the same type of care as 
their country's citizens. Belinda Stronach, a former Canadian Member of 
Parliament, opposed the privatization of Canada's health care system. 
Well, that was at least until she got sick. She was diagnosed with 
breast cancer in June 2007. Although she had led the charge against 
having a private system in Canada, she didn't want to wait in line in 
Canada to obtain treatment--so what did she do? As a matter of fact, 
she traveled to the United States for care--on the advice of her 
doctor. She went to UCLA for surgery and she paid for that treatment 
out of her own pocket. I have a feeling that she came to the United 
States because she knew that if she waited for care in Canada, the 
chances of her having successful treatment would be a lot lower.
  Madam President, the wait to see a doctor is not the only wait 
Canadian patients face. Canada and other countries with government-run 
health care systems are slow to adopt new medical technologies. And, 
access to the latest medical technologies is limited. As a

[[Page 29560]]

result, patients often have to rely on old or outdated medical 
equipment for treatment.
  Canadians have less access to MRIs, CT scanners, and lithotroptors 
than patients in other countries belonging to the Organisation of 
Economic Co-Operation and Development. Lack of access to cutting-edge 
medical technology has significant consequences. New medical 
technologies can often provide faster and more efficient identification 
and treatment of disease. They can offer the patient safer, less 
invasive and more comfortable treatments and care, as well as offering 
new treatment options where none previously existed. What is the secret 
to other countries' keeping costs down? One is refusing to approve or 
cover new life saving drugs and medical devices.
  In 2007, the United States had 25.9 MRI machines per million people. 
Canada had 6.7 MRIs per million people and the United Kingdom had 8.2 
per million people. In 2007, the United States had 34.3 CT machines per 
million people. The same year, Canada had 12.7 machines and the United 
Kingdom had 7.6 machines per million people.
  It took France 5 years to approve the endoscopy pill camera and 10 
years to approve implantable defibrillators. Japan is well known for 
refusing to pay for the latest technologies because of budgetary 
constraints and has yet to approve, for example, prosthetic titanium 
ribs and imaging masks for head surgery that have been approved in the 
United States for the past 6 years.
  In my home State of Nevada, robotics surgery has become an exciting 
new frontier. Across Nevada, six hospitals are now equipped with the da 
Vinci Surgical System which allows patients access to cutting-edge 
minimally, invasive surgery. In all of Canada, the entire country, 
there are nine such machines. The United States has 968 machines. 
Wouldn't you prefer a system that thrives on innovation in medical 
technology? Where you have access to the most cutting-edge technology 
that can better diagnose and treat you?
  Even with this clear discrepancy in technology investment, Democrats 
have argued that the United States spends more money than any other 
country on health care and gets worse results. The implication is that 
we should look to other countries for guidance on how to run our own 
system better. But if we look, for example, at cancer survival rates, 
we see that the United States gets better results than other countries 
that have experimented with broader government control of health care.
  International studies have found Americans have far better access to 
new cancer drugs than do patients in Europe and the United Kingdom. The 
United States also has higher rates of cost-effective prevention 
measures that can detect certain cancers early when they are cheaper, 
easier, and more effective to treat. As a result of this superior 
prevention and treatment, the United States has higher cancer survival 
rates.
  Madam President, I would like to show another chart. This chart shows 
the European cancer survival rates for the major cancers in comparison 
to the United States. The United States data is in gold; the European 
Union data is in red. This chart shows 5-year survival rates. This part 
of the chart shows kidney cancer survival rates. We have significantly 
higher survival rates in the United States for colorectal cancer, 
breast cancer, cervical cancer, breast cancer, and skin cancer. You 
name it, across the board we have better survival rates because we 
don't ration care, we don't delay care, and we have access to better 
technology in the United States.
  Madam President, I would like to be a little more specific when it 
comes to these facts and figures. A study published in The Lancet 
Oncology found that when comparing 5-year cancer survival rates, the 
United States had better outcomes than European countries. Among men, 
nearly two in three American cancer patients survived for at least 5 
years, while fewer than half of Europeans did. Among women, 63 percent 
survived for 5 years in the United States, versus 56 percent in Europe. 
According to the study, survival rates for breast cancer were 11 
percentage points higher in the United States than in Europe. Prostate 
cancer is even more alarming, with a 99 percent 5-year survival rate in 
the United States versus 78 percent in Europe. Colorectal cancer rates 
were 10 percentage points higher in our country than in Europe. And, 
survival rates for kidney cancer, cervical cancer, and melanoma were 
higher in the United States than in Europe.
  Madam President, I think this body should take a look at what it 
would mean for quality of care and access to medical care in the United 
States if we were to adopt a government-run health care system. Many of 
us on this side of the aisle are opposed to government-run health care 
systems. We don't want these type of survival rates that are common in 
the European Union. We don't want people from Canada coming here and 
not having a place to go to obtain medical treatment. As a matter of 
fact, if the United States ends up going to a government-run healthcare 
system, where will Americans go for high-quality care when they need it 
most? All Americans should think about that as this bill is being 
considered on the floor of the Senate.
  We should be very careful that reforms to our health system do not 
lead to reduced preventive care and poor access to lifesaving drugs. 
These reforms have led to lower rates of survival in places with 
greater government control over health systems.
  These reforms have also proven unsustainable in other countries. The 
British National Health Service trust is issuing a report that says it 
will face the most severe and sustained financial shortfall in its 
history after 2011. In fact, the NHS trust is asking staff to work a 
day for free, take unpaid leave, and carry forward their vacations in 
order to save money. Germany's new proposal to reform the health care 
system met with thousands of protesters because it faces a massive 
budget shortfall due to rising costs. What are they looking at doing? 
Introduce fees, raise taxes, and do away with private plans to bring 
people with those plans into the public system. Sound familiar? France, 
too, has a gaping hole in its health care budget. France is looking at 
cutting subsidies in order to stop the problem. Japan faces one of the 
most difficult problems because of its rapidly aging population. It too 
has budget problems and has to find a way to offset a 5-percent 
increase in next year's health care budget despite all of its massive 
price controls on doctor, medical device, and drug prices. Is this the 
future of U.S. health care?
  These are not health care systems that we should want to copy. 
Contrary to the opinion of some, the United States provides among the 
best care in the world for patients. The World Health Organization 
identifies the United States as 37th in the world, but these ratings 
are faulty. The United Nations World Health Organization uses 
subjective criteria such as ``fairness'' to rate many countries. 
``Fairness'' means that any out-of-pocket expense by a patient is 
regressive and therefore penalizes poor people more. So, in the view of 
the United Nations, the United States is 54th in terms of their view of 
fairness. Consequently, according to the WHO ratings, countries like 
Colombia, Cuba, Micronesia, Mozambique, Saudi Arabia, Samoa, and 
Uruguay are ``fairer'' and therefore better than the United States. 
Something is wrong with that rating.
  In contrast, the United States is No. 1 in responsiveness to patient 
care according to WHO. So, if you are sick and want the best care, even 
the United Nations agrees that the United States is the place to be 
treated.
  Michael Moore's movie ``SICKO'' advertised how great Cuban health 
care is, but he apparently did not see the system used by the 11 
million ordinary Cubans where patients ``have to bring their own food, 
soap, sheets'' with them to the hospital.
  Some of my colleagues ask, if the United States is No. 1 in 
responsiveness according to WHO, then why is there lower life 
expectancy compared to other developed countries? Simple. Because the 
numbers are wrong. Life expectancy in the United States has been rising 
as it has been in most of the developed world. All of the life 
expectancy statistics include accidental and

[[Page 29561]]

even intentional deaths that clearly have no relation to the merit of 
our health care system.
  For example, if you remove car accidents and homicides, both of which 
are higher in the United States for reasons unrelated to the 
effectiveness of health care, then the actual U.S. life expectancy is 
higher. Some economists rank the United States near the top of world 
rankings when that point is factored in. Moreover, the history of 
exceptionally heavy smoking in the United States and the recent 
increase in obesity means that diseases and shortened life expectancies 
related to these factors have little to do with the effectiveness of 
our health care system. That is why my approach to health care reform 
includes creating incentives for people to make healthier choices. We 
need to get to the root of health problems, not chase phantom foreign 
statistics.
  Another example is high infant mortality. The United States has a 
higher level than other countries in part because of the higher number 
of low weight babies from teenage pregnancies. That social problem is 
not related to how effective our health care system is. In fact, a low 
birth weight baby in the United States has a better chance of survival 
than in Canada, but we have three times the quantity of low weight 
babies as Canada does.
  The bottom line is that the United States has the best doctors, 
nurses, medical and nursing schools, medical research, medicine, 
hospitals, medical devices, innovative companies, and health care in 
the world. It is like that because we demand it.
  Every night on the news for the past month or so, there are stories 
about the lines for the H1N1 vaccine. The vaccine supply has been 
slowly trickling out, and Americans are not accustomed to waiting for 
their care. They are frustrated about these lines and the priority 
groups that have denied some of them the vaccine. Welcome to 
government-run health care.
  What Canada and Great Britain and other countries do with their 
health care systems is their business. They have determined that they 
want the government at the center of their health care system. The 
government decides what treatments patients can have, how long they 
have to wait, and how much is invested in technology. Here in the 
United States, that is the last kind of system we need. Instead, we 
need to move to a patient-centered system. We want to continue to 
empower patients to make decisions about their own treatment, to be 
consumers in the process, and to have access to the care they need.
  The United States is home to some of the greatest medical 
advancements in the world. Turning away from that system at a time of 
great medical promise is not the direction we should be heading.
  For generations, American researchers, scientists, physicians, and 
patients have worked together to push the envelope on the best tools 
for diagnosis and treatment. We have invested in finding cures and 
vaccines for illnesses. We could be on the cusp of cures for cancer, 
Alzheimer's disease, Parkinson's disease. The list goes on and on. But 
what happens when we become a one-size-fits-all, government-centered, 
bureaucracy-run health care system? We become like Canada and Great 
Britain, where wait times are unacceptable, where care is rationed, 
where technology and innovation are not a priority, where the doctor-
patient relationship is devalued, and where patients have lost their 
say in their own care. So, it is not surprising that when people in 
other countries want the best, they come here.
  Madam President, let's not put Americans in a position where they may 
have to wait weeks and even months for medical care. Let's not put 
Americans in a position where they can't access the latest medical 
technology or the best prescription drugs. And, let's not have 
government bureaucrats stand in the way of medical care. This is about 
patients. This is about creating a patient-centered healthcare system. 
The bill before us is not the answer.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. ENSIGN. I thank the other side for their indulgence and I yield 
the floor.
  The PRESIDING OFFICER. The Senator from Minnesota is recognized. As a 
result of the previous agreed-upon conditions, 3 minutes will be added 
to the Senator's time.
  Mr. FRANKEN. Madam President, I actually was kind of feeling bad 
because I thought I was going to be changing the subject, when Senator 
Durbin said I would be the next Democrat to speak. Because our good 
colleague from Nevada brought up an amendment on medical malpractice 
liability and the Senator from Illinois responded to it and I thought 
the Senator from Nevada was going to respond to his response with some 
factual information or something, he completely changed the subject. So 
he went from the Canadian system to rationing, and he will include his 
entire statement, which included this: We don't ration care here in the 
United States, we let--meaning the government--we let the private 
sector do that.
  They do a great job of rationing care in the private sector. That is 
where we ration care in this country. They ration it by cutting off 
your insurance when you get sick. They ration care by not giving you 
insurance if you have a preexisting condition.
  I wish to speak about an amendment I have--that is why I was going to 
change the subject--but let me talk a little bit about tort reform, 
liability insurance. Senator Durbin mentioned Atul Gawande. He wrote 
that article in the New Yorker. Senator Ensign talked about how great 
the tort reform was in Texas. McAllen, TX, has the most expensive 
health care in the country. What kind of progress is that? They have 
the most draconian medical liability reform. In Minnesota, we don't 
have anything such as that. We do it for a third of the cost that they 
do it for in Texas and with better outcomes.
  The reason I actually asked for time today is to express my support 
for Senator Lincoln's amendment to limit the tax benefits that health 
insurance CEOs receive--not limit their salaries, limit the tax 
benefits. This does not limit their compensation, as was claimed by the 
Senator from Nevada.
  Most Americans would agree that the government, though, shouldn't be 
giving tax breaks to insurance companies for lining the pockets of 
their CEOs at the expense of working families who are forced to pay 
more and more as their premiums spiral out of control. The savings from 
removing this tax deduction in Senator Lincoln's amendment will go 
directly to our seniors as a direct deposit into the Medicare trust 
fund. This amendment is immensely important because it reinforces one 
of our primary goals with this bill, which is to rein in the cost of 
health care. One of the key ways we can control costs is by holding 
insurance companies accountable.
  I am pleased to be working with Senator Lincoln on another effort to 
make our health care system focused on patients, not profits. 
Yesterday, Senator Lincoln joined me, Senator Rockefeller, and others 
in introducing an amendment to require that at least 90 percent of your 
premium dollars go toward actual health services. We do that in 
Minnesota. We do that in Minnesota--91 cents, actually.
  I urge my colleagues to support both our amendments to ensure we get 
the highest possible value for our premium dollars because nobody can 
contest the fact that for-profit health insurance companies have been 
making obscene amounts of money, while Americans watch their premiums 
skyrocket. From 2000 to 2007, insurance company profits rose 428 
percent--in 8 years. During that same time, we saw more than 6 million 
more Americans become uninsured. During that same period, American 
families saw their premiums almost double.
  So nobody can stand on this floor and argue that American families 
aren't suffering. No one can dispute what I hear from Minnesotans every 
day, that in this economic downturn, one of the greatest fears families 
have is: What happens if I get sick? What happens if my spouse or my 
child gets sick? We are hardly holding on now. We are just

[[Page 29562]]

one illness away from losing everything. That is what I hear. That is 
what I hear from Minnesota families, and this is a State that has less-
expensive, higher quality health care than the rest of the country. If 
Minnesotans are struggling, we know we have a crisis on our hands.
  That is why I am working to make sure this bill does everything it 
can to bring down costs, improve quality, and hold private insurance 
companies accountable.
  The current reality is, most of us don't know where our health 
insurance premiums go. It is difficult enough to understand a billing 
statement from your health insurer, much less track where your money is 
spent. Well, we are going to change that. We are going to change that 
with transparent reporting of how health insurance companies are 
spending your money. That is in this bill. Clear reporting, written in 
plain English will help us hold them accountable for every dollar we 
spend on health insurance. But reporting isn't enough because, right 
now, some of the health insurance plans being marketed and sold in this 
country are nothing short of a rip-off.
  A recent report in BusinessWeek magazine described a policy being 
sold in Florida to college students in which only 10 percent of the 
premium went toward actual health services. Again, only 10 cents out of 
every dollar goes to health care in this plan. The rest goes to 
marketing, wasteful administrative costs, and, of course, profits. And 
this is legal. It has been legal. It was legal when the Republicans had 
the White House and controlled this Congress. We are going to make it 
illegal.
  I don't think this is what we want for our children--insurance 
companies pocketing millions of dollars at the expense of our physical 
and economic health. Is that the kind of country we want to be? I 
believe we can all agree this health care reform bill must guarantee 
that Americans get value for the premiums we pay.
  I implore my colleagues to support these efforts because health 
insurance should be about providing the best possible health care, not 
about marketing, wasteful administrative costs, CEO pay, and profits.
  Madam President, I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from New Jersey is 
recognized.
  Mr. LAUTENBERG. Mr. President, how much time is available?
  The ACTING PRESIDENT pro tempore. There is 4\1/2\ minutes remaining.
  Mr. LAUTENBERG. I ask unanimous consent to be able to speak for up to 
10 minutes. It will be less, I promise. I think we had a little miscue 
in our timing. Is there any objection to that?
  The ACTING PRESIDENT pro tempore. The Senator from Wyoming is 
recognized.
  Mr. ENZI. Mr. President, reserving the right to object, would it be 
possible for the Senator from Arizona to do a 5-minute speech and then 
the Senator from New Jersey do his speech?
  Mr. LAUTENBERG. All right. If we can be assured that the Senator who 
speaks will not take more than 5 minutes, I will consent to that. That 
includes a unanimous-consent agreement for me to have up to 10 minutes. 
I also see our colleague from Michigan, and I don't know whether that 
would disturb her.
  Mr. ENZI. I am willing to let her go as well, and we will make up the 
time on our side after that.
  Ms. STABENOW. May I ask my friend a question. Do I understand it 
would be the Senator from New Jersey and then the Senator from Arizona 
and then myself?
  Mr. ENZI. The Senator from Arizona, the Senator from New Jersey, and 
then the Senator from Michigan.
  The ACTING PRESIDENT pro tempore. The Senator from Arizona is 
recognized.
  Mr. KYL. Mr. President, I thank my colleagues for their courtesies. I 
am sure the Chair will cut me off at 5 minutes.
  I wish to respond to some comments made earlier relative to the 
amendment of the Senator from Nevada on capping attorney's fees. We 
have an amendment we will vote on tomorrow that caps executive 
compensation, effectively, and the response to that from Senator Ensign 
was, if we are going to do that, let's cap the attorney's fees because 
we can accomplish something by doing that in medical malpractice cases. 
We can make sure the people who were injured get more of the money 
coming from these awards, with less going to the attorneys.
  I think this would be a very salutary situation. This contingent fee 
system can really result in some abuses. I will cite some statistics 
from the Jury Verdict Research in a study done in 2005: Fifty-two 
percent of all awards in medical liability lawsuits exceed $1 million. 
Think about that. Over half of the awards in these malpractice cases 
exceed $1 million. The average award now weighs in at $4.7 million. 
That is a lot of money. Obviously, juries have felt that is what the 
victims in these cases needed in order to be properly compensated.
  The Ensign amendment would limit the amount of contingency fees in 
these kinds of lawsuits to no more than a third of the first $150,000 
recovered and a quarter of any recovery in excess of $150,000. For 
example, an attorney representing a client in this average case, with a 
$4.7 million verdict, would still receive $1,187,500 for his or her 
services under the Ensign amendment. That is not a bad deal with a $4.7 
million verdict. The attorney gets $1.1 million-plus and the injured 
party, the plaintiff, gets the remainder. I ask my colleagues, in that 
situation, isn't $1.1 million-plus enough compensation?
  We are limiting the compensation for an entire year for an executive 
of an insurance company to $400,000 as the amount that would be 
deductible to the company as a usual and ordinary business expense. 
Here, a lawyer has just one case, and you can have many cases in a 
year. He would be limited, in this particular situation, to $1.1 
million.
  A lot of folks have been asked to sacrifice under this legislation--
hospitals, doctors, and States, by accepting more Medicaid patients 
under their program; seniors would face sacrifices because of the $500 
billion cuts in Medicare; individuals would see their premiums rise; 
and small businesses would get hit. The one constituency that hasn't 
been asked to sacrifice anything is the trial lawyers. I don't think it 
is much of a sacrifice to say, when you get this kind of award--a $4 
million award--for your client, your fees should not exceed a little 
bit over $1 million.
  Even Howard Dean stated:

       Tort reform is not in the [health care] bill because the 
     people who wrote it did not want to take on the trial 
     lawyers. And that is the plain and simple truth.

  We know that to be the case. Surely, it wouldn't be too much to ask 
our trial lawyer friends to limit just a little bit the contingency 
fees they make in these cases.
  There is a study that was recently conducted by the Institute for 
Legal Reform that found that medical liability lawsuits are being 
driven by the plaintiffs' bar. It cites all the advertising costs and 
the increase in the amount of advertising they are doing. That is where 
a lot of this money is going--to advertise for these lawsuits. 
Additionally, it showed that spending for these ads has increased 
dramatically in the last few years.
  The threat of these ``jackpot justice'' suits against doctors is one 
of the reasons health insurance premiums are rising faster than the 
rate of inflation. In fact, a PricewaterhouseCoopers study concluded 
that approximately 10 percent of the costs of health insurance premiums 
are attributed to the cost of litigation and defensive medicine.
  An even bigger health care cost related to the threat of frivolous 
lawsuits is the practice of defensive medicine. A 2005 survey in the 
Journal of the American Medical Association found that 93 percent of 
physicians reported practicing defensive medicine, costing the health 
care system $200 billion annually.
  We clearly need to reform the tort system, and not in the form of 
some sense of the Senate but in the way of something real. It seems to 
me the Ensign amendment begins that process by saying: Let's at least 
allow the injured plaintiffs in these cases to keep more

[[Page 29563]]

of the award granted to them and have less of that go to the lawyers 
who bring the cases. Surely, it is an adequate incentive that they 
receive about $1 million out of a $4 million lawsuit.
  I thank my colleagues from New Jersey and Michigan for allowing me to 
speak first.
  The ACTING PRESIDENT pro tempore. The Senator from New Jersey is 
recognized.
  Mr. LAUTENBERG. Mr. President, I rise to speak in support of the 
amendment proposed by Senator Lincoln from Arkansas. I thank her for an 
excellent idea.
  At the outset, before I came to the Senate, I was a founder and CEO 
of a major New York Stock Exchange company--a company now employing 
over 40,000 people. I say that because I do understand how business 
works. I know we have to pay executives to encourage their full 
capacity. But the money being paid to top health insurance executives 
is simply outrageous.
  Most of these companies where these executives work get subsidies 
from the Federal Government through payments to Medicare Advantage and 
Medicare Part D. Our tax dollars then wind up stuffing the pockets of 
insurance company executives.
  Remember, these companies are obliged to provide health care funding 
when people are ill or need counseling to improve their health and 
their longevity.
  The average compensation package for the top five insurance chief 
executives between 2006 and 2008 was almost $15 million a year.
  I think their services in these companies more closely resemble a 
fire department or an emergency response organization than a 
traditional product producer or a Wall Street firm. These companies are 
not selling lawnmowers. They have a different obligation, to provide a 
guarantee to help people maintain better health, which is essential for 
individuals and should be great for our country. Our country will save 
money by reducing overhead and improving programs that will fight to 
help people live better and longer.
  As their executives make millions of dollars every year, their 
customers are getting messages such as this: Sorry, this operation or 
that operation is not covered by your policy, or, we don't pay for that 
kind of medication.
  Here is an example that really lays it out perfectly.
  There is a company called UnitedHealthcare. It is a major health 
insurance company. After that company engaged in the practice of 
backdating hundreds of millions of dollars in stock options--and that 
was done to get an even better price than the shielded gain they get--
after backdating hundreds of millions of dollars of stock options, 
their CEO, William McGuire, was forced to quit for his questionable 
performance. Despite this scandal, United gave Mr. McGuire a golden 
parachute of more than $1 billion. Where did that money come from? It 
came from the pockets of senior citizens and from the people who had 
programs that were covered by this company--$1 billion for an outgoing 
CEO who engaged in misconduct, while hard-working, everyday Americans 
get turned down for needed and critical medical procedures. There was a 
disease in that boardroom when they permitted those inexplicable 
decisions.
  While health insurance executives have been gouging working families, 
they are gorging themselves with their outrageous pay, corporate jets, 
and other perks. A cancer victim may not get critical chemotherapy. A 
family may not be able to cover the ravages of a child with diabetes. 
But health insurance company executives draw down millions of dollars. 
It doesn't add up.
  This amendment will not tell insurance companies what they can pay 
their executives. They can pay them whatever they choose to. But only 
$400,000 annually can be treated as an expense. That is what the 
President of the United States makes. The rest of it will be taxed, 
with those funds going to make Medicare more solvent. Again, the 
Lincoln amendment wisely uses that new tax revenue generated by this 
measure to further shore up Medicare.
  An observation I wish to make is that I have listened to the debate 
over a long period of time--not just in recent weeks but long before 
that--about getting health care improved for the people across our 
country, the over 40 million people who cannot go to a doctor but who 
will go to an emergency room, draw a ticket as if they are waiting for 
a table in a restaurant, and hope they get seen before some critical 
disease gets worse. What we hear is objection after objection. They 
like the status quo. They have their friends in the industry. Look at 
the advertising budgets we see and the percentage of commercials paid 
for by those who are opposed as contrasted with those who desperately 
need the insurance.
  We are seeing now, for instance, that one element of our reform 
program is the government plan, the plan that makes the industry more 
competitive, the public option. We hear all kinds of reasons why that 
cannot be.
  What is the ultimate conclusion? It is that this lush field these 
insurance companies plow day after day, year after year, should be held 
intact. It is the wrong way to go. I say to them: Stand up, say you 
don't want 40 million people, or somewhere near that number, to get 
health care coverage. Say they don't deserve it because they may not be 
able to afford it. Say you don't deserve it, you don't have the money 
to pay for it. Who do you think you are, citizens of this country.
  People who are here, who have worked, in many instances, who have 
lost jobs in this recession, are being told--they don't use the 
language but the message is clear--you don't deserve it. But they want 
the insurance company executives to be treated particularly well.
  We need clarification of the thinking of the Republicans--and I have 
a lot of good friends over there, and I know there are a lot of good 
thinking people. But when the Senator from South Carolina said publicly 
that if we can bring down this health care plan, we will present a 
Waterloo for President Obama, what they are seeking is a political 
victory. They are not seeking to help people who are desperate.
  More people are worried about the loss of their health insurance than 
they are about their jobs because a job of some sort often can be 
available. But if you lose your health care, if you have a condition 
that the insurance company is not going to cover, you are in deep 
trouble.
  I plead with my colleagues and I plead with the people across our 
country who may hear our voices to protest this assault against logic, 
this assault against those who need help, those who understand that 
government can be better.
  I was a young boy when I enlisted in the Army, 18. My father was sick 
with cancer. He was 42 years old when he was diagnosed with cancer. He 
was a healthy man. He used to work out at the Y and take care of 
himself, but cancer overtook him and after 13 months of illness--a 
painful illness because they did not have the materials in those days 
to reduce the pain victims felt--he died, leaving a 37-year-old widow, 
my mother, who not only was grief-stricken but flat broke, no money. 
She owed pharmacists. She owed doctors. She owed hospitals.
  I learned then that if you cannot turn to government in the United 
States, you are in bad shape. We have the means to do it, and we must 
do it.
  I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Michigan.
  Ms. STABENOW. Mr. President, I want to specifically respond to the 
Senator from Nevada who was talking about the Canadian health care 
system a little earlier. I appreciate the information, the education. 
Of course, it has nothing to do with this debate, but it was nice to 
hear. We now understand a little bit more about the Canadian health 
care system.
  The great news for us is that what we are designing is a uniquely 
American health care system. I want to walk through the elements.
  About 60 percent of the folks of the great State of Michigan get 
their health insurance through their employer. That will continue. We 
are told that either their premiums will stay the same or go down, 
according to the Congressional Budget Office. And we

[[Page 29564]]

believe many of the efforts in this bill will actually bring costs 
down.
  One of the reasons that costs will come down is those of us with 
insurance will no longer be paying through the back door for people who 
use the emergency room who are sicker than they otherwise would be. 
They use the emergency room and then the costs are shifted on to people 
with insurance. We know there is about a $1,100 hidden tax we each pay 
on our premiums to pay for people right now who do not have insurance 
and use the emergency room inappropriately. Those with insurance now 
will not see their insurance change in terms of how they relate to 
their employer and their insurance company, but they will see costs go 
down because others will actually have insurance and not be using 
emergency rooms inappropriately.
  We also put in place protections for consumers, basically those, as 
the Senator from Minnesota was talking about, who have a preexisting 
condition and cannot find insurance now. Or somebody who has insurance. 
I don't know how many times I have heard from constituents of mine who 
have paid all their life and said, I don't have a problem, I have 
insurance, and then somebody gets sick and somebody gets dropped. They 
get dropped from their insurance because the insurance company does not 
want to pay for it.
  People with insurance now will keep the system they have but will 
benefit from consumer protections and from gradually seeing costs come 
down because we are not paying for people who are using other health 
care services inappropriately.
  We have about 80, 85 percent of the public right now who are covered 
with insurance, either through their employer or through Medicare, the 
great American success story we have been talking about, or through 
Medicaid, the VA, and so on. For the 15 to 20 percent of the public we 
are trying to provide options for affordable insurance, those are 
mainly people working. A vast majority of the people we are talking 
about work for a small business, they work part time, they work two 
part-time jobs, they work three part-time jobs.
  I have been hearing from small businesses for years: We wish we had 
the same clout as big business. We wish we could pool all the small 
businesses and the individuals, that entrepreneur working out of their 
garage, that realtor who does not have a pool. Pool us and give us the 
same clout as big business.
  That is what we are doing in this bill. Versions of this have been 
proposed by the distinguished Senator from Wyoming. I know back during 
the Clinton years during the debate, Senator Bob Dole proposed 
something similar. This has been a Democratic idea and a Republican 
idea for years.
  We are calling this an insurance exchange where basically if somebody 
right now cannot find affordable insurance by going out by themselves 
in the individual market, they are going to be able to go to a place 
where companies will bid on the large pool of everybody who does not 
have affordable insurance now. Just like what we do for the Federal 
Government, like our insurance plan, our Federal employee insurance 
plan, which is an insurance exchange, someone will be able to go to a 
Web site or be able to get information and be able to find out about 
the private insurance companies that want to offer insurance to them 
through this insurance pool.
  One of the things we are debating is whether there should be a public 
insurance choice for people. I believe there should be. I believe that 
in order to provide competition for the for-profit companies, we should 
have that. But the exchange is set up basically for small businesses 
and individuals to purchase--and we are told that people will see 
cheaper rates being able to do that. And to be sure they are able to do 
that, we are including tax cuts, refundable tax credits for 
individuals, for small businesses that cannot afford insurance today, 
to help them afford insurance. That is what the exchange is about. That 
will affect 15 to 20 percent of the public who do not have insurance 
today.
  We also have in the bill another option where a State could choose to 
take the tax credits available to people in the exchange and could 
decide to pool those and do a basic health insurance plan and negotiate 
with an insurance company to get a better deal for people in their 
State.
  We also have something I wish had been in place a couple of years ago 
for my own children, and that is, we are going to say to young people 
that you can stay on your parents' insurance until your 27th birthday. 
We also have a policy that is more geared to young people within the 
exchange that will be less cost to them.
  Can you imagine all of the young people today, college or not, who 
come out, get the first job, like my children, no health insurance, who 
will benefit by saying you can stay on your parents' insurance until 
your 27th birthday? That is in this bill, and it is very important. 
Also basically make Medicaid for low-income individuals a safety net so 
that anyone below 133 percent of poverty can qualify. What that says 
is--and this is very important to people in my State where we have the 
highest unemployment rate in the country--if you lose your job, you are 
not going to lose your insurance. It is a very important right for 
Americans.
  We are improving the Medicare system. We have certainly talked about 
that for a long time on the floor. A lot of time has been spent on the 
Medicare Program. We are cutting out overpayments to insurance 
companies, the for-profit companies right now that are being paid more 
than they should be and putting that back into the Medicare system to 
make it stronger for the future, to help pay for prescription drugs and 
to create more preventive care for seniors.
  Then another very important piece I was very proud to coauthor with 
Senator Kerry relates to early retirees. We have a lot of folks who are 
retiring early not by choice. They are being told they are going to 
have to retire early at age 55 or age 58 or 59. They may or may not 
have insurance. If they do, they are a higher cost for their employer, 
and if they do not, it is extremely difficult to find affordable 
insurance for somebody more likely to be using health care at that 
point.
  We have a provision where the Federal Government will partner with a 
business, with an insurance plan to make sure the costs are lower for 
the early retiree. It is called reinsurance. But for higher cost 
procedures or episodes, the Federal Government will come in above a 
certain level and cover the costs. It is a partnership between the 
private sector and the Federal Government to make sure early retirees, 
who are already being hit with a thousand different challenges as a 
result of early retirement, can afford insurance.
  This is a snapshot of what we are doing. Again, the vast majority of 
people are in private employer-based insurance today. That will not 
change, other than this will over time bring their costs down and it 
will give them new protections because if something happens--and it is 
happening every single day where an employer has to decide, Do I pay 
the 30 percent increase in premiums or do I keep people employed? If 
people find themselves in a situation where their employer drops 
insurance or drops employees as a result of costs, they have another 
option. They have someplace to go where they cannot today. They can go 
into the insurance exchange. They can get tax cuts that will help them 
purchase more affordable insurance from a large group pool as a big 
business does.
  Let me say that bottom line for all of this for us, despite 
everything that is being said, is that this is about saving lives, it 
is about saving money, and it is about saving Medicare. Every year we 
are losing 45,000 Americans who are dying prematurely because they 
cannot find health insurance and cannot get the health care they need. 
We have a variety of ways in this bill in which we are saving dollars. 
We have analysis from the Congressional Budget Office and Joint Tax 
showing that. And finally, we are saving Medicare for the future.
  The ACTING PRESIDENT pro tempore. The Senator has spoken for 10 
minutes.

[[Page 29565]]


  Ms. STABENOW. I yield the floor.
  The ACTING PRESIDENT pro tempore. The Senator from Wyoming.
  Mr. ENZI. Mr. President, I have found this afternoon to be very 
interesting. We have actually two debates going on at the same time, 
and sometimes they do not seem very related, but they are.
  One of the amendments we are debating is the one authored by the 
Senator from Arkansas, and it limits the deductible compensation for 
insurance executives to $400,000. Then we have the Ensign amendment 
which suggests that we should do the same for lawyers bringing junk 
lawsuits, although it doesn't go quite as far or is not quite as 
unreasonable in that it only limits it as a portion of the lawsuit.
  Of course, one of the reasons being given on the Senate floor for 
supporting the amendment of the Senator from Arkansas is that 
Republicans are funded by insurance companies. Well, I have to object 
to that kind of wording. We could make a lot of insinuations about who 
junk lawsuits are being supported by and where the money from those 
folks goes. The Democrats say: Well, the evidence is that the insurance 
companies are putting so much money into defeating this piece of 
legislation. Well, I found out the pharmaceutical industry is now so 
firmly in the President's camp that it is developing plans to spend 
$150 million promoting the plan on TV. That certainly makes me kind of 
curious as to why the Arkansas Senator did not include executives of 
pharmacy companies in her piece of legislation.
  Mr. President, I don't begrudge anybody anything that they make, but 
I do find it interesting that the CEO of Abbott Laboratories makes $28 
million, the Allergan CEO makes $14 million, the CEO of Bristol-Myers 
Squibb makes $23 million, the CEO of Eli Lilly makes $12 million, the 
CEO of Johnson and Johnson makes $29 million--the Senator from New 
Jersey was mentioning these things, so I checked--and the CEO of Merck, 
which is New Jersey based, makes $25 million; the CEO of Pfizer, $15 
million; Schering-Plough, $18 million; Valeant Pharmaceuticals, their 
CEO makes $20 million; and Wyeth Pharmaceuticals' CEO makes $25 
million.
  Why would we want to leave these people out of the same formula? Is 
it because they are taking the side of passing the bill as opposed to 
the side of opposing the bill and informing the people? We ought not to 
be about that sort of thing.
  Mr. President, I ask unanimous consent to have printed in the Record 
an article from CBS News titled, ``White House & Big Pharma: What's the 
Deal?''
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

               White House & Big Pharma: What's the Deal?

                         (By Sharyl Attkisson)

       While much of the health care debate has been carried out 
     publicly, some very private negotiations have gone on too--
     between the White House and the pharmaceutical industry. So 
     private, neither side will release all the details, yet they 
     potentially involve millions of Americans, reports CBS News 
     correspondent Sharyl Attkisson.
       Sources say negotiations involving the White House and the 
     pharmaceutical industry shifted to fast-forward in mid-June. 
     President Obama had just taken a serious hit on the 
     escalating cost of his health care plan and needed a shot in 
     the arm. Days later, he got it with the full backing of the 
     pharmaceutical industry and its promise to save Americans $80 
     billion in health care costs.
       ``This is just part of the legislative process--working 
     with industry, part of getting this done,'' said Nancy-Ann 
     Deparle, director of the White House Office of Health Reform. 
     ``And the great thing is the pharmaceutical industry and 
     others in the health care sector are supporting reform this 
     time.''
       But what did the pharmaceutical industry get in return? 
     Initial reports said the White House agreed not to seek price 
     controls on drugs for seniors on Medicare and would not 
     support importing cheaper drugs from Canada. Both the White 
     House and the pharmaceutical industry now dispute that.
       But news of a backroom deal riled even some fellow 
     Democrats, including a key committee chairman Henry Waxman.
       ``We're not bound by that agreement,'' Waxman said. ``We 
     weren't part of it and we feel strongly that the drug 
     companies shouldn't get off with a windfall at the expense of 
     our seniors.''
       Whatever the case, the pharmaceutical industry is now so 
     firmly in the president's camp, it's developing plans to 
     spend up to $150 million dollars promoting it with TV ads.
       ``The president and Congress have a plan,'' reads one ad.
       Consumer watchdog Dr. Sidney Wolfe says there's reason for 
     the public to be skeptical.
       ``We'll give you this, you'll give us this,'' Wolfe says. 
     ``All sort of off the record, not really incorporated in any 
     kind of legislation and I believe in the long run a very bad 
     deal for the American public even if it's a good deal for the 
     drug industry.''
       The president may have won crucial support from the 
     pharmaceutical industry but the question is whether that 
     could jeopardize support among Democrats and the public.

  Mr. ENZI. Mr. President, I am sorry the Senator from Minnesota 
finished his presiding in the Chair. I will still address the question 
to him--I did not expect him to give me an answer at the moment 
anyway--because he said there was a 428-percent increase in profits for 
the insurance companies. I didn't quite get what the dates were, but he 
was talking percentages. As the accountant, I like to talk dollars. I 
would like to know what those dollars were from that first year to the 
final year because, for example, if a person makes $1 in the first year 
and in the last year cited they make $5.28, that is a 428-percent 
increase. If you start with the low number of zero, you can have an 
unlimited--or infinity--increase in whatever year you pick after that, 
if they even make a penny. So percentages can give some bad numbers.
  Also, the Senator from New Jersey was talking about administrative 
costs, and so was the Senator from Minnesota. I would like to get the 
figures from Minnesota to see how that is working--to have a limitation 
of 91 percent of all insurance money going to evidently pay claims--
because I am not aware of the administrative costs being quite that low 
in almost any business. Again, as the accountant, I find that most 
people--and when I say most people, I would include my colleagues--
think most businesses are pretty simple. But when I visit one of those 
businesses, and I learn a little about it, I find that when I scratch 
the surface, there is a lot going on that the average person out there 
couldn't handle.
  Some of that shows up in the legislation that we do. For instance, 
Cash for Clunkers. That was supposed to be a 4-month program. We ran 
out of money in 4 days. That shows how much we knew about the car 
business.
  So when we are talking about these different things, I got involved 
with some of these administrative costs when I was working on health 
plans. I did small business health plans, and that is something that 
has been rattling around here for about 12 years. It still is, and now 
it is 15 years. Now, how that works is that it allows small businesses, 
through their associations, to group together to form a big enough pool 
so that they can effectively lobby against insurance companies or 
negotiate with providers. They can make these associations across State 
lines, even make them nationwide if that will work better.
  Presently, they have to do it within their own State. That is the law 
that we have set up. But I found an example of one in Ohio that is very 
successful. It works well. That is kind of how I modeled my small 
business health plan. When I did small business health plans, I was 
taking on the insurance companies. They were pretty upset that I was 
doing anything in that area, and they joined with some other people to 
keep me from getting cloture on the motion to proceed to the debate on 
that. So I know how tough health care is to move along.
  But Ohio has that association within its State boundaries, and it 
works because they have a huge population. We have less than 500,000 
people who live in Wyoming, and so if you break that down by 
associations, it would be small pools, and you don't get the actuarial 
value out of it that you would if you go to a big population. But in 
Ohio they can do it within the State, and in Ohio they did do it within 
the State. It brought down the cost of health insurance. It brought 
down the cost.
  Now, not only that, the biggest savings was actually in 
administrative

[[Page 29566]]

costs. It costs a lot more to keep track of all of the claims and 
everything from a small business than it does from a big business. The 
bigger the pool, again, the more capable you are of handling unusual 
situations. But administrative costs came down from 37 percent to 12 
percent, which is a 25 percent savings. Every business would like to 
have that. But that is how much it costs to administer small ones, so 
that is why they wanted to group together to form associations to form 
this bigger pool, which we haven't been able to do.
  I would ask the Chair how much time I have remaining?
  The PRESIDING OFFICER (Ms. Landrieu). There is 2 minutes 15 seconds 
remaining.
  Mr. ENZI. I do want to make some quick comments about the junk 
lawsuits. We do have to do something about that. When I am talking 
about junk lawsuits, I am talking about a bunch of them being filed 
these days that are $25,000, $45,000, $95,000, or whatever is less than 
what it would cost to defend that lawsuit because if it is less than 
what it would cost to do the lawsuit, the insurance company is going to 
say: Let's just pay them and we will be saving money. It is bad 
precedent and it leads to more junk lawsuits being filed.
  It is interesting to note that both lawyers who are with the 
insurance companies and lawyers who are with the people who have been 
harmed don't want to have tort reform. That kind of surprised me. Then 
I thought: Well, they probably learned a lot of this in law school. In 
law school they probably are taught how important it is to somebody's 
retirement. Then I remembered the Old West and the story about how when 
one lawyer comes to town, he is broke. But if they can get two, they 
can both make a good living. It does take lawyers on both sides working 
these lawsuits, and it does amount to a lot of money.
  So we do have to do something, particularly in the medical area, 
because we could save $45 billion a year if we were to have something 
done about junk lawsuits, particularly with OB-GYNs. We are losing all 
of them in Wyoming, and it is because there is such a long tail on it. 
Somebody can sue for 18 years after they are born. So the OB-GYNs have 
to pay a lot longer insurance tail than that.
  We had one dramatic case of a doctor attending a basketball game in 
Douglas. The reason he chose to announce his retirement is because he 
couldn't afford the insurance he had to pay. The reason he did is 
because he had birthed almost every kid on both teams. So the mothers 
there don't have OB-GYN help as a result of his retirement, simply 
because of what it cost him for insurance.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. ENZI. I thank the Chair, and I yield the floor.
  The PRESIDING OFFICER. The Senator from Ohio.
  Mr. BROWN. Madam President, I come to the floor pretty often reading 
letters from people in my State who have had problems with their health 
insurance. What is interesting about these letters is that in almost 
every case, if you had asked these people--Mary from Madison County, 
Ann from Montgomery, Sheila from Richland County--a year or two years 
ago if they were satisfied or happy with their insurance, most of them 
would have said yes. But today they say something very different, maybe 
because a baby was born with a preexisting condition, so they can't get 
insurance now or maybe they got very sick and the insurance company 
took them off their plan, kicked them off their plan because they were 
costing too much or maybe they changed jobs and lost their insurance or 
maybe they got laid off.
  The other thing I noticed--and as the Presiding Officer knows, from 
what happens in Louisiana and the letters you get from Baton Rouge and 
Shreveport and all over--is so many people who are 58 or 62 or 63 years 
old, and who don't have insurance, they just pray that they can make it 
until they are 65 because they know they have a good strong public plan 
at 65 that doesn't deny people with preexisting conditions. Medicare 
doesn't do that, of course. It is a plan that is predictable and they 
can stay with it and it will help them.
  I want to share a handful of these letters, Madam President, and I 
will start with Mary from Madison County. Madison is just west of 
Columbus. And Mary writes:

       For the past 26 years, I've worked hard and carried my own 
     insurance. When I started a home-based business, I joined my 
     husband's employer-based plan. But when he had an on the job 
     injury and went on Social Security Disability in 2006, I had 
     to find my own insurance. Guess what? I was turned down by 
     almost every health insurance company because of a pre-
     existing condition--which was a heart attack I had in 2004. 
     The only insurance I could buy was a short-term policy.

  Mary says she then got sick and had $40,000 in medical bills from a 
procedure, that she has wiped out her savings, and she says:

       I'm still unable to buy a major medical policy. I am too 
     young for Medicare and I make too much to qualify for 
     Medicaid.

  Mary is an example of someone who would absolutely be helped by this 
bill. She could go to the insurance exchange, choose a private company 
or choose a public option, and she could make a decision based on what 
her needs are whether she wants the private or the public. She would 
know that with the public option prices will be more stable and that 
the quality will be better because there will be more competition than 
there would be otherwise.
  Here is a letter from Ann, from Montgomery County, the Dayton area. 
She writes:

       Our insurance premiums have nearly tripled in the last six 
     years--going from about $560 per month to about $1,500 per 
     month. At the same time, none of our benefits have increased. 
     Since we bought our policy, we have paid the insurance 
     company $68,000 for the insurance.

  Then she writes as though she is writing in a magazine, and she says:

       Anthem's total spending from my family's claims since we 
     bought the insurance: $4,064.24. Anthem's profit from my 
     family: just under $464,000. Anthem's CEO's total 
     compensation last year alone: $10 million.

  Now, clearly, one of the biggest, strongest supporters of my friends 
on the other side of the aisle is the insurance industry. They are as 
supportive of the insurance industry as the industry is of them. Well, 
we do know that if we do insurance reform right--as I think we will--
and the Presiding Officer from Louisiana has been in a lot of these 
meetings where we have discussed some of these changes that we want to 
make--insurance companies are not going to be able to deny coverage. 
When someone gets sick and submits their claims, they are going to get 
paid instead of having to fight over it. And we know if there is a 
public option, there will be more competition and that these CEO 
salaries are probably not going to be as high. The average salary for 
CEOs of the top 10 health insurance companies in the country is $1 
million. That kind of salary is probably not going to happen if we have 
the type of insurance reform we hope to have because they will not make 
the kind of money to do that.
  The next letter is from Sheila from Richland County--Mansfield, my 
hometown--and Sheila writes:

       I moved to Ohio five years ago to be with my grand-
     daughter. I've worked hard all my life, and now, I'm 60 years 
     old still working and paying for my insurance. The other day 
     I learned that my health insurance has doubled. I am alarmed 
     because I'm wondering how long I will be able to pay for my 
     benefits. I've talked to some other people my age and they 
     are feeling the same way. I have always worked, never sat 
     down, or expected hand-outs. But insurance companies are 
     downright greedy. I do have a problem with seniors being 
     gouged because of age and health issues.

  I think that says it all.
  Most of these people, as you can see, happen to be women. Women are 
much more likely to write us about these problems, often not just for 
themselves but often because they are taking care of their families. 
They are the major caregivers and they are the ones who navigate their 
way through these complicated policies to advocate for their families. 
These people who work hard and play by the rules--they do everything we 
ask of them as American citizens. We owe them a little better treatment 
than that.

[[Page 29567]]

  This last one I will read is from Kelly, from Delaware County, north 
of Columbus.

       I am a 39-year-old mother of two young sons. My husband and 
     I decided it would be better for me to leave my job and stay 
     at home and take care of our children.
       But this also meant we would lose our health insurance 
     through my employer.

  She had the insurance in the family.

       My husband works for a small business that does not provide 
     benefits.
       We ended up purchasing at what we thought was a reasonable 
     price. But it tripled within a year.
       In February 2008 I found out I was pregnant and I inquired 
     about the maternity coverage we added despite the high cost.
       I was shocked to learn there was a nine-month waiting 
     period before the coverage took effect--and that the 
     pregnancy and birth would not be covered because it's a pre-
     existing condition.
       That is $15,000 to $20,000 that would not be covered. My 
     husband and I talked about that if I needed critical medical 
     care, could we end up bankrupt? Could we lose our home? [How 
     about] our child's college fund?

  That $15,000 or $20,000 obviously is without major complications.

       By the grace of God my husband's company decided to offer 
     health benefits and pregnancy was covered.

  Then she writes, thinking of people other than herself--Kelly writes:

       Please take up reform in a serious manner and consider 
     among your reforms, a public option. Why can't insurance 
     companies compete? What are they so afraid of?

  Kelly gets it. She understands that a public option will mean that 
insurance companies will have to compete.
  For instance, in southwest Ohio, the Cincinnati area, two insurance 
companies have 85 percent of the insurance business. You create a 
public option, it doesn't mean someone from Lebanon or Batavia or 
Cincinnati or Blue Ash or Evendale or Middletown or Hamilton has to 
take that public option. But it does mean, because of the existence of 
the public option, there will be more competition and the insurance 
company will behave better. You get better quality, lower prices, and 
you will not have these companies dropping coverage because of a 
preexisting condition.
  Let me add one other thing. There was a Dow Jones story a couple of 
years ago entitled ``Humana's Third Quarter Profits Up 65 Percent, Sees 
Strong Medicare Advantage Gains.''
  Let me excerpt from the first few paragraphs. Humana Inc.'s third-
quarter earnings rose 65 percent amid improved margins in government--
i.e., Medicare Advantage--segment. The company also gave an initial 
2010 forecast in which the health insurance projects ``substantial'' 
Medicare Advantage membership growth, resulting in revenue of $32 
billion to $34 billion--well above analysts' average estimate of 29 
billion. Humana's forecast takes into account reductions in Medicare 
Advantage overpayments.
  We were on this floor in the last few days, listening over and over 
to my friends on the other side of the aisle defend the insurance 
industry, saying if you do this the insurance industry is going to be 
in such trouble and they will have to cut benefits.
  The insurance industry under our plan will get 20, 25, 30 million new 
customers because all these people without insurance are going to buy 
insurance. Of course we are putting some new rules on them. We don't 
want them to continue to deny care for preexisting condition; we don't 
want them to continue discriminating against women, as the Presiding 
Officer knows. As a female, but as a good Senator, she understands that 
women are paying oftentimes way more than men for more or less 
identical coverage and more or less identical situations. The insurance 
companies will not be able to do that anymore. So they will have these 
new customers. We have some rules so they will not be able to keep 
gaming the system.
  My friends on the other side of the aisle I hope would sort of back 
off the defense of the insurance industry because that is not what we 
are here for. We are here to help make this insurance system work 
better for all Americans. That is the reason for the public option. 
That is the reason for the insurance reforms. It will mean people will 
not be denied for a preexisting condition, it means people will not 
have to fight so hard when they submit their claims and have the 
insurance companies turn them down.
  About a third of claims that people submit to the insurance industry 
are denied. That means on the initial round that people do not get 
reimbursed for their expenses. It also means people have to fight with 
their insurance companies, far too often, people in a situation where 
they should not have to do that, they are sick, caring for a loved one, 
whatever it is.
  That is the reason this insurance reform is so important. I ask we 
move forward and pass this bill.
  I yield the floor.
  The PRESIDING OFFICER. Who seeks recognition? The Senator from 
Oklahoma is recognized.
  Mr. COBURN. Madam President, I ask unanimous consent that myself and 
the Senator from North Carolina consume the next hour discussing the 
health care bill.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. COBURN. Madam President, we have been discussing health care in 
Washington for the past 8 months rather vigorously. Four years ago I 
started working on a bill with my colleagues in the Senate and we 
introduced a bill 2 years ago and modified it this year. It was 
introduced before the House bill, it was introduced before the Senate 
bill. It was introduced before the bill we have on the floor at this 
time. It is called the Patients' Choice Act.
  We have heard several times that the Republicans want to stop this. 
As a practicing physician, I fully recognize the need to significantly 
reform health care. There is no question. I recognize that. In that 
bill is a guaranteed issue--no preexisting conditions are allowed in 
exchanges under our bill. But I also recognize that as we fix health 
care, some of the things we cannot do are make our fiscal situation 
worse and also our inefficiencies worse.
  Earlier today I referred to research put out and published in October 
of 2009, which is a white paper on the waste in our health care. This 
is Robert Kelly, vice president, Health Care Analytics, at Thomson 
Reuters, a highly esteemed, reputable firm which says that every year 
between $600 and $850 billion of money is wasted in health care. It is 
wasted. It doesn't help anybody get well and it doesn't prevent anybody 
from getting sick.
  When you look at the breakdown of where that comes from, it is rather 
apparent that the largest component of it is unwarranted use. They 
break that down. What is that? That is me as a physician--I am a 
practicing physician, delivered thousands of babies, cared for 
thousands of grandmoms, granddads, kids, set bones, done operations--
old-time, broad-based practice.
  But what is this unwarranted use? Madam President, 40 percent of $700 
billion is $280 billion a year. They are saying a total of $700 
billion, times 10 years in my math, at least from Oklahoma, is $7 
trillion.
  We have not begun to touch in any of these other bills this 
unwarranted use, the fraud and abuse--19 percent--that comes to $175 
billion a year in fraud. Most of it is not in the private sector, it is 
in Medicare and Medicaid. That is where most of the fraud is. We have 
not begun to touch that, we have not attacked it. There is a minimal $2 
billion over 10 years of direct fraud elimination in the bill we have 
on the floor.
  Administrative inefficiencies. That is the bureaucratic paperwork 
that both the hospitals and the doctors spend money on to make sure 
they maintain compliance with the regulation of medicine--17 percent. 
That 17 percent comes to somewhere between $100 billion and $150 
billion a year that does not help one patient get well. It doesn't 
prevent one patient from getting sick.
  In this unwarranted use happens to be the very thing that none of the 
bills attack, except our bill, which is the defensive medicine costs in 
this country. Why would it be important to fix that? Because it is 
close to $200 billion a year. That is $200 billion of tests that are 
ordered on patients, on procedures that are done on patients they do 
not need, because the doctors need to do it to prevent themselves being 
exposed to

[[Page 29568]]

unnecessary litigation. That is $200 billion a year, that is $2 
trillion over 10 years. Yet we do not address it, not one iota in the 
bill we have on the floor.
  Avoidable care--those are complications. Those are things that we 
cause. Iatrogenic, they are induced complications. We are not going to 
be able to do much with that. We could fix this--lack of care 
coordination with accountable care organizations--by incentivizing 
outcomes, by grouping in payment for how we pay. But we have not done 
any of that.
  So here is Thomson Reuters that is showing if we want to drive down 
costs in our health care system, what do we have to do? We have to 
attack where the waste is. There is nary a gnat's rear end of reduction 
in these things in the bill that is before us.
  The other thing I referred to earlier today was a report by the 
Congressional Research Service, which was issued December 1, this year, 
last week. What did they say? The question that was asked of them: What 
percentage of health care is run or funded by the Federal Government 
today--or the governments today? The number came back--I have been 
quoting 61 percent on my back-of-the-envelope calculation. The number 
came back, as affirmed by Congressional Research Service, that 60 
percent of all health care in America is funded through or by your tax 
dollars funding through a government organization.
  The question has to be asked: How well are we doing? Could there be 
any coordination or connection to the fact that the government is now 
running 60 percent of the health care, and health care inflation is 
twice what all the rest of the inflation is? Could there be any 
connection between the inefficiencies that are in health care and the 
fact that we have bureaucracies that have themselves in between 
patients and their providers? I think the answer to that is an 
astounding yes.
  I visited with a cardiovascular surgeon, because I have made this 
statement on the floor and people have disputed it.
  Find me a doctor who has trained in the last 30 years in this 
country, who spent part of his training at a VA medical center, and ask 
him or her the following question: If you or your family were sick and 
you had the choice of where you trained at a VA hospital or any other 
hospital you trained, would you go to the VA hospital or would you go 
to one of the private hospitals where you trained? One hundred percent 
will say no.
  Our VA system has markedly improved. I will readily admit, in certain 
areas, they are better than anybody else, especially prosthetics, 
especially post-traumatic stress disorder. They are better. But on the 
vast majority of the issues, they are not. They are run by the 
government. Look at the Indian Health Service. We have a profound legal 
treaty obligation to provide health care to Native Americans. Yet 
Indian health care is abysmal. That is a government-run program. Then 
look at Medicaid, which we are going to put millions of people in. What 
happens? In Medicaid, 40 percent of the doctors and 65 percent of the 
specialists will not see you. But we are going to say: We will give you 
coverage in a system where you have access to only 60 percent of the 
doctors. That is not choice. That is relegating you to a system that 
says you can't get care.
  I have talked on this floor about pediatric subspecialties. Because 
of Medicaid, we have an absolute dearth of pediatric subspecialties 
because the payment mechanism is so low that nobody will spend the 
extra time in residency to become a pediatric subspecialist. Whether it 
is a cardiologist or gastroenterologist or pediatric neurologist, we 
can't find them. Nobody will go there. The rates for reimbursement are 
set so low. So physicians graduating from medical school make an 
economic decision based on the health and well-being of their family to 
not go into those areas because we have forced them.
  What we know is, there are poorer health outcomes in Medicaid. That 
should not be surprising. Some of the best doctors are not available to 
Medicaid patients because we will not pay for their expertise. We also 
pay an extra $1,800 per family, everybody in this country who has 
insurance, because of the underpayment of Medicare and Medicaid. 
Finally, with the large tranche of people under this bill who are going 
into the Medicaid Program, we are going to break the States, if they 
are not broken already. We are going to cover it for 4 years. For 
certain States, we will do a whole lot better than that; Louisiana and 
a few others for which we have made special exceptions. But we are 
basically going to transfer a load of fiscal responsibility, call it 
equal, and put that load on the taxpayers of the individual States.
  As we look at health care, one of the things I wished to do was to 
talk about the problems but also talk about the bill we have before us 
and make this point. Are we better off with the government running 
health care or are we better off changing the system in such a way so 
the patient is put first, the government is put last, and the doctor is 
a 100-percent advocate for their patient? Which would be the better 
way? Knowing that we have $7 to $800 billion a year wasted, why would 
we not design a system that goes after that waste and create the same 
opportunity for everybody?
  When you look at the Patients' Choice Act, which my colleague, 
Senator Burr, will talk about in a minute, there are some important 
things. First, let me tell what the CBO says about it. The CBO says it 
will reduce future budget deficits, relative to protections under 
current law, by amounts that increase over time--the first 10 years, 
$70 billion. But what it will do for the States is $1 trillion in 
savings the first 10 years. It will lead to lower budget deficits. That 
is what the CBO said. It said it also would reduce spending on health 
care because it will be more efficient spending. Then, finally, the 
Federal contribution for Medicaid would grow at a lower rate, lower 
than health care inflation, which means it is going to save a ton of 
money for the States.
  The bill we have before us creates 70 new government programs. It has 
1,696 times that we will write bureaucratic rules and regulations that 
are going to cause the government to step between the patient and their 
caregiver. It is estimated, right now, to add somewhere around 20,000 
new Federal employees--we are trying to get a handle on that--20,000 
new Federal employees to tell you what you will and will not do in your 
health care. It is going to create at least $5 to $10 billion in new 
requirements for the Internal Revenue Service just to check on you. 
That is per year to check on you to make sure you are filling out the 
forms right. It will create a massive disruption in the insurance 
market.
  Nobody who practices medicine today likes insurance companies. The 
very fact that we would have our colleagues claim we are defending the 
process is absurd. What we are defending is allowing the free market, 
with legitimate regulation, to allocate a scarce resource without 
putting the patient second. There is a big difference. I can tell you 
horror stories about insurance companies, but I can tell you worse 
stories about the Federal Government and the fact that it denies twice 
as many claims per 10,000 claims as all the other insurance companies.
  So when we are talking about access to care, both of the 
bureaucracies are a nightmare. Yet this bill creates the mother of all 
bureaucracies, the mother of all new programs.
  I will make one last point and yield the floor. We have been down 
here fixing things that are wrong. We fixed the Preventive Services 
Task Force. We said it doesn't apply to breast cancer screening. That 
is what we said. We voted for it. It doesn't apply. Are we going to 
pass that every time? We didn't get rid of it. We didn't get rid of the 
Medicare Advisory Commission. We didn't get rid of the Comparative 
Effectiveness Panel. Every time they make a bad decision, are we going 
to pass a law and say: You were wrong or are we going to trust the 
professionals, the professional societies that guide my practice of 
medicine today or are we going to have a bureaucrat and a bureaucratic 
system that says what you will get and what you won't? Under the bill 
we have, you are going to have

[[Page 29569]]

that. We have taken the hot potato off the floor in terms of breast 
cancer, in terms of what they said. We said it doesn't apply. We passed 
something for women's health which I applaud. But what about men's 
health? What about children, what about prostate screening for men? 
What about colon screening for men? What about cardiovascular screening 
for men? We didn't do a thing. Why didn't we? Because we know a larger 
percentage of the emotional attraction has to do with those things 
associated with women. So we pounded our chests and passed the Mikulski 
amendment for preventative care for women, and we ignored the 
preventative requirements of everybody else. How does that fit with 
what we should be doing?
  It doesn't connect. It is political. It makes good news. It satisfies 
vocal interest groups. But does it fix the long-term problem?
  I yield to my fellow Senator from North Carolina.
  The PRESIDING OFFICER. The Senator from North Carolina.
  Mr. BURR. Madam President, this debate to date has not been about 
health care reform. It has been about coverage expansion. We are 
learning how expensive it is not to do reform. In fact, incorporated in 
this bill, just short of $900 billion, we are required to offset 100 
percent of it because you don't receive savings unless you reform.
  When Dr. Coburn and I started work over 3\1/2\ years ago to try to 
figure out how you change the health care system to the most efficient, 
yet maintaining the same quality of care and innovation and 
breakthrough, we went on a search. We went to States to look at 
creative things that States had done. I daresay everybody trumpeted the 
reforms in Massachusetts. What we learned very early on was 
Massachusetts didn't have any reforms. They did coverage expansion. 
Where they used to pay for it out of the right pocket, now they paid 
for it out of the left pocket. They promised that coverage would be 
extensive and include everyone.
  Where are we today, just a few years later? The companies they said 
they would never send bills to, they are sending an additional 
surcharge to the Massachusetts people, and they said everybody would be 
covered. This year they are throwing people off the Massachusetts plan 
because they don't have enough money to cover them.
  Real health care reform means we are going to make sure every 
American has the resources to be covered or to be able to pay out of 
pocket because the real boogeyman of health care today is the cost 
shift. It is cost that is incurred when a service is delivered to you 
that the person or the institution delivering the service isn't 
reimbursed for. If they receive no payment for the service they 
provide, then they have to shift the cost of delivery of that service 
over to somebody else. The somebody else is people who privately pay. 
They either pay out of their pocket or they walk in with insurance, and 
the cost of those services is shifted to everybody who falls into that 
category.
  Up until this debate, most Americans had thought cost shift was only 
generated by people who had no insurance. What we have learned in this 
debate is it doesn't stop there, that the cost shift is also initiated 
from somebody who is underinsured, meaning they haven't got enough 
insurance to take care of the services they need. But it doesn't stop 
there. For every beneficiary that Medicaid covers, we reimburse at an 
average rate of 72 cents of every dollar of service provided, meaning 
for the millions of Americans who are covered under every State 
Medicaid plan, we automatically cost shift 28 cents of every dollar of 
service they get to the private side.
  As a matter of fact, for the 35 to 40 million seniors under Medicare, 
we reimburse at 91 cents for every dollar of service provided. 
Therefore, 9 cents is shifted in some fashion to the private pay side. 
No wonder health insurance and the cost of health care has continued to 
rise at an unsustainable rate. It is because we keep growing the pool 
of people who don't provide 100 percent of the cost of the service 
provided.
  We are here debating a plan that they say is a reform. Well, I will 
give them credit for this: They do cover 31 million Americans who are 
not covered today. It still leaves 24 million Americans uninsured, 
uncovered, but they do cover 31 million. Fifty percent of that number, 
15 million Americans, are going to be thrown into Medicaid in the 
States they live in. If the attempt is to reform health care, the first 
place you start is with eliminating cost shift. The first place they 
have started is to take the least-efficient medical delivery system in 
the country, Medicaid, and jam 15 million Americans into it. Forget the 
fact that it is an unfunded mandate to the States at some point, after 
the Federal Government pays 100 percent of the initial charge. We are 
exacerbating the problem that exists in health care today because we 
are putting 15 million new covered lives into Medicaid, and we know for 
every dollar of services they get, we are going to cost shift 28 cents 
of that over to people who pay out of pocket or have insurance.
  The direction we have started in is flawed because we haven't tried 
to address the cost shift that exists in our health care system. 
Senator Coburn and I attacked that. After we got past Massachusetts, we 
looked at innovative plans such as North Carolina's for Medicaid, where 
they were making progress reaching new efficiencies and last year saved 
$200 million in their health care plan.
  Most people don't know it, but Medicaid is an opt-out program. States 
can choose to opt out.
  That word has been used a lot as we talk about health care reform in 
the United States, and that as long as you do an opt-out, we will be 
fine for a public option for the government-run system. Well, we have 
one of those. It is called Medicaid. It is an opt-out government health 
care program. How many States opt out? None. Why? Because the subsidy 
is so big they cannot do it.
  But what happens when they want to change their plans? Let's go back 
to North Carolina. North Carolina would like to change their plan 
further, now that they have learned things they can do. They asked the 
Centers for Medicare and Medicaid Services for a waiver. Religiously, 
what happens? They are denied the waiver to change their health care 
plan to raise the quality and to reduce the cost.
  Sound eerily similar to what we are talking about, potentially, in a 
health care plan we are going to roll out for the rest of the country? 
Maybe an opt-out plan where States could opt out, where they say it is 
not a government takeover. Well, if you have to go to the government 
and ask their permission to change it, to increase the quality of the 
care and to decrease the cost because of the efficiencies you get 
through how you design it, I will tell you that is a government-run 
plan, plain and simple.
  We talked to self-insured companies. There was a gold mine of great 
ideas from companies such as Dell, SAS, Safeway, and Pitney Bowes, 
companies that had frozen their health care costs year after year after 
year. We had one simple question. How did you do it?
  They looked at us and said: We invested in prevention, wellness, and 
chronic disease management--even to the degree that one company offered 
the employees who had chronic disease the ability to have a program 
specifically designed for them for free, if they would enter into the 
program. Employees in some cases chose not to go into it. The company 
turned around and financially rewarded them by writing them a check to 
get into the program.
  At one company, when they wrote them a check, they had 80 percent 
enrollment, and in the first 18 months they saved $1,782 per employee. 
That is real savings. That is bending the cost curve of health care 
down. That is not what we are doing in this debate. Even the CBO says 
you are going to spend almost $900 billion and you have to raise $900 
billion to do it because there is no savings because there is no 
reform.
  So Senator Coburn and I went through that process, and we began to 
construct a bill. He did a majority of the work. What did we find? We 
found that we needed massive insurance reform in this country. As he 
said earlier, you cannot be excluded if you

[[Page 29570]]

have a preexisting condition. You cannot be excluded because you get 
sick. What you have to have is competition.
  Well, I will tell you, in this plan, where they say there is choice 
and competition and innovation, they actually mention choice 40 times, 
they mention innovation 25 times, and, believe it or not, they mention 
competition 13 times. Yet when they talk about taxes, fees, and 
revenues, they mention it 899 times. That gives the American people 
some insight as to where the focus of this health care bill is.
  Dr. Coburn and I went exactly the opposite way. This is not a reform 
effort that needs to be dominated by government. We chose the carrot 
versus the stick. In the bill on the Senate floor we are talking about, 
if an individual does not buy insurance, they are fined. They are fined 
if they do not buy insurance. We thought the Constitution said that if 
you tax the American people, you have to do it equally. You have to 
apply the same tax to this group that you do to that group.
  Through equalizing the application of taxes in this country, we were 
able to come up with a plan that provided every American family $5,700 
per year in refundable tax credits. So every American family would get 
that $5,700 every year.
  If, yes, we had that individual who was not married, and he or she 
got a $2,800 refundable tax credit, and they did not use it, we gave 
the States the option that they could opt them in. They could actually 
enroll them with that $2,800 into a high-risk catastrophic plan. We did 
not penalize the individual. We took what the government had provided 
and made sure they had insurance so that the next weekend, if they were 
riding their Harley-Davidson and they had a wreck and they ended up in 
the emergency room with no insurance, at least for the $200,000 bill to 
get them well, the hospital was not going to cost-shift that to 
somebody else because they were going to have catastrophic insurance. 
Maybe the hospital had to eat the first $5,000. But after that, they 
had an insurance policy.
  But this is the difference in approaches. We are not penalizing the 
American people. We want them to be part of a health care system that 
is reformed.
  We looked at Medicaid. We saw this problem with a 28-percent cost-
shift. We said we have to reform Medicaid. How do you do it? We gave 
States the option: If you want to enroll your Medicaid beneficiaries 
into this new plan that we created in this new competitive insurance 
market, then we will double the investment in your Medicaid 
beneficiaries so they can have $10,000 worth of coverage through the 
private sector.
  Again, we did not force them. We did what Dell did, what companies 
did: we gave them cash because we think we can increase the quality and 
decrease the overall cost.
  Tort reform: Dr. Coburn has talked about tort reform. Every doctor 
has talked about tort reform and defensive medicine, how it has run up 
the cost of diagnostic procedures because you have to cover yourself 
for the one lawsuit you get.
  We came up with quite a unique approach to it. We gave States three 
options. We gave them the ability to have arbitration, we gave them the 
stability to create a health court, and we said to States: If you adopt 
any one of these three options, we will give you a 1-percent bonus on 
your Medicaid. You do not have to adopt the tort reform. But if you 
want the 1-percent bonus on Medicaid, then you have to adopt one of the 
three options we have put into it.
  So, in essence, what are the three things we have done in our bill, 
which Dr. Coburn, once again, said was the first bill introduced in the 
Congress of the United States? I have sat on this floor, as Dr. Coburn 
has, as many people have, and, yes; we have had a sharp exchange about 
what is in this bill and whether it is beneficial or whether it hurts. 
I happen to think it hurts. But I have also listened to folks on that 
side of the aisle say: When are Republicans going to offer something 
constructive? When are they going to offer a pathway?
  We have. We were the first. We were ignored. We will get an 
opportunity to debate it as we go through this. We will get an 
opportunity to vote on it, I can assure you. I do not expect it to 
pass. But there are a lot of good things in here.
  Mr. COBURN. Madam President, will the Senator yield for a question?
  Mr. BURR. I am happy to yield.
  Mr. COBURN. Does the Senator recall the vote in the HELP Committee 
when this bill was offered--this bill that allows you to keep whatever 
you have, if you like it; this bill that gives no tax increases on 
American families; this bill with no increase in taxes on American 
business; this bill that lowers everybody's health insurance premium; 
this bill that covers preexisting conditions, period; this bill that 
protects seniors' high quality of care and keeps their choices; this 
bill that increases personal control over health care; this bill that 
does not do a Medicaid expansion but, instead, puts Medicaid patients 
into real insurance so they can have the same choice as every other 
American; this bill that protects physician-patient relationships; and 
this bill that empowers patients, families, physicians, and providers, 
but does not empower the government--what was the vote, does the 
Senator recall?
  Mr. BURR. All the Republicans voted for it and all the Democrats 
voted against it.
  Mr. COBURN. Exactly right. The difference is, you can either trust 
people or you can put all your trust in a nanny state, and the nanny 
state is running 61 percent, 60 percent of our health care today.
  I thank the Senator for answering my question.
  Mr. BURR. Let me conclude and give the floor back to the Senator.
  There are three objectives Dr. Coburn and I set out to accomplish for 
all Americans in the bill. The first was to cover all Americans, make 
sure everybody had the capability to access affordable coverage.
  Two, remember what the companies that were self-insured told us: 
Invest in prevention, wellness, and chronic disease management. The 
only direct cost savings in health care today is prevention, wellness, 
and chronic disease management. There are a lot of indirect savings--
tort reform, insurance reform, purchasing insurance across State 
lines--but the only direct savings comes from prevention, wellness, and 
chronic disease management.
  Third, and probably most important, make sure it is financially 
sustainable.
  Well, I do not know why, right now, we would create a health care 
plan in America that could not financially be sustainable for decades. 
Why would we create a health care plan that for the current generation 
entering adulthood would not live with that health care plan in a 
financially sustainable fashion for their lives? This one will not. It 
costs $2.5 trillion. It does not make it through the first 10 years.
  Yet we have an option. It is an option that Republicans have already 
introduced. We have let the American people see it. It is not 2,074 
pages. I think it is barely 240-some pages, and it incorporates much 
more. Oh, by the way, it fulfills--it checks all the boxes the 
President said we needed to do when we started on health care reform. 
It covers all the American people, is financially sustainable, 
maintains the level of quality, and it bends the cost curve down.
  What is the most disappointing thing out of this debate so far? It is 
that we do not have to get down here to tell the American people this 
is going to cost them more. They know it. They know their insurance 
premium is going up if they have coverage today. They know the doctors 
are going to have to charge more because Medicare is going to cut its 
reimbursements. They know more doctors are going to drop seeing 
Medicaid beneficiaries because the reimbursements are going to continue 
to go down. The American people get it. That is why, in an overwhelming 
fashion, they are opposed to what we are here debating.
  My hope is that at some point in this debate we will talk about some 
rational things, like what we have in the Patients' Choice Act. I do 
not expect it to

[[Page 29571]]

become law, but I expect reasonable people to accept things that really 
do reform health care, and a lot of them are in this bill.
  Madam President, I yield to my good friend.
  Mr. COBURN. Madam President, could I inquire of the Chair how much 
time we have remaining?
  The PRESIDING OFFICER (Mrs. Gillibrand). There is 24 minutes 
remaining.
  Mr. COBURN. Madam President, I want to go back over some of the 
things in the Patients' Choice Act because people ask me why they have 
not heard of it, and it is because the press does not want to cover a 
commonsense bill that does not spend money. The majority does not want 
to incorporate the ideas because it is not government-centered, it is 
patient-centered. We have a bill on the Senate floor that is totally 
government-centered.
  But what does the Patients' Choice Act do? Senator Burr alluded to a 
lot of it. But I want to go into it in a little bit of depth.
  What it does it is looks at the five preventable diseases in this 
country that consume 75 percent of our dollars, five chronic diseases: 
heart disease, cancer, stroke, chronic obstructive pulmonary disease, 
and diabetes. They cause two-thirds of the deaths and consume 75 
percent of our dollars. The Patients' Choice Act invests in preventing 
those diseases.
  The second thing it does is it creates affordable and accessible 
health insurance options--not government-run, not government-mandated, 
but uses the experience of 50 States through exchanges and sets a 
floor. What is the floor? The floor is the same level of care Members 
of Congress can get. That is the floor. But you get to choose. Nobody 
says you have to have this.
  Do you realize that 15 million Americans who are going to be forced 
into Medicaid in this bill will not have any choice? They will just 
say: You have Medicaid. And they will be denied 60 percent of the 
doctors in this country.
  It eliminates preexisting conditions. It eliminates the ability of an 
insurance company to drop you if you are sick. You get offered health 
insurance regardless of your age or regardless of your health. Yet we 
are saving trillions, and they are spending trillions.
  What is the difference? What is the disconnect? It gives you, as 
Senator Burr talked about, an auto enrollment mechanism. If you choose 
to be irresponsible, that is fine, but the rest of us should not have 
to pay for your irresponsibility. So if you do not sign up, you have an 
automatic enrollment with your tax credit that puts you in a very high 
deductible plan, so if you have a catastrophic illness, the rest of us 
do not have to pay for you.
  It also allows States to join in pooling arrangements, or regional 
areas, where they increase their buying power through these exchanges.
  Whatever you have today, if you like it, you really can keep it. That 
is not true in this bill that is coming across the Senate floor. There 
is an absolutely zero tax increase on American families, and it is not 
true in this bill on the floor. There is $500 billion worth of tax 
increases on either families or businesses.
  It lowers the cost of health insurance premiums. This one on the 
floor says, at best, in the large group and medium group market, it is 
going to be about the same trajectory of twice the inflation rate. But 
if you are in the individual market, it is going to be 10 to 13 percent 
higher. Our bill lowers everybody's cost. It protects the seniors' 
high-quality care and choices today. It doesn't pick winners and 
losers; it allows patients to pick what is best for them. It increases 
patients' own personal control over their health care, and it converts 
Medicaid to a system where no longer are patients in Medicaid 
discriminated against because what we do is we buy them an insurance 
system--allow them to buy insurance where nobody will ever know they 
are a Medicaid patient, so nobody will ever know to deny them, because 
the patient rate will be equivalent to anybody else in the insurance 
market. So we give them the same access.
  We treat Medicaid as we treat Indian health care: Here is your health 
care, but it is not as good, so tough it. Here is your health care. We 
know the outcomes aren't as good. So what. Those aren't Tom Coburn's 
opinions. Those are published data where we know the outcome in 
Medicaid isn't as good as any of the other insurance programs or it is 
not as good as people who are in the cash market even though they pay 
more.
  It protects patients and their caregivers' relationship. Finally, it 
empowers patients. It empowers mothers to make choices for their 
children; gives them a broad array of choices. It empowers, but it 
doesn't empower the Federal Government.
  The Federal Government is failing in health care right now. It really 
isn't my ingenuity that came up with this chart, but since I am around 
my three daughters and a lot of younger people who work for me on my 
staff, this is a comparison of the Patients' Choice Act or the act we 
have here. It is like comparing old Ma Bell to an iPhone.
  The Patients' Choice Act is the iPhone.
  A little over a decade ago, iPhones or even cell phones in general--
who would have thought they would be so widespread? Apple's iPhone was 
the fastest growing smartphone of 2008, and its 2008 sales were 2\1/2\ 
times higher than 2007. Why the increase? Why did iPhone sales take 
off? What did they do? They are hugely popular because they are user 
friendly and they allow tons of options and you get a personalized 
iPhone experience that you control.
  So what does an iPhone have to do with health care? Both sides of the 
political aisle rhetorically agree that American consumers prefer 
products that are personalized, that fit their needs, that are 
affordable, and that are portable. It sounds a lot like an iPhone. As a 
matter of fact, my colleagues across the aisle are now using the 
language ``choice and competition'' to try to sell this monstrosity on 
the American people, the most massive expansion of Federal Government 
control since Johnson's Great Society.
  The problem is that the policies in this bill would discard the 
iPhone's individual choices and consumer control. But what it would 
embrace is Ma Bell, the old land line black phone with a rotary dial. 
That is what we are going to embrace with this bill. We are not going 
to embrace the iPhone; we are going to embrace being locked to your 
house with limited choices, limited capability to expand your choices, 
and limited freedom.
  Mr. BURR. Would the Senator yield for a question?
  Mr. COBURN. I am happy to.
  Mr. BURR. My question is this: It sounds as though the Patients' 
Choice Act allows an individual to design the coverage to meet their 
age, their income, and their health condition.
  Mr. COBURN. Absolutely right.
  Mr. BURR. That is customizing your health care choice.
  Mr. COBURN. It puts the consumer--i.e, the patient--in charge of 
their health care rather than the government in charge of their health 
care.
  Mr. BURR. So one could then conclude that the current legislation we 
are debating in the Senate not only limits but it takes away choices 
that currently exist to seniors, to people who work, and to the younger 
generation.
  Mr. COBURN. I don't think there is any question that is going to 
happen. Actually, it is even going to be worse than that because we 
have shrunk the differential for young people. If you are a young 
person, listen to me. The cost of your insurance is going to double 
under this bill. If you are a young couple or a young individual--and I 
am talking 40 and under, 24 to 40--your insurance is going to double 
under this bill. What you are going to do, you are going to do this: 
You are going to say, I am going to pay the tax rather than coverage 
for insurance because it is financially much more important for me to 
do that. And what we know is that between 6 million and 11 million 
young people are going to cancel their insurance under this bill, 
according to a report put out by--and I will reference it here--Oliver 
Wyman and Associates.
  Mr. BURR. But typically children are a lot less expensive to insure 
because

[[Page 29572]]

they are younger and they are healthier.
  Mr. COBURN. What do you think is going to happen?
  Mr. BURR. What happens?
  Mr. COBURN. What is going to happen is the spread--the people who 
have insurance, if you are over 40, because these young people drop 
out, your premium is going to go up. So what is available today because 
of the mix of people who are in the broad group of pools who are 
insured--we are going to drop out young, healthy people, so that small 
younger group insurance is going to go up. But because there are going 
to be 6 million to 11 million fewer of them and the insurance company 
keeps them in the pot to lower the cost for the older ones, the 65 and 
above, their premiums are going to go up.
  So we are going to have exactly the opposite effect because when you 
mandate coverage and you force people to buy it with a big government 
program, people are going to make an economic decision--and the first 
year of this is $250 is all you have to pay, and it goes up to $750--
they are going to say: Why would I do that? I will buy the insurance 
when I get sick.
  So what we are going to do is totally disrupt--and it may be planned 
to be that way so we can come back and say: Well, look at the private 
insurance industry. It is not working. The government needs to take it 
all over. I don't know that is the case, but the consequences of what 
this bill is going to do----
  Mr. BURR. From the way the Senator has described it, the current bill 
that is being debated in the Senate really doesn't benefit anybody. 
Everybody loses.
  Mr. COBURN. Oh, yes, it does. We will have at least 20,000 new 
Federal Government employees. It will benefit them. It will benefit the 
bureaucracies. It will give them power to control. It is not a soft 
control or a light control; it is a heavy control. We will mandate on 
States bankruptcy through Medicaid--mandate to the States--the mother 
of all mandates to the States. So it will benefit the Federal 
Government and the bureaucracy but will have minimal benefit for the 
patients in this country.
  Mr. BURR. So at best, we can claim that the bill being debated in the 
Senate is a $2.5 trillion bill designed to try to stop waste, fraud, 
and abuse in the health care system.
  Mr. COBURN. Supposedly.
  Mr. BURR. Think about that. We are spending $2.5 trillion to try to 
get waste, fraud, and abuse out of just the government side of health 
care. Yet the bill itself is making the government a bigger factor in 
health care, which means the likelihood is, because of the design not 
changing, you have more waste, fraud, and abuse. So there is no real 
value to the $2.5 trillion, except to the government workers who are 
hired to either collect the fines and the new taxes or sit on the 
panels to determine who gets coverage and who doesn't.
  Mr. COBURN. Well, I wouldn't go quite that far. There is no question 
that some people who have no coverage today will get Medicaid. But 
compared to the Patients' Choice Act, they could get a private 
insurance policy instead of Medicaid. They would get access to all of 
the physicians, not just 60 percent of them.
  Mr. BURR. And save $2.5 trillion of the American people's money.
  Mr. COBURN. And save $2.5 trillion and have the flexibility of choice 
based on what they need and what they perceive their children or family 
needs.
  So they do increase coverage, but how do they do it? They put you 
into a substandard plan. They put you into a plan that doesn't give you 
the same access Members of Congress have. They put 15 million people 
into that, and they decrease the flexibility and choice for those 
people, 11 million people, in Medicare, because we know better.
  Mr. BURR. My good friend probably remembers the day we marked this up 
in the Health, Education, Labor, and Pensions Committee. As a matter of 
fact, it wasn't a day, it was 3\1/2\ weeks and 56\1/2\ hours, if I 
remember exactly. One of the amendments they accepted was an amendment 
that is titled this: The 2220 rule. My good friend being a doctor would 
recognize this was a program the Federal Government had to allow 
medical students to delay the repayment of their student loans until 
they actually got their practice up and running. That was eliminated 
about 2 years ago. I am sure the good doctor remembers that was 
accepted under a UC in the committee. But if you read the 2,074 pages, 
it was noticeably absent in the 2220 rule. Yet, as you know, we have 
less than a million doctors in the United States of America trying to 
provide medical coverage to 300 million people and growing. And some 
suggest that if this bill passed, we would lose 25 percent of our 
doctors in the first year who decided: This is it. I am going to 
retire. I am out of here.
  The 2220 provision is the only thing we had in our bill that actually 
created an incentive for more individuals to seek medicine as a career.
  Mr. COBURN. Madam President, if I may inquire how much time we have 
remaining.
  The PRESIDING OFFICER. Nine minutes.
  Mr. COBURN. Thank you.
  Again, going back to incentive, carrots versus sticks, how is it that 
we have a shortage of primary care physicians in the country? Why is 
that? We have put a lot of money into medical schools. The States have 
put a lot of money into medical schools. We have student loans for 
physicians who average about $170,000 in debt when they get out of 
there. How is it that people don't want to be a pediatrician and a 
general internist or a family practice doctor? Why is that?
  Mr. BURR. Reimbursements.
  Mr. COBURN. The reimbursements, where you can invest 1 additional 
year in residency and double the income you can make from being a 
physician.
  How did the payment rates get where they are? Who set the payment 
rates? The Federal Government set the payment rates because 60 percent 
of the payments to private physicians come from Medicare, Medicaid, 
TRICARE.
  Mr. BURR. Indian Health.
  Mr. COBURN. Those are contracted. Those are even lower. So they set 
them. Private insurance sets all the rates based on what the government 
does. So the government has created a shortage of primary care which we 
are going to see just explode as we put other people--the CBO has 
rightly said, if you add lots of people, you will get some increased 
utilization, a significant amount. They are not there. They are not 
there.
  So you take somebody in their late fifties, mid- to late fifties or 
early sixties, who planned on practicing 10 or 15 years, and all of a 
sudden you say--and we don't in this bill. We had the claim today that 
this extends the life of Medicare. Well, here is how it does that. It 
uses the Medicare Advisory Commission to force cuts in Medicare, not 
fraud necessarily, just cuts. It doesn't pay for the doctor fix, which 
is $250 billion, and then it cuts Medicare.
  So the reason--and I don't have any problem extending the life of 
Medicare--I think so--but it ought to be all about fraud. It ought to 
be all about--the vast majority of fraud in health care today is 
through government programs, not the private sector. The fraud rate in 
the private sector is less than 1 percent. Here we have $150 billion. 
We could save $1 trillion over the next 10 years if we had an effective 
fraud program, which this bill minimally addresses, which our bill 
aggressively addresses--aggressively addresses. We even have undercover 
patients, undercover doctors where we create sting operations to put 
people in jail--not fine them, not ban them from Medicare; we put them 
in jail if you are stealing from the American people.
  There is nothing anywhere close to that in this bill. So, in fact, we 
are aggressively going after the largest problem of the $800 billion 
that is wasted every year, which is fraud.
  The second largest problem is we need to incentivize the States to 
fix the tort extortion that is going on in this country that causes 
people to have tests done on them, not necessarily without any 
consequence to their health, and money wasted on tests so the doctors 
can be in a better defensive position.
  Mr. BURR. How could a group such as AARP, whose primary role, by 
design, is to represent our Nation's seniors, be in favor of a reform 
package

[[Page 29573]]

that doesn't provide any additional benefits to our Nation's seniors?
  Mr. COBURN. And it doesn't reform. I have wondered that.
  Mr. BURR. As the Senator knows, we drastically cut Medicare 
Advantage, the only private sector option that a senior has for 
coverage. We basically eliminate that. That is 11 million seniors in 
this country.
  Mr. COBURN. Well, we have protected some through earmarks in this 
bill--certain States; we have protected some. In some States, if you 
have Medicare Advantage, you are protected. In other States, if you 
don't happen to be on that side of the aisle, or you don't need help in 
your reelection, you don't get that.
  Mr. BURR. If somebody didn't have Medicare Advantage as a choice, 
what insurance product would they have to go into the marketplace to 
buy?
  Mr. COBURN. If they could afford it--and that is where a large number 
of Medicare Advantage people will be hurt; most of those people cannot 
afford to buy a supplemental policy. The fifth largest seller of 
insurance policies in the country happens to be AARP.
  Mr. BURR. AARP, yes. So to eliminate Medicare Advantage is a 
tremendous financial windfall to AARP.
  Mr. COBURN. For AARP.
  Mr. BURR. That association supposedly looking out over the seniors in 
this country.
  Mr. COBURN. We are fairly cynical, and we don't mean to be. We need 
to wrap up, if we can. There are two ways of fixing health care in this 
country. One is, we have the government running it--I make this point. 
Everybody agrees that in 2017 or 2019, Medicare will go belly up. 
Medicaid is already belly up. They are all in trouble. They are running 
deficits. The Census is broke. Social Security is going to be broke. 
The U.S. Post Office is absolutely broke. Cash for clunkers was broke 
before we started. The highway trust fund is $18 billion in the red. 
And we are going to put another 16 percent of health care--76 percent 
instead of 60--in the hands of the government. Or we can utilize what 
we know works, which if you incentivize the management of chronic 
disease and incentivize prevention, incentivize transparency, and you 
create a way for people to have access, the Patients' Choice Act will 
insure 94 percent of Americans with a real insurance policy, not 
Medicaid or Indian health care.
  By the way, Native Americans, listen up. Under our bill, if you are 
due health care, you get a card and you can go anywhere you want and it 
will be paid for. We need to do that for veterans, too.
  The point is there is a choice. We can run a large government option 
or we can run a small government with 50 States, incentivizing them to 
do the right and best thing for their citizens, where we will actually 
lower costs, increase access, and have better care, and we won't 
destroy the best health care system in the world.
  I challenge my colleagues to come down here to the floor and debate 
me on that, because I guarantee you that in their families I can find 
somebody who was saved because they lived in this country and, had they 
not, they would not be alive. It is the best health care system in the 
world. Why should we destroy that as we try to fix what is wrong in 
health care in America today?
  Mr. BURR. I ask my colleague to put that next chart up.
  I ask unanimous consent for 5 additional minutes.
  The PRESIDING OFFICER (Mrs. McCaskill). Without objection, it is so 
ordered.
  Mr. BURR. Madam President, this is self-explanatory, I think. Today 
we are borrowing 43 cents out of every dollar we spend; 43 cents of 
every dollar we spend in the Federal Government we are borrowing from 
somebody. You know, we talk about these unbelievable numbers in 
Washington--billions and trillions. The most popular bumper sticker out 
there is this: Don't tell Congress what comes after a trillion. 
Personally, I don't want to know, because I know if we get there, we 
are at the point of no return. Senator Coburn and I are close to the 
same age. We have kids just getting started raising families. We know 
what they are going to be faced with to raise their families, to make 
sure their children and grandchildren get educations, to make sure they 
go to college and have that opportunity, and make sure they have an 
opportunity after that for a place to work and an income. Do you know 
what is going to be the thing that dictates most of what they are faced 
with? It is right there on that chart. For every penny we borrow, it 
means we have an obligation to pay interest on that penny. Today 
interest is practically zero. We provide, as a Federal Government, 
money to banks they can lend out, and we charge them practically zero. 
That will not last forever. At some point, interest rates will go up.
  Depending upon how much money we have borrowed, that will dictate how 
much we are obligated to pay in interest.
  Mr. COBURN. Let me interrupt my colleague. Here is what the 
constellations show. Walk with me slowly. If you are 25 years of age or 
younger today in America--and we go out 20 years--that will be 45 and 
younger--that is 103 million Americans who will be in that group. Here 
is what they are each going to owe based on the unfunded liabilities of 
Medicare, Medicaid, and Social Security: 103 million Americans, 45 
years and younger, will each owe $1.119 million. That is what they will 
be responsible for. They will have to pay the average interest on that, 
which will be about 6 percent. Before they ever pay the first bit of 
income taxes, they will have to cover that interest; otherwise, that 
will grow.
  How does that fit a young family 20 years from now? We are talking 
about tax rates that allow no increased standard of living. As a matter 
of fact, they are rates that decrease the standard of living by 35 
percent. That is the heritage we are creating and what we are going to 
expand with this health care bill the majority leader has brought to 
the floor. We are going to steal the future and the opportunity for 
those 25 years and younger today, because we cannot live and make the 
hard choices that are necessary, and we think the answer to every 
problem is more government, rather than more personal responsibility, 
competition, transparency in a market, and incentivizing people to do 
the right thing, rather than punishing them when they do the wrong 
thing.
  Mr. BURR. The Senator is absolutely correct. What we can only hope to 
pass on to the next generation is an opportunity equal to what we have 
had. To strap them with this debt, to continue to go down this road and 
pile on the obligations, we will limit the next generation's 
opportunity. As you choke that opportunity for them, you will choke the 
fabric of this country in a way that the problems we are faced with 
today are minor in comparison to what they will deal with in the 
future.
  As we sit here and debate the pluses and minuses of this health care 
legislation, I remind my colleagues, when you talk about $2.5 
trillion--and you probably never will save that money out of Medicare; 
you probably never will cut that doctors' reimbursement quite as much 
as in there--every time you don't do that, we are borrowing 43 cents of 
every dollar we spend. That is the obligation our children will inherit 
from us.
  I am not willing to do that anymore. I want to make sure we are 
focused on the opportunity that is there for them. We can only do that 
if we do it in a responsible way, do the right thing as it relates to 
health care here.
  Mr. COBURN. I yield the floor, and I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. PRYOR. 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. PRYOR. Madam President, I ask unanimous consent that no 
amendments be in order to the pending amendments prior to the votes on 
Sunday, December 6.
  The PRESIDING OFFICER. Without objection, it is so ordered.

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